Physical Therapist's Guide to Hamstring Injuries
A hamstring strain injury occurs when 1 or more of the 3 hamstring muscles or tendons (at the back of the thigh) is torn, either partially or completely. It is one of the most common injuries of the lower body, particularly affecting athletes participating in sports involving high-speed running, such as football, soccer, or track. After tearing a hamstring muscle, a person is 2 to 6 times more likely to suffer a subsequent injury. In most cases, hamstring strain injuries are successfully managed with physical therapy.
What are Hamstring Injuries?
The hamstring muscle group includes 3 muscles along the back of the thigh that connect the pelvis to the leg. They are the primary muscle group responsible for straightening (extending) the hip and bending (flexing) the knee. The 3 muscles are:
- Biceps femoris
The anatomy of muscles includes the muscle “belly,” the portion that contracts or relaxes to move a limb, and the tendon, the portion that connects the muscle belly to the bone. Hamstring strain injuries occur when there is damage to the muscle belly caused by excessive force being generated while the muscle is being stretched. This typically happens during high-speed running, with sudden starts or changes in direction, or when the muscle is overstretched by activities such as sprinting, hurdling, kicking, or heavy lifting.
Risk factors for hamstring strain injuries include:
- A history of prior hamstring strain injury
- Hamstring weakness
- Increasing age
- Poor flexibility of the quadriceps and hip flexors (muscle tightness)
- Inadequate warm up before activity
- Muscle fatigue
How Does it Feel?
When a person experiences a hamstring strain injury, a sudden onset of pain is felt in the back of the thigh. It happens very quickly and causes the individual to stop performing an activity. The symptoms caused by a mild injury may only last for a few days; symptoms of a more severe injury can last for weeks. Common symptoms include:
- A sudden, sharp pain in the back of the thigh or in the buttocks
- A feeling of a "pop" or tearing in the muscle
- Bruising within hours or days after the injury
- Tenderness to touch in the affected area
- Difficulty sitting comfortably, lifting the leg when lying down, or straightening the knee
- Difficulty walking or running, resulting in a limp
How Is It Diagnosed?
Diagnosis of a hamstring strain injury starts with a thorough understanding of your health history and the cause of the injury. The questions your physical therapist may ask include:
- What were you doing when you first felt the pain, and did you feel a “pop"?
- Where do you feel the pain now?
- Did you notice any bruising after the injury?
- What were you not able to do immediately following the injury, and how have you been functioning since the injury (eg, walking, sleeping, lifting your leg)?
- Have you had a similar injury before?
Your physical therapist will also perform a clinical evaluation, including some of the following tests and measures to determine the nature of your injury:
- Observation, to note any discoloration or bruising
- Pain assessment, to identify your current pain level, and the activities that make your pain better or worse
- Palpation (gently pressing with the fingers), to pinpoint the location and size of the tender area through touch, which will help determine the severity of the injury
- Range-of-motion test, to compare the motion of your injured leg with your healthy leg
- Muscle-strength test, to determine the strength of the hamstring muscles when bending or straightening your knee and hip
- Gait analysis, to note any limping or changes in how you are walking
Typically, hamstring strain injuries are classified as Grade I, II, or III depending on the severity of the injury:
- Grade I: Mild strain with minimal tearing; usually feels like a pulled or cramping muscle.
- Grade II: Moderate strain with partial tearing; may cause a stinging or burning sensation at the back of the thigh.
- Grade III: A severe, complete muscle tear; may result in a “lump” on the back of the thigh where the muscle has torn.
If your physical therapist suspects a severe injury (Grade III), you will likely be referred to an orthopedic physician for medical diagnostic imaging, such as an X-ray or MRI, to evaluate the extent of the injury. In the event of a fracture of the ischial tuberosity (the “sit-bone,” part of the pelvis) and/or a complete rupture of the muscle, surgery may be recommended.
How Can a Physical Therapist Help?
Immediately after experiencing a hamstring strain injury, seek help from a physical therapist. Prior to your physical therapy session, you can:
- Rest the injured area by avoiding aggravating activities, such as walking or working out. If you are having notable difficulty walking, you may need crutches. Do not overstress the injured area.
- Apply ice to the injured area 3 to 4 times a day for 15 to 20 minutes (with a towel placed between your skin and the ice).
Your physical therapist will design an individualized treatment program specific to the exact nature of your injury and your goals. Your treatment may include:
Manual therapy. Physical therapists are trained in manual (hands-on) therapy to gently move and manipulate muscles and joints to improve motion, flexibility, and strength. Your physical therapist may gently massage and move the affected area to encourage healing. These techniques can target areas that are difficult to treat on your own.
Range-of-motion exercises. Although it is common for your hamstring muscles to feel stiff after an injury, it is important not to stretch these muscles early in the recovery process. Your physical therapist will indicate when it is safe and appropriate to begin gentle flexibility exercises, and will guide you through how to do them in the clinic and at home.
Muscle strengthening exercises. Hamstring strengthening will be an essential part of your rehabilitation program. Your physical therapist will compare the strength of the muscle groups in each leg, and prescribe and teach you specific exercises to target areas of weakness.
