Understanding Hamstring Injuries and Recovery: A Physiotherapy Perspective by Bill Kelly APA Physiotherapist
Hamstring injuries are one of the most common musculoskeletal injuries, particularly among athletes involved in sports requiring sprinting, jumping, and quick changes in direction. Whether you're a professional athlete or someone who enjoys recreational activities, understanding the causes, symptoms, and effective recovery strategies for hamstring injuries can help you return to your activities faster and with reduced risk of reinjury.
What is a Hamstring Injury?
The hamstring is a group of three muscles located at the back of your thigh: the semimembranosus, the semitendinosus, , and biceps femoris. These muscles are responsible for bending the knee and extending the hip, playing a critical role in walking, running, and jumping.
Hamstring injuries typically occur when the muscle is overstretched or subjected to an excessive load during activities that involve running or sudden movements. The injury may range from a mild strain, where the muscle fibres are slightly stretched, to a severe tear or rupture of the muscle.
Types of Hamstring Injuries
Grade 1 (Mild): Slight stretching or tearing of a few muscle fibres. Recovery is usually quick, often within a few weeks.
Grade 2 (Moderate): Partial tear with more significant discomfort, swelling, and loss of strength. Recovery may take 4-6 weeks.
Grade 3 (Severe): Complete rupture of the muscle fibres, often requiring surgery or a lengthy rehabilitation period. Recovery can take several months.
Causes of Hamstring Injuries
Hamstring injuries are commonly caused by:
Sudden acceleration or deceleration: Sports like sprinting, football, soccer, and basketball often involve rapid speed changes, putting strain on the hamstring muscles.
Overuse or fatigue: Repetitive motions or fatigue from prolonged activity can lead to muscle failure.
Weakness or imbalances: A disproportionate strength ratio between the quadriceps (front thigh muscles) and hamstrings can increase the risk of injury.
Poor flexibility: Tight hamstrings are more prone to injury during high-intensity movements.
Symptoms of a Hamstring Injury
The primary symptoms of a hamstring injury include:
Sudden sharp pain at the back of the thigh, often during or immediately after physical activity.
Difficulty walking, running, or fully extending the leg.
Swelling and bruising may develop within a few hours, especially in more severe injuries.
Muscle weakness and stiffness.
Diagnosing Hamstring Injuries
A physiotherapist will typically diagnose a hamstring injury based on a physical examination and the patient's history. In some cases, imaging such as ultrasound or MRI scans may be used to assess the severity of the tear and rule out other conditions.
Rehabilitation and Recovery
Recovery from a hamstring injury can take anywhere from a few weeks to several months, depending on the severity. However, following the right treatment plan can significantly speed up the recovery process and reduce the risk of future injuries. Here are the key stages of recovery:
1. Initial Management (Protection, Elevation, Avoid anti-inflammatories, Compression, Education and Load, Optimism, Vascularisation, and Exercise) (Dubois, 2020)
P for protect
· Unload or restrict movement for 1–3 days to minimise bleeding, prevent distension of injured fibres and reduce the risk of aggravating the injury. Rest should be minimised as prolonged rest can compromise tissue strength and quality. Pain signals should guide the cessation of protection.
E for elevate
· Elevate the limb higher than the heart to promote interstitial fluid flow out of tissues. Despite weak evidence supporting its use, elevation shows a low risk-to-benefit ratio.
A for avoid anti-inflammatory modalities
· The various phases of inflammation help repair damaged soft tissues. Thus, inhibiting inflammation using medications may negatively affect long-term tissue healing, especially when higher dosages are used. Standard of care for soft-tissue injuries should not include anti-inflammatory medications.
· We also question the use of cryotherapy. Despite widespread use among clinicians and the population, there is no high-quality evidence on the efficacy of ice for treating soft-tissue injuries. Even if mostly analgesic, ice could potentially disrupt inflammation, angiogenesis and revascularisation, delay neutrophil and macrophage infiltration as well as increase immature myofibers. This may lead to impaired tissue repair and redundant collagen synthesis.
Note: Some physiotherapists may advise icing the hamstring post injury
C for compress
· External mechanical pressure using taping or bandages helps limit intra-articular oedema and tissue haemorrhage. Despite conflicting studies, compression after an ankle sprain seems to reduce swelling and improve quality of life.
E for educate
· Therapists should educate patients on the benefits of an active approach to recovery. Passive modalities, such as electrotherapy, manual therapy or acupuncture, early after injury have insignificant effects on pain and function compared with an active approach, and may even be counterproductive in the long term. Indeed, nurturing an external locus of control or the ‘need to be fixed’ can lead to therapy-dependent behaviour. Better education on the condition and load management will help avoid overtreatment. This in turn reduces the likelihood of unnecessary injections or surgery, and supports a reduction in the cost of healthcare (eg, due to disability compensation associated with low back pain). In an era of hi-tech therapeutic options, we strongly advocate for setting realistic expectations with patients about recovery times instead of chasing the ‘magic cure’ approach.
· After the first days have passed, soft tissues need LOVE.
L for load
· An active approach with movement and exercise benefits most patients with musculoskeletal disorders. Mechanical stress should be added early and normal activities resumed as soon as symptoms allow. Optimal loading without exacerbating pain promotes repair, remodelling and builds tissue tolerance and the capacity of tendons, muscles and ligaments through mechanotransduction.
