In this blog you will learn signs, symptoms, causes, and the best way to recover from a hamstring injury.

Hamstring injury is related to sport injuries in activities that involved kicking, sprinting, and fast movements. For instance, soccer accounts for the most frequent hamstring injury, following with football, track, field, water skiing, and rugby.

What is the Hamstring Located?

The hamstring is a group of three muscles biceps femoris, semitendinosus, and semimembranosus, located in the back of the thigh. In addition, the hamstring muscles originate in the lower buttock or ischial tuberosity and goes all way down behind the knee. Therefore, the hamstring muscles are responsible for the hip and knee movement during walking, bending the knees, and squatting.

Signs and Symptoms of a Hamstring Injury

Signs and symptoms are related to the amount of fibers injured and is classified in 4 degrees, according to the British Athletic Muscle Injury Classification.

Symptoms of Anxiety

  • Grade 0 injuries present with muscle soreness after exercise, normal range of motion and strength.
  • Grade 1 injuries are small tears of 10% of the muscle. Pain is reported during or after exercise, the range of motion and strength are normal.
  • Grade 2 injuries are moderate tears of the muscle between 10% and 50%. Pain is present with movement or during activity. Range of motion, and muscle strength are slightly reduced.
  • Grade 3 injuries are extensive tears to the muscle greater than 50%. The injured person presents with sudden onset of pain, difficulty with putting weight on the affected leg, and the athlete may fall. Range of motion, strength, and gait ability are noticeable reduced.
  • Grade 4 injuries are complete tears or avulsion of the tendon (100% tendon or muscle disrupted). The injured person presents sudden pain, is unable to walk or put weight on affected leg. Therefore, a palpable gap is noticed under palpation. Avulsion of the hamstring tends to occur due to forced hip flexion with knee extended such as in water skier sports.

Sign and symptoms according to the degree of injury

  • Hamstring feels tight with hip flexion and knee extended (grade 1 and 2).
  • Unable to extend the knee and heel strike with walking, and hematoma appears after few days of injury (grade 3).
  • Unable to put weight on affected leg while walking and crutches are required (grade 4).

Most Common Sign and Symptoms of Hamstring Injury

  • Sudden pain in the back of the thigh.
  • Audible click.
  • Inability to walk.
  • Difficulty with moving the leg back with the knee bent.
  • Hematoma in the back of the thigh adjacent to the lower buttock.
  • Discomfort in sitting.
  • Posterior thigh feels stiff and tight.
  • Increase of pain with stair climbing, squatting, or sit-stand.
  • Difficulty with straighten the hip and knee.
  • Increase pain after prolonged sitting.
  • Tight hip flexor.

Causes and Risk Factors

  • History of recurrent hamstring injury.
  • Start playing to soon before the hamstring is completely healed.
  • Overtraining may produce microtear to the hamstring.
  • Tight quadriceps
  • Muscle Imbalance between quadriceps and hamstring.
  • Hamstring muscle fatigue after training, inhibiting the person’s ability to stretch.
  • Lack of coordination in the lower back and pelvis while running, overstretching the hamstring in the late swing phase of gait.
  • Forward trunk posture while running, increases the anterior pelvic tilt, and the hip flexor over stretch the hamstring during the stance phase of running.
  • Prolonged hip flexion with knee extended (very common in dancers, skiers, yogis, and gymnasts).
  • Pain at the terminal swing phase of gait.
  • Ambulate with short steps.
  • Decrease weight bearing on affected leg.

Recovery Time

It depends on the location of the injury and the type of sport. Hamstring strain that is closer to the gluteal tends to take a longer recovery time. Runners require an average of 16 weeks for full recovery, and dancers up to 50 weeks. 

What Physical Therapy Can Do?

Physical therapy can reduce the pain without using pain medications, improve range of motion, enhance strength, and gait without the risk of re-injury, and speed up the healing process in a safe way. In addition, the physical therapist may refer the patient to an orthopedic surgeon if a fracture is suspected.

Physical Therapy designs a customized rehabilitation program after performing a detail assessment that includes:

Range of Motion. 

Mobility may be restricted in the lower leg if inflammation is present.

Muscle Strength. 

