A hamstring injury can be agonizing. Think of athletes running a marathon or race, only to stop and clutch the back of their thigh. Not all hamstring injuries or tears are as obvious as this example. If there is pain at the back of your thigh when bending your knee, or you’re suspecting that you’ve torn your hamstring muscle, read this article.

A torn hamstring muscle is very common injury in  sports. Athletes put a lot of strain on hamstrings during high speed running, jumping and kicking. Cilliers & Swart offers hamstring treatment for injuries developed in an instant (single overload) or over time (repetitive muscle tearing).

Each person’s case is unique, and we want to address your specific needs. If you would like us to investigate or provide some insight, we invite you to contact us by clicking the link below.

Three muscles make up your hamstring and are grouped in the following two groups:

• One group on the inside of your thigh (made up of two muscles called the Semimembranosus and Semitendinosus)
• -Another group on the outside of your thigh (called the Biceps Femoris).

All the muscles mentioned above, attach to the thigh bone (Femur) and the hip/pelvic bone (ischium). A The term hamstring injury describes damage to any of these muscles.

All the hamstring muscles are attached to tendons  (on both sides) which attach the muscle to bone. The joining point between muscle and tendon is called the Musculo-tendinous junction. These joining points are the most common places where muscles tear, pull or take strain – resulting in a hamstring injury. Next, let’s look at an example of how runners develop this type of injury.

Picture yourself running a race. In the corner of your eye you see another runner getting ready to pass you. You instantly increase your pace and put more effort into pushing off for a burst of speed to keep your place in the race. Instantly overloading your muscles, in this way, can cause tearing in some (or all) of your muscles’ fibers. Muscles contracting (shortening) at a very high rate and under immense force causes overloading or ‘pulling’ on the muscle. In short, this means that the small (microscopic) muscle fibers are tearing because they cannot take the strain.

Your nervous system is responsible for noticing these micro tears. Micro tearing causes your nervous system to react. Your nervous system responds by pulling the muscle and increasing the tension (e.g. pulling the muscle into a tight ball) to protect itself from further harm. The temporary shortening allows the muscle to start healing.

Sure you have torn a hamstring muscle?

Attempting a big stride, you will feel a sharp stinging feeling. This stinging feeling confirms a torn hamstring muscle. Your hamstring muscle stretch when taking a big stride. Stretching these muscles (while feeling this stinging feeling) can cause more damage the muscle. Stretching in this case is like ripping open a wound after it has been stitched shut. Patients usually describe one of the following happening to them:

This can happen in a slit second. One event. For example, a long jump athlete puts his/her hamstring muscles under too much force, causing the muscle to tear in one single jump. In this type of injury, the hamstring muscles will look severely shortened, due to lack of stretching and flexibility.

Additionally, a tendon can tear out a muscle if the pull (on the tendon) from the muscle is too strong and fast it. The tendon tears because it can’t take the force of the muscle jerking it. When a sprinter starts (pushes off out of the blocks) at the beginning of a race, a cyclist pedaling up a steep hill or people running sprints up inclines – all are examples where hamstrings under strain can become hamstrings in pain.

Stretching your stride while running, forces your hamstrings to contract in a lengthened position. The muscles contract as your heel hits the floor – to propel your body forward. If your muscle is short and weak, this movement will cause the muscle fibers to take too much strain. Too much strain will cause tearing of the (micro) muscle fibers. Putting your muscles under constant strain (like this) will cause more fibers to tear over time.

Your body responds to this strain by limiting your muscle range (shortening your strides). This is a protective mechanism to prevent your muscles from stretching (to its outer range) to save the muscle from more trauma. A small hamstring strain will feel stiff and tight no matter how much you stretch. If you run through this stiff feeling, you will force the muscle to contract outside its normal boundaries and the tear will worsen and increase your pain. You can continue this practice for weeks or months until one day – when the small tears along the muscle connect and they become one big tear.

