Addressing Hamstring Injuries with Physical Therapy
Hamstring injuries are common in activities that involve high-speed running, jumping, kicking, or explosive lower extremity movements combined with rapid changes in direction. A hamstring injury involves a strain or tear of one of the three hamstring muscles, causing pain, swelling, and difficulty walking and running. Physical therapy plays a critical role in helping athletes recover after a hamstring injury, return to sport safely, and regain function, mobility, and strength in the hamstring muscle complex through a targeted therapeutic exercise, functional training, and return to sport program.
Hamstring Muscle Anatomy
The hamstrings are made up of three muscles that extend along the back of the thigh, connecting the pelvis to the leg. The three muscles are the semitendinosus, the semimembranosus, and the biceps femoris muscles. The hamstring muscles allow you to flex, bend, extend, and stretch your leg and are used when running, climbing, sprinting, lunging, and jumping.
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How Hamstring Injuries Occur
Hamstring injuries are common in activities that involve high-speed running, jumping, kicking, or explosive lower extremity movements combined with rapid changes in direction. Sports like track and field, soccer, football, and rugby that involve such intense lower limb activity have the highest frequency of hamstring injuries. While the biceps femoris is the most commonly injured hamstring muscle, injury can occur to the other hamstring muscles as well. An athlete who previously injured their hamstring muscles has a 2 to 6 times higher rate of injury recurrence.
There are three gradations of a hamstring strain, based on the severity of the injury. A grade 1 strain is a mild strain involving minimal tearing, slight pain when the muscle is stretched or activated, and minimal strength loss. A grade 2 strain involves moderate tearing of the muscle fibers but the muscle remains intact with increased localized pain, stiffness, weakness, and possible bruising. The athlete may also experience limitations in their ability to walk, particularly 24-48 hours after injury. A grade 3 strain is severe, involving a complete tear of the muscle, widespread swelling and bleeding, a possible palpable mass of muscle tissues at the tear site, and extreme difficulty walking.
Common symptoms of a hamstring injury include:
Sudden, sharp pain at the back of the thigh or buttocks at time of injury
Feeling of a pop or tearing of the muscle, particularly for a grade 3 strain
Bruising and swelling at site of injury hours or days after injury
Tenderness to touch in the affected area
A significant decrease in strength and flexibility of the muscle group
Inability to sit comfortably, lift the leg when lying down or straightening the knee
Difficulty walking or running
A hamstring injury can also be caused by muscle imbalances, an inadequate warm-up before activity, or from overuse and fatigue of the hamstring muscle group. If there is an imbalance between the strength and flexibility of the hamstring muscles and the quadricep muscles, this can increase the risk of a hamstring injury. If the quadriceps are stronger or tighter than the hamstrings, this can create an imbalance that places more strain on the hamstrings during movement.
If muscles are not properly warmed up before intense activity, they are less flexible and more prone to muscle strains and injury. A thorough warm-up helps increase blood flow to the muscles, raises muscle temperature, and improves flexibility, all of which reduces injury risk. If an athlete is repeatedly engaging in activities that involve rapid or excessive stretching of the hamstrings, like sprinting or jumping, this can lead to overuse and fatigue of the hamstring muscles, meaning the muscles are less able to withstand stress and become more susceptible to injury.
Physical Therapy for Hamstring Injuries
Physical therapy plays a critical role in helping athletes recover after a hamstring injury, return to sport safely, and regain function, mobility, and strength in the hamstring muscle complex. Initially, the physical therapist conducts an evaluation that involves an injury and health history, palpating the hamstring muscle and surrounding tissue, measuring range of motion and flexibility in the knee and hip, taking strength measurements of the hamstrings and functional mobility observations, and guiding the patient through balance and proprioception tests. Based on the evaluation, the therapist designs a personalized rehabilitation program for the athlete to restore normal flexibility, range of motion, and strength in the hamstrings, control pain and swelling, and help the athlete return to optimal function for a safe return to sport.
Physical therapy treatment for a hamstring injury can include:
Pain management using ice to control swelling and decrease pain, heat to relax hamstring muscles and improve tissue extensibility prior to stretching, ultrasound using deep heat to improve circulation, and electrical stimulation to help improve hamstring muscle contraction
Manual therapy involving gentle mobilizations of the knee and hip muscles and joint to improve motion, flexibility, and strength
Targeted hamstring stretching, involving both static and dynamic to improve hamstring function and remodel healing scar tissue.
Hip and core strengthening exercises targeting the spine, hip, and pelvic muscles. A strong core and hip muscle complex takes stress off the lower leg and supports proper alignment of the legs during movement.
Agility drills involving hopping and jumping. The therapist can help the athlete to jump and land properly to protect the hamstrings.
Balance and proprioception exercises: These exercises work to ensure muscles are working properly to keep hips, knees, and ankles in proper position when walking, running, and jumping.
Lower extremity strengthening exercises: Strengthening exercises targeting the quadriceps and hamstrings are essential to address any muscle imbalances. Eccentric strengthening is a key aspect of hamstring rehabilitation and involves contracting the muscle while it is lengthening. The Nordic hamstring exercise is an eccentric loading exercise has been shown to decrease the incidence of hamstring strains in elite athletes. It produces the highest activation levels in all three of the hamstring muscles and is effective in building hamstring strength safely.
Gait training: The therapist helps the athlete to relearn correct movement patterns and walking stride post-injury as well as improve balance and coordination and prevent compensatory movements due to injury.
Functional training can involve sport-specific drills and a progressive return to running program to prepare the athlete for the demands of their sport and to ensure that the athlete has regained full function and strength in the hamstrings before returning to competition.
Research studies have shown that an effective hamstring injury rehabilitation program should include stretching, stability training, eccentric strengthening, functional movements (sport-specific, agility, high-speed running), and the Nordic hamstring exercise. One review noted a lower risk of hamstring strain re-injury when athletes performed progressive agility and stabilization exercises after injury, compared to only doing static stretching and strengthening exercises. Those athletes who engaged in agility and trunk stabilization exercises had no reinjuries within 16 days after return to play and only 1 reinjury within a year. The group of athletes who did the static stretching and isolated progressive strengthening exercises had 6 reinjuries within the first 16 days and 7 reinjuries within a year.
A hamstring strain injury is a common sports-related injury to the muscles located in the back of the thigh. If you are suffering from a hamstring strain injury, call our physical therapists! Our physical therapists are trained to rehabilitate you gradually and safely to return you to sport at your prior functioning level and minimize the risk of a recurrent hamstring injury.
