Hamstring Strain/Tear
1. Introduction
The hamstrings are comprised of three different muscles (bicep femoris, semimembranosus and semitendinosus). The role of the hamstring muscles is primarily to flex (bend) the knee and extend (moving the thigh backwards) the hip, but they also have a role in rotational movements of the leg (7, 9, 11). The hamstrings are strong and powerful muscles which work hard when we are running especially at high speeds and when completing explosive movements such as jumping. As a result of the forces that the hamstrings must generate and control it is one of the more common muscles to become strained in a sporting situation (2,3,5,12).
Injuries to the muscle in non-sporting situations are rare.
Frequently Asked Questions
- An over-stretch or tear to one or more of the muscles located at the back of the thigh.
- Very rare in a non-sporting situation.
- In football they account for approximately 12.5% of all injuries (1).
- They are one of the most common injuries in rugby and cricket (2,3).
- No.
- Most hamstring strain injuries improve with conservative management (4).
- This condition is not related to any other serious diagnosis but has a similar presentation to a different condition called sciatica. This occurs when pressure is placed on a lower back nerve giving rise to pain that can travel through the buttock, back of the thigh, calf and/or foot.
- People who have previously had a hamstring strain injury (4).
- Those who participate in sports that involve high speed running.
- Higher standards of sport place greater loads and demand on the hamstrings increasing risk of injury (4,5).
- Posterior thigh pain (back of thigh).
- Potential bruising.
- Pain when walking.
- Reduced range of movement of the knee and hip.
- Pain with knee flexion (bending the knee).
- Early management centres around the Peace & Love acronym which is explained in detail below (12).
- Following this, rehabilitation will focus on optimal flexibility and strength of the muscles around the area.
- This is dependent on the level of injury.
- Most injures heal with 3-12 weeks (4).
- Severe injuries may last 6 months or more. This is very rare amongst the general population (7).
We recommend consulting a musculoskeletal physiotherapist to ensure exercises are best suited to your recovery. If you are carrying out an exercise regime without consulting a healthcare professional, you do so at your own risk.
2. Signs and Symptoms
- Posterior thigh pain.
- Initially there is potential for swelling and bruising
- Pain when walking.
- Reduced range of movement of the knee and hip.
- Pain with knee flexion.
3. Causes
Hamstring strain injuries are most frequently caused by a rapid contraction or stretch of the hamstring muscle group (3 muscles at the back of your thigh). This can result in varying degrees of damage to the affected muscle.
For example, high-speed running in football is thought to account for approximately 70% of injuries of which approximately 84% occur within the biceps femoris (6). The hamstrings can also be injured following an excessive stretch outside of an individual’s physical capacity which can cause unwanted stress and potential damage. Both these examples can result in varying degrees of injury within the affected muscle.
4. Risk Factors
This is not an exhaustive list. These factors could increase the likelihood of someone sustaining a hamstring strain injury. It does not mean everyone with these risk factors will develop symptoms.
- Weak hamstrings – reduced ability to manage increased load and demand.
- Lack of flexibility – reduced ability to manage increased load and demand.
- Imbalances between the strength of the quadriceps (muscles at the front of your thigh) and hamstrings (7,9).
- Poor sleep – quality sleep produces important hormones that contribute to muscle development and recovery (9).
- Poor nutrition – good nutrition provides the building blocks for muscular development.
- Higher levels of psychological stress – it is well established in research that our mental well-being plays an important role in muscle injury (10).
5. Prevalence
Injuries to the muscle in non-sporting situations are rare.
Most of the research in hamstring strain injuries comes from sport and prevalence reports vary drastically between sports. Most hamstring strain injuries occur in sports involving sprinting such as football, rugby, cricket (particularly fast bowlers) and track and field sprinting (2,3,5,12). Within football it has been suggested that hamstring strain injuries make up 12% of all injuries (1).
6. Assessment & Diagnosis
Musculoskeletal physiotherapists and other appropriately qualified health care professionals can provide you with a diagnosis by obtaining a detailed history of your symptoms. A series of physical tests might be performed as part of your assessment to rule out other potentially involved structures and gain a greater understanding of your physical abilities to help facilitate an accurate working diagnosis.
Your treating clinician will want to know how your condition affects you day-to-day so that treatment can be tailored to your needs and personalised goals can be established. Intermittent re-assessment will ascertain if you are making progress towards your goals and will allow appropriate adjustments to your treatment to be made. Imaging studies like MRI or ultrasound scan are usually not required to achieve a working diagnosis, but in unusual presentations they may be warranted.
