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Hamstring strain diagnosis and treatment

Runner holding her hamstring due to pain
Maryke Louw
Maryke Louw
Mar 4, 2021
In this article we take a look at what happens when you strain a hamstring, how to best diagnose it and what treatments are essential to the healing process.

Hamstring Anatomy

Your hamstrings are a group of 3 muscles that run down the back of your thigh. They all originate from tendons that attach to your sit-bone (ischial tuberosity). Two of them, the Semimembranosus and Semitendinosus, run along the inner part (medial) of the back of your thigh and attach around the inner part of the knee, onto the tibia. The Biceps Femoris actually has two “heads”. The long head originates from the sit bone while the short head originates from the femur. The two heads combine to form one muscle and its tendon attaches to the outside of your knee, onto the fibula.

Anatomy of the hamstring muscles

The hamstring muscles consist mainly of 3 parts namely muscle cells, fascia, and tendons. The muscle belly is made up mostly of muscle cells. These muscle cells are grouped together in bundles that are held together by a thin layer of fascia (that white sinewy stuff in meat). The bundles are grouped together to form the muscle. The muscle itself is also surrounded by a layer of fascia.

Muscles can’t attach directly to bones. The muscle belly attaches onto a tendon which then attaches onto the bones. The attachment between the tendon and muscle belly isn’t a clean-cut line; The two gradually merge into one another which makes it a nice strong attachment.

There are also nerves, arteries, and veins that run in and around the muscles.

Skeletal muscle structure

What’s the difference between a pulled hamstring, a hamstring strain, and a hamstring tear?

There is no difference. These are just different names for the same injury and all of them involve some tearing of the muscle tissue. In practice I find that people often refer to more minor hamstring tears as a pulled or strained hamstring while they tend to only talk about a torn hamstring when they feel that it is a more serious injury.

There is no difference

Pulled hamstring, a hamstring strain, and a hamstring tear are just different names for the same injury and all of them involve some tearing of the muscle tissue

What happens when you pull/strain a hamstring?

When you pull a hamstring, you tear some of the muscle fibers. Depending on where in the muscle the injury occurs, you may also injure part of the fascia or tendon. Hamstring strains that happen closer to your sit-bone or to the knee (upper and lower quarter of the thigh) are more likely to involve the tendons. If your injury is in the middle of your thigh, it is likely that you’ve mainly injured the muscle tissue. Why is this important? Injuries that involve the tendons can take several months to heal; Ones that only affect the muscle fibers heal much more quickly.

It is quite common to also tear some blood vessels which is why you may have a bruise.

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How do I know if I’ve torn a hamstring?

There are other conditions (like sciatica, back pain, hamstring tendinopathy etc.) that can cause pain in the same area. That’s why you shouldn’t just assume that pain you feel in the back of your thigh is a pulled hamstring. Here are the main criteria to decide whether you pulled your hamstring:

Decision criteria

How do I know if I’ve torn a hamstring?
Mechanism of injury
You can only strain a hamstring during activity – most commonly through running, jumping, or some other quick movement. You usually feel a sudden sharp pain in the back of your thigh and it often forces you to stop running. If your hamstring pain started because you sat for too long or you can’t link it to a specific activity, it is likely not a hamstring strain.
Where you feel the pain
You feel the pain from a hamstring strain in the back of your thigh, somewhere between its origin on the sit-bone and it’s attachment around the knee. It doesn’t usually refer pain into the buttock or below the level of the knee.
How it feels
The symptoms or pain that you experience after you’ve strained your hamstring may vary according to the severity of your injury. In mild cases, you may still be able to walk or even jog and move your leg without much pain or restriction. In more severe cases, even walking around the house may be difficult and it can be painful to straighten your leg fully. Stretching the hamstrings are usually painful.
Bruising and swelling
You may notice some bruising in the back of your thigh but this is not always present. The bruising can often take a few days to show and may be lower than where you feel your pain. This is because gravity makes the dead blood sink towards the floor. Mild hamstring strains usually don’t cause much swelling.