O for optimism
· Optimistic patient expectations are associated with better outcomes and prognosis. Psychological factors such as catastrophisation, depression and fear can represent barriers to recovery. Beliefs and emotions are thought to explain more of the variation in symptoms following an ankle sprain than the degree of pathophysiology.
V for vascularisation
· Cardiovascular activity represents a cornerstone in the management of musculoskeletal injuries. While research is needed on dosage, pain-free aerobic exercise should be started a few days after injury to boost motivation and increase blood flow to the injured structures. Early mobilisation and aerobic exercise improve physical function, supporting return to work and reduce the need for pain medication in individuals with musculoskeletal conditions.
E for exercise
· There is a strong level of evidence supporting the use of exercise for the treatment of ankle sprains and for reducing the prevalence of recurrent injuries. Exercises help to restore mobility, strength and proprioception early after injury. Pain should be avoided to ensure optimal repair during the subacute phase of recovery, and should be used as a guide for exercise progressions.
Ice: Apply ice to the injured area for 15-20 minutes every 2-3 hours to reduce swelling.
2. Pain Management and Soft Tissue Healing
Pain management is crucial in the early stages of rehabilitation. Non-steroidal anti-inflammatory drugs (NSAIDs) can be used under professional guidance to manage pain and inflammation.
3. Early Rehabilitation (Gentle Stretching and Strengthening)
Once the acute pain subsides, gentle stretching and strengthening exercises can be introduced. Physiotherapists may guide you through range-of-motion exercises, isometric contractions, and light stretching. Strengthening exercises will initially focus on the quadriceps and hip muscles to prevent imbalances while allowing the hamstring to heal.
4. Advanced Rehabilitation (Sport-Specific Training)
As the injury heals, more dynamic exercises are incorporated. These may include eccentric strengthening (lengthening of the muscle while under load), plyometrics (jumping exercises), and sport-specific drills to restore agility and power.
5. Return to Sport
A return-to-sport program should be gradual and should be monitored by a physiotherapist. Testing the muscle's strength, flexibility, and endurance is important to ensure the hamstring is ready for full participation.
Note: It’s important to avoid rushing the recovery process, as premature return to activity can lead to reinjury.
Prevention of Hamstring Injuries
While not all injuries are preventable, there are several steps athletes and active individuals can take to reduce the risk of hamstring injuries:
Strengthening: A balanced strength program focusing on both the hamstrings and quadriceps can prevent imbalances.
Flexibility: Regular stretching or yoga can help maintain muscle flexibility and prevent tightness.
Warm-Up and Cool-Down: Proper warm-up routines that involve dynamic stretches and a gradual increase in intensity can prepare the muscles for exertion. Likewise, cooling down after exercise with static stretches helps to prevent muscle stiffness.
Sports-Specific Training: Drills that mimic the actions of your sport, including sprinting, cutting, and decelerating, can prepare the hamstrings for the specific loads they will encounter.
Recovery Time and Statistics
According to a study published in the Journal of Orthopaedic & Sports Physical Therapy, hamstring injuries represent about 12-16% of all injuries in athletes (Graham et al., 2014). Furthermore, the recurrence rate for hamstring injuries is high, with up to 25% of individuals suffering a reinjury within the first year, often due to insufficient rehabilitation (Askling et al., 2007).
A study in The American Journal of Sports Medicine found that the average recovery time for grade 1 injuries is 2-4 weeks, while grade 2 injuries can take 4-8 weeks. Severe grade 3 injuries, which may require surgical intervention, can extend recovery time to 3-6 months (Lamb, 2020).
Recovery time varies:
Grade 1 injuries typically take 2-4 weeks to heal.
Grade 2 injuries may require 4-8 weeks for full recovery.
Grade 3 injuries, including complete tears, can take 3-6 months for full recovery, especially if surgery is needed.
Conclusion
Hamstring injuries can be debilitating, but with proper care, rehabilitation, and preventive measures, most individuals can make a full recovery and reduce the risk of future injuries. Working closely with a physiotherapist to design an individualized treatment plan is crucial for ensuring a safe and effective recovery process.
References:
Graham, S. M., Rigg, C. A., & Clarke, L. (2014). Hamstring injury in sport: A review of the current research. Journal of Orthopaedic & Sports Physical Therapy, 44(10), 745-753.
Askling, C. M., Tengvar, M., Saartok, T., & Thorstensson, A. (2007). Acute hamstring injuries in Swedish elite soccer players: The importance of rehabilitation for preventing reinjuries. American Journal of Sports Medicine, 35(3), 4-7.
Lamb, K. L. (2020). Hamstring injury prevention: Exploring the role of eccentric training. The American Journal of Sports Medicine, 48(12), 2900-2907.
Heiderscheit, B. C., Sherry, M. A., Silder, A., Chumanov, E. S., & Thelen, D. G. (2010). Hamstring strain injuries: Recommendations for diagnosis, rehabilitation, and injury prevention. Journal of Orthopaedic & Sports Physical Therapy, 40(2), 67-81.
Dubois, B., & Esculier, J. F. (2020). Soft-tissue injuries simply need PEACE and LOVE. British journal of sports medicine, 54(2), 72-73.