7. Self-Management
Self-management directly after a hamstring strain injury is vital, and it is encouraged to utilise the PEACE & LOVE acronym (12):
Protect: the injury the first few days, avoid activities that increase pain.
Elevate: the leg higher than the heart as often as possible.
Avoid anti-inflammatories: they may reduce tissue healing in the early stage.
Compression: can help reduce swelling.
Education: your body knows best, avoid unnecessary treatments.
&
Load: let pain guide your return to normal activities.
Optimism: remain confident and positive.
Vascularisation: choose a pain-free exercise that elevates your heart rate.
Exercise: restore strength by adopting an active approach to recovery.
8. Rehabilitation
Rehabilitation after a hamstring strain injury should address risk factors identified by yourself and your musculoskeletal physiotherapist. Exercise and exercise progression is a key component, but not solely responsible for return to pre-injury levels of function.
9. Hamstring Strain/Tear
Rehabilitation Plans
Our team of expert musculoskeletal physiotherapist have created rehabilitation plans to enable people to manage their condition. If you have any questions or concerns about a condition, we recommend you book an consultation with one of our clinicians.
What Is the Pain Scale?
The pain scale or what some physios would call the Visual Analogue Scale (VAS), is a scale that is used to try and understand the level of pain that someone is in. The scale is intended as something that you would rate yourself on a scale of 0-10 with 0 = no pain, 10 = worst pain imaginable. You can learn more about what is pain and the pain scale here.
Early rehabilitation is individualised depending on risk factors for future injury, how the initial injury occurred, and which hamstring muscle was injured. All this information will guide rehabilitation selection (4,13).
Rehabilitation in the early stages will consist of the self-management strategies explained above. Lower load eccentric (muscle lengthens as it is put under tension) exercises should be started as soon as possible and a gradual introduction to low intensity jogging is also recommended. Starting eccentric exercises early allows for muscle lengthening addressing a potential risk factor for future injury (1,13). During the early phase of rehabilitation, it is ok to exercise with some pain, ideally less than 3 out of 10 on an individual’s self-perceived pain scale.
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During the next stage of rehabilitation, exercises are progressed and more challenging. This might include single leg eccentric exercises and the introduction of the Nordic hamstring exercise. This exercise is an invaluable exercise when rehabilitating and preventing hamstring strain injuries as it has been shown to reduce the incidents of injury by 51% (13). Building running acceleration, deceleration and speed should now be built into your programme if it is your intention to return to a higher level of function or sport.
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During the advanced stages of rehabilitation plan, you should be building towards and achieving a near full levels of fitness. In sport this translates to upwards of 90-95% of your maximum sprinting ability as well as the ability to quickly change direction, accelerate, and decelerate.
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10. Return to Sport / Normal life
Returning to sport should be a shared decision-making process between yourself and the treating clinician. Ideally, there should be no pain with direct compression over the initial injury site, your range of movement and strength should ideally be the same as the un-injured side, and you should be able to sprint without pain or apprehension on returning to play. Perhaps most important is that you only return to sport when you are confident that you are ready to do so.
11. Other Treatment Options
In very significant tears of the muscle and in particular, where the person is involved in high-level sport there is the possibility that surgery is needed to repair the muscle. This is exceptionally rare and in the vast majority of cases, rehabilitation will be successful in achieving a full recovery (14).
References
- Kerkhoffs, G.M., van Es, N., Wieldraaijer, T., Sierevelt, I.N., Ekstrand, J. and van Dijk, C.N. (2013). Diagnosis and prognosis of acute hamstring injuries in athletes. Knee Surgery, Sports Traumatology, Arthroscopy, 21(2), 500-509.
- Brooks, J.H., Fuller, C.W., Kemp, S.P.T. and Reddin, D.B. (2005). Epidemiology of injuries in English professional rugby union: part 1 match injuries. British journal of sports medicine, 39(10), 757-766
- Orchard, J.W., Kountouris, A. and Sims, K. (2017). Risk factors for hamstring injuries in Australian male professional cricket players. Journal of sport and health science, 6(3), 271-274.