Do you need a scan to diagnose a hamstring strain?

No, in most cases the diagnosis can be made just going through the history of how your injury happened, where your symptoms are and by getting you to do some simple test movements to see how sensitive the hamstrings are when being stretched or contracted.

How does a hamstring tear heal?

Our bodies heal acute injuries, like muscle tears, through a 3 step healing process. It’s important that the treatments that you apply or rehab exercises you do, should be at the right level for the stage of healing, otherwise you can make your injury worse. Have a look at the hamstring strain rehab plan in the Exakt Health App – it’s designed to help you monitor your hamstring’s recovery and progress your exercises at the right time and with the right intensity.

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  • STEP 1: When you tear your hamstring, your body first has to get rid of the damaged cells. This period is known as the inflammatory phase because the body uses inflammation cells to break down and absorb the damaged tissue. So inflammation is a very important part of your healing response. This is also why it’s not a good idea to take anti-inflammatory drugs (like ibuprofen) for a sports injury. It takes between 3 to 5 days for your body to complete this process.
  • STEP 2: The body then has to form new cells to replace the ones that you’ve damaged. This step is called the proliferation phase and can take up to 21 days. However, more serious injuries may take a bit longer.
  • STEP 3: The new cells that form are not yet strong or aligned in the optimal way. The final step of healing is called the remodelling phase and can last anything from 4 weeks to more than 12 weeks for a more severe strain. During this phase your body requires carefully graded strength training exercises to stimulate the new muscle fibres to grow stronger. The strength training program has to be progressed as your hamstring recovers and grows stronger. It has to eventually simulate the movements and muscle contractions that you need for your sport. If you don’t follow a progressive program that properly prepares your muscle for your sport, you’ll risk reinjuring your hamstring.

How long does it take to recover from a pulled or torn hamstring?

Your recovery time will depend on the extent of your injury (how many fibers did you tear) as well as what part of the hamstring you’ve torn. Minor hamstring pulls that only damage a few muscle fibers take about 4 weeks to fully recover. More significant hamstring tears can take 12 weeks. Tendons take much longer to heal. If you’ve injured your tendon when you pulled your hamstring, your recovery time may take anything from 3 months and longer.

What treatments work best for hamstring strain?

You don’t need any fancy treatments for your hamstring strain to heal. Even popular treatments like massage, dry needling and ultrasound do very little to speed up the healing process. The body is extremely good at healing itself if you provide it with what it needs, when it needs it.

What your hamstrings need to recover is the right combination of rest and exercise and this combination will vary depending on what part of the healing process your injury is in. The treatment for hamstring strains can be split into 3 main stages according to the stage of healing:

What you need to recover

What your hamstrings need to recover is the right combination of rest and exercise and this combination will vary depending on what part of the healing process your injury is in.
  • STAGE 1: During the inflammatory phase the focus is on protecting the injury and limiting the extent of the damage. You want to allow the injury to settle and for the body to get rid of all the damaged tissue. This is done through following the PRICE regime (protect, rest, ice, compression, elevation).
  • STAGE 2: As your healing progresses and the body starts forming new cells, the focus starts to shift away from rest and towards carefully loading the injured muscle through a progressive rehab programme. Remember, it is only through strength training and movement that the cells can grow stronger
  • STAGE 3: The final stage in the treatment plan should focus on getting the hamstring ready to contract and work in the same way as it would have to work when you do your normal training. This is known as sport specific training and it usually involves running drills and exercises that mimic how you move in your sport.

We’ll discuss all of these components in a lot more detail in future blog posts.

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Maryke Louw
Maryke Louw
Maryke Louw is the Medical Lead at Exakt Health and a chartered physiotherapist. She has a BSc in Physiotherapy and an MSc in Sports Injury Management and has been working with athletes of all abilities and ages for more than 20 years. Maryke combines her extensive knowledge of sports injury treatment with the latest research to provide effective injury treatment and prevention advice.
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More for your hamstring strain
  • Man holding his pulled hamstring due to pain
    Maryke Louw
    Maryke Louw
    Feb 26, 2021