Functional training. As you regain the strength in your hamstrings, your movement quality will need to be assessed so you no longer put excessive stress on the previously injured area. Your physical therapist will develop a functional training program for the hamstring muscle group, with a gradual progression back to more demanding activities.
In the event that the severity of your hamstring strain injury requires surgical treatment, a physical therapist will guide your postoperative rehabilitation. Your physical therapist will communicate with your surgeon to ensure complete and consistent postoperative care.
Can this Injury or Condition be Prevented?
You can decrease your risk of a hamstring strain injury in the following ways:
- Always warm up before participating in athletic activities.
- Avoid starting a new activity too quickly; gradually increase the frequency and intensity of the activity so that your body may adapt to the new movement patterns.
- Maintain the strength of your hamstring muscles.
- Listen to your body after you work out (and stretch, apply ice, rest as needed) prior to engaging in the same routine again.
Real Life Experiences
John is a 28-year-old former collegiate football player. Since graduating from college, his workout routine typically involves several days of weightlifting and the occasional pick-up basketball game. John is an engineer working 40 hours a week, primarily seated at his desk. Recently, work has been very busy, as his company has been assigned a new project. John hasn't made it to the gym in several weeks.
One Friday afternoon as he is leaving the office, John runs into a colleague on his way to the gym for a game of pick-up basketball. John decides to join him. When he gets to the gym, the game has already started, so he has to rush and doesn't have time to warm up.
During the first game, John runs down the court on a fast break and quickly accelerates to get to the open basket. As he is running, he feels a sudden, sharp pain in the back of his thigh and has to limp off the court. Even after 20 minutes of resting and gentle movement, John is unable to walk normally without pain. John decides to head home for the night and put some ice on his hamstring.
When John wakes up the next morning, the back of his thigh is very sore. He is still unable to walk properly, and sees a bruise forming on the painful area. He applies more ice to his hamstring and contacts his physical therapist.
During his initial evaluation, John's physical therapist assesses his signs and symptoms and indicates that he has suffered a grade II hamstring strain injury. That day, John is given a compression wrap for his thigh, is instructed to avoid stretching exercises for now, and educated on modifying his activity level. He discusses his goals with his physical therapist, indicating that, following his recovery, he would like to be more consistent with his workout routine and participate in a recreational basketball league.
Over the next 4 weeks as his pain improves, John is guided by his physical therapist through a progressive exercise program to strengthen his hamstrings and improve his body control when running, jumping, and cutting. His physical therapist also uses manual therapy techniques to improve the mobility and flexibility of his hamstring muscle. When he is reevaluated, his physical therapist is happy with his progress and offers recommendations for a gradual rebuilding of his workout routine.
A month later, John calls his physical therapist and states that he is feeling great! He is going to the gym 3 times a week, using the physical therapist's recommendations for exercise as his guide. John says he has started playing pick-up basketball games again without any trouble, and he's planning to sign up for the basketball league.
This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and experience to treat hamstring strain injuries. However, you may want to consider:
- A physical therapist who is experienced in treating people with hamstring strain injuries. Some physical therapists have a practice with an orthopedic or sports rehabilitation focus.
- A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in orthopedics or sports physical therapy. This physical therapist has advanced knowledge, experience, and skills that may apply to your condition.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association, to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you're looking for a physical therapist (or any other health care provider):
- Get recommendations from family and friends or from other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people with hamstring strain injuries.
- During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and report activities that make your symptoms worse.
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.
The following articles provide some of the best scientific evidence related to physical therapy treatment of hamstring strain injuries. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
Sherry MA, Johnston TS, Heiderscheit BC. Rehabilitation of acute hamstring strain injuries. Clin Sports Med. 2015;34(2):263–284.
Opar DA, Williams MD, Timmins RG, Hickey J, Duhig SJ, Shield AJ. Eccentric hamstring strength and hamstring injury risk in Australian footballers. Med Sci Sports Exerc. 2015;47(4):857–865.
Sanfilippo JL, Silder A, Sherry MA, Tuite MJ, Heiderscheit BC. Hamstring strength and morphology progression after return to sport from injury. Med Sci Sports Exerc. 2013;45(3):448–454.
Silder A, Sherry MA, Sanfilippo J, Tuite MJ, Hetzel SJ, Heiderscheit BC. Clinical and morphological changes following 2 rehabilitation programs for acute hamstring strain injuries: a randomized clinical trial. J Orthop Sports Phys Ther. 2013;43(5):284–299.
Opar DA, Williams MD, Shield AJ. Hamstring strain injuries: factors that lead to injury and re-injury. Sports Med. 2012;42(3):209–226.
Askling CM, Malliaropoulos N, Karlsson J. High-speed running type or stretching-type of hamstring injuries makes a difference to treatment and prognosis. Br J Sports Med. 2012;46(2):86–87.
Heiderscheit BC, Sherry MA, Silder A, Chumanov ES, Thelen DG. Hamstring strain injuries: recommendations for diagnosis, rehabilitation, and injury prevention. J Orthop Sports Phys Ther. 2010;40(2):67–81.
* PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.
Revised by Bryan Heiderscheit, PT, PhD. Authored by Laura Stanley, PT, DPT. She is a board-certified sports clinical specialist. Reviewed by the MoveForwardPT.com editorial board.
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