- Jarvinen,T.A, Jarvinen, T.L, Kaariainen, M., Kalimo, H. and Jarvinen, M (2005) Muscle injuries: biology and treatment. The American Journal of Sports Medicine, 33(5), 745-764
- Speer, K.P., Lohnes, J. and Garrett JR, W.E. (1993). Radiographic imaging of muscle strain injury. The American journal of sports medicine, 21(1), 89-96
- Ekstrand, J., Healy, J.C., Waldén, M., Lee, J.C., English, B. and Hägglund, M. (2012). Hamstring muscle injuries in professional football: the correlation of MRI findings with return to play. British journal of sports medicine, 46(2), 112-117
- Timmins, R.G., Bourne, M.N., Shield, A.J., Williams, M.D., Lorenzen, C. and Opar, D.A. (2016). Short biceps femoris fascicles and eccentric knee flexor weakness increase the risk of hamstring injury in elite football (soccer): a prospective cohort study. British Journal of Sports Medicine, 50(24), 1524-1535..
- Gao, B., Dwivedi, S., Milewski, M.D. and Cruz Jr, A.I., 2019. Chronic lack of sleep is associated with increased sports injury in adolescents: A systematic review and meta-analysis. Orthopaedic Journal of Sports Medicine, 7(3_suppl), p.2325967119S00132.
- Croisier, J.L., Ganteaume, S., Binet, J., Genty, M. and Ferret, J.M. (2008). Strength imbalances and prevention of hamstring injury in professional soccer players: a prospective study. The American journal of sports medicine, 36(8), 1469-1475
- Ivarsson, A., Johnson, U., Andersen, M.B., Tranaeus, U., Stenling, A. and Lindwall, M. (2017). Psychosocial factors and sport injuries: meta-analyses for prediction and prevention. Sports medicine, 47(2), 353-365. Ekstrand, J., Hägglund, M. and Waldén, M. (2011). Injury incidence and injury patterns in professional football: the UEFA injury study. British journal of sports medicine, 45(7), 553-558. .
- Dalton, S.L., Kerr, Z.Y. and Dompier, T.P. (2015). Epidemiology of hamstring strains in 25 NCAA sports in the 2009-2010 to 2013-2014 academic years. The American journal of sports medicine, 43(11), 2671-2679
- Dubois, B. and Esculier, J.F. (2020). Soft-tissue injuries simply need PEACE and LOVE
- Al Attar, W.S.A., Soomro, N., Sinclair, P.J., Pappas, E. and Sanders, R.H. (2017). Effect of injury prevention programs that include the Nordic hamstring exercise on hamstring injury rates in soccer players: a systematic review and meta-analysis. Sports Medicine, 47(5), 907-916.
- Marín T, Centro F, Profesional M, Mercedes L, Hospital SM, Vasiliadis AV, et al. Surgical Treatment of Distal Hamstring Tendon Injuries Yield a Higher Return-To-Sports Rate: A Systematic Review. 2024 -05-15.
Other Conditions in
Hips & Pelvis, Upper Legs, Knees
Sacroiliac Joint Dysfunction
Pain originating from the sacroiliac joint at the base of your back where the spine joins the pelvis.
Proximal Hamstring Tendinopathy
Pain and weakness under the buttock or the back of your upper thigh caused by tendon issues.
Pelvic Girdle Pain
Typically seen in pregnancy causing pain, instability and limitation of mobility and functioning of the pelvic joints.
Pelvic Floor Dysfunction
The inability to effectively control the muscles of your pelvic floor, leading to issues with continence and pain.
Lumbar Disc Injury
Lumbar discs sit between each of the bones of the spine. Problems can occur when these discs become irritated.
Low Back Pain and Sciatica
Sciatica is a symptom describing pain and/or pins and needles down the back of the leg.
Iliotibial Band Syndrome
Presents as pain on the outside of the knee, normally occurring because of overload due to prolonged or repeated bouts of exercise.
Hip Replacement Surgery
Replacement of the hip ball and socket joint, typically as a result of severe osteoarthritis or trauma.
Hip Osteoarthritis
Common age-related changes to the structure of the hip joint may be associated with pain, stiffness and loss of function.
Greater Trochanteric Pain Syndrome
A condition affecting the tendons that insert into outside of the hip. A common cause of pain felt around the hip and pelvis.
Femoroacetabular Impingement
A condition that results in pain in the groin, hip and down the front of the thigh.
Femoral Nerve Radiculopathy
This is where the nerve that supplies the front of the leg is irritated and causes pain/numbess.
Benign Joint Hypermobility Syndrome
Common age related changes to the structure of the knee joint which may be associated with pain, stiffness and loss of function.
Adolescent Hip Dysplasia
A result of an abnormality of the hip joint anatomy resulting in pain in the hip with occasional instability.
Adductor-Related Groin Pain
Localised discomfort to the inner upper thigh and groin.