Weak hip extension with knee flexed

Special Test

  • Straight leg raise to assess thigh flexibility.
  • Slump test to assess sciatica nerve quality and rule out radicular symptoms

Strengthening exercises

  • Start strengthening once pain and flexibility have improved.
  • Plan of care and Precautions
  • Avoid aggressive stretching or aggressive workouts to prevent hamstring reinjuries.
  • Be patient and respect the recovery time.
  • Do not rush to go back to work outs and reinjury the hamstring.
  • Be aware
  • Scar tissue in the tendon may compress the sciatic nerve producing dropped foot and sciatica symptoms.

How Physical Therapy Can Help?

The goal of physical therapy is helping the patient to  reduce pain, speed up the healing time, improve gait, educate the patient about what to do safely, and prepare the patient to go back to practice at the right time.

Physical Therapy Treatment

Hamstring Protocol

  • Avoid non-steroidal anti-inflammatory drugs (NSAIDs) and steroids due to lack of benefits and negative effects on muscle function, following recovery.
  • Ice packs to reduce pain and inflammation, including rest, compression, and elevation (RICE) two to three times a day during acute phase.
  • Ice packs after therapeutic exercises as needed after the acute phase.
  • Prevent aggressive stretches and focus on pain free activities.
  • Hot packs before stretching in the post-acute phase.
  • Gentle stretches to improve knee range of motion. Muscles to be stretched are hip flexors, glutes, Quadriceps, hamstrings, and calves.

Stretches progression

  • Start with static stretches and move to dynamic stretches when pain is gone during walking.

Stretches: 

  • Straight leg kick dynamic hamstring stretches
  • Static lunges
  • Four times a day

0-4 Weeks-Therapeutic exercises

  • Warm up with stationary bike to improve leg mobility
  • Trunk control and stabilization exercises as follow:
  • Front plank on forearms and toes.
  • Hip bridge.
  • Side plank on forearm and feet.
  • Hold each exercise 10 seconds, repeat 5-10 times, daily.
  • Agility progression 30 to 60 seconds each.
  • March in place
  • Boxer shuffle
  • Side stepping
  • Grapevine stepping
  • Balance

Therapeutic Exercise (2-8 week)

  • Trunk control and stabilization exercises as follow:
  • Side planks with trunk rotation
  • Pushups with trunk rotations
  • Low to high and high to low wood chops
  • Agility progression 60 to 90 seconds each.
  • Fast marching
  • Boxer shuffle
  • Side stepping
  • Grapevine stepping
  • Windmill touches
  • Gluts Bridge walkout
  • Balance

Standing on foot on dyna-disc or uneven surface with eyes open and closed for 60 seconds to 2 minutes.

  • Eccentric Exercises
  • Hip bridge with heel slides both heels at the same time.
  • Modified single leg bridge (with Swiss ball, or chair).
  • Single leg dead lift with foam roller
  • The glider hamstring

Therapeutic exercises (4 to 8 week)

  • Trunk Stabilization and agility exercises progression
  • Lunge walk with trunk rotation
  • Side shuffle
  • Single leg dead lift
  • Repetitive hops to improve speed
  • Forward and backward sprints
  • A Skips
  • Monster Walks

Eccentric exercise progression

  • Forward and backward walkout and jog outs with resistance band at waist level.
  • Forward and backward fast feet with resistance band at ankle level.
  • Modified Nordic curls holding resistance cables with hands, with tall kneeling, slowly lower trunk forward without bending hip, and keeping core engaged.

Improve Gait Ability

  • Ambulate with short step length in the acute phase, and crutch if necessary.
  • Normalize gait when the pain is gone.
  • Stay away from jogging and running if pain is still present.

How Do you know you are ready to go back to play sports?

  • Normalized gait without pain
  • No pain in the injury site
  • No pain with stretching
  • Able to jog without pain

Please contact your doctor if pain persist at night or at rest.

If you are dealing with balance issues, or you want to be more active and you don’t know how to start, call now to find out how Physical Therapy can help you recover faster, move easier, and freer:

Call Dr. Alexandra Chaux:  805-203-9940

The information in this blog is for educational and informational purpose only, its content is provided based upon evidence-based physical therapy research, knowledge, and experience as a Doctor of Physical Therapy (DPT).