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 and can range from mild to severe. Immediate first aid includes applying cold therapy and a compression bandage followed by a full rehabilitation program of stretching, strengthening and sports specific exercises
- 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 complain of tightness in the back of the thigh but will be able to walk normally without pain. If they attempt to run, they will be aware of some discomfort and will be unable to operate at full speed. There will be little or no swelling and trying to bend the knee against resistance is likely to reproduce mild pain with possible some weakness.
Grade 2 - With a grade 2 hamstring strain, the athlete's gait (walking pattern) will be affected and they will most likely be limping. Sudden twinges of pain during activity will be present and they may notice some swelling and pain that is being reproduced when pressing the hamstring muscle. There will also be
Grade 3 - A grade 3 hamstring strain is a severe injury involving a tear to the majority or all of the muscle. The athlete may need crutches to walk and will feel severe pain and weakness in the muscle when trying to use it. Swelling will develop rapidly and bruising will usually appear within 24 hours. We advise seeking a medical opinion urgently if you suspect a severe grade 2 or 3 injury.
During an injury assessment of a hamstring strain, a professional therapist will take a full history and perform some specific tests to help diagnose the type and extent of the injury and these include the straight leg raise (also called Lasegue test), resisted knee flexion the and the slump test. A doctor may request an MRI scan for severe hamstring tears that can help determine the exact location and extent of the injury that can give a more accurate prognosis and
Hamstring strain causes & anatomy
A hamstring strain is a tear or strain to the muscle
Stretch related vs sprint related hamstring strains
There are other less common causes of hamstring pain such as a “dead legs” (also known as contusions) resulting from a direct blow or impact to the muscle 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 if you suffer from recurrent hamstring strains.
Hamstring strain treatment & rehabilitation
The sportsinjuryclinic.net rehabilitation program () discusses the healing process, how to treat them including stretching exercises, strengthening exercises and finally how to maintain fitness while the muscle heals. Treatment can be divided into immediate first aid and then longer-term treatment which begins after the initial acute stage of healing. 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 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 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 instead should be wrapped in a wet tea towel. There are commercially available cold packs and wraps that are just as effective and 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 times 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 gives advice on the initial treatment of hamstring strains.
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 (play video) 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 (play video) for the hamstrings can help to massage the muscle and this technique is called “myofascial release”. To perform this,
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.
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 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.
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
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 should always be done pain-free and 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. To do these, you lie on your front in the prone position and your partner or therapist provides resistance as you contract the hamstring muscles, and then hold this for 3 or 4 seconds and then relax.
The angle of knee flexion (bend) is then 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,
The athlete can then gradually progress through a serious of more dynamic and functional exercises that involve
Read more on our 10 essential hamstring strengthening exercises.
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 (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