• Overuse – Increasing your running distance too fast or sudden high repetition of hamstring contractions.
• Overload – Increasing the leg curl machine too fast. You can just imagine if you jump from 20kg to 40kg in one week. The muscle won’t be able to keep up. The muscle is subjected to sudden forceful contraction.
• Overstretch – Running downhills or on a incline will force the muscles to contract from its stretched position. Muscles are very weak in its stretched position. When the hamstring is forcibly stretched beyond its normal boundaries, the muscle will tear.
• Weakness – Muscle fatigue can play a role in runners who are not strong enough to run the distance.
• Poor technique – During training (Wrong movement pattern), that can load the hamstrings significantly more.
• Inadequate warm-up – A fast sudden contraction like a jump or start sprinting while the muscle is not prepared for it can put you at risk of tearing the hamstrings
• Excessive stretching – of the muscle against a force, for example during weight lifting like a dead-lift, when the load is applied on both sides of the tendon, while it needs to contract and lengthen at the same time.
• Wrong shoes – Poor support for your foot will cause muscle forces to concentrate along the inside of your leg, which loads those muscle fibers more that the outer part. This abnormal force on the inside of your leg will cause the fibers to fatigue faster and tear first.

Symptoms of a Torn Hamstring Muscle

1. Hear a pop, tear or snap when it happens
2. Pain when bending the knee to your buttocks
3. Pain at the back of your thigh when walking
4. Swelling or bruising at the back of your thigh
5. Pain giving a big stride when walking/ running
6. Pain when the hamstring muscle is stretched.
7. Unable to continue playing (sport), have to stop moving.
8. Loss of muscle strength
9. Limping to avoid pain
10. Unable to climb stairs

A sure sign of a hamstring injury is if you have trouble taking any weight on your injured leg. A less severe strain may only be painful on exertion, you may struggle walking up or down stairs. A small strain may only be painful during a push off in running, or you may feel you cannot reach 100% of your speed.

Here are some tests that you can determine if you have torn your Hamstring muscles

Length of your Hamstring muscle :

1. Lie on your back (have a towel/belt nearby)
2. First raise the unaffected leg, by bending your hip, but keep the knee straight
3. Hook the towel around your foot and pull your leg up, keeping the knee straight
4. See how far you can reach, then repeat on the painful side and compare
5. This self test can show if the muscle length is compromised.
6. You should be able to reach the same height on both legs.
7. If you are unable to reach the same height on both sides, the test is positive.

Strength of your Hamstring muscle :

1. Lie on your stomach, legs straight
2. First bend the unaffected knee, aiming your heel towards your hip
3. Repeat on the painful side
4. This test shows if the muscle can contract against the force of gravity.
5. If it is painful to do this movement, the test is positive.

Lenght Test in Standing:

1. Stand with your feet facing forward, at shoulder width apart.
2. While keeping your back straight, push out your buttocks backwards and
   bend forward to reach for your toes (but ensure your lower back does not round)
3. You should be able to reach between 30 – 40 cm from the floor.
4. If your pain stops you before you are able to reach 40 cm from the floor the test is positive.

We use a scale from 1 to 3 to determine how severe the tear is. Here’s a short breakdown of how the different grades will look like, but for more info click here

1st Degree (Mild)

A small amount of muscle fibers are torn. The muscle will feel stiff during warm-up or start of training, and eases off during training, but after you have cooled down, the muscle tends to tighten up again.Tenderness and cramps over the hamstring after training is common. You will be able to jog or run, but you will experience some pain when climbing stairs or running with a longer stride. It may feel like you cannot give it a 100%, only reaching about 80% of your usual speed. Hamstring tears present more with stiffness than pain when stretched.

Contracting the hamstrings during the push off phase of your sprints will feel tight and uncomfortable.
No bleeding or bruising will be present

Recovery Time:

2 – 3 weeks, if you follow the treatment plan

Symptoms of a 1st degree Hamstring muscle tear

• Able to continue playing (sport), jogging, but with pain.
• Stiffness rather than pain.
• Cramp-like feeling or tightness at the back of the thigh
• Pain only at the end of range (when you pull your toes toward your head)
• No loss of muscle strength (Able to curl your foot to your buttocks)
• Dull pain when stretching or bending forward towards the floor (pick up off the floor)
• Little swelling
• No bruising
• Unable to pinpoint it to one specific spot in the hamstring

2nd Degree (Moderate)

Grade 2 injuries cover the spectrum from slightly more fibers being torn that a grade 1 injury, but less than 50% of the fibers are torn. You will experience an immediate onset of pain, usually associated with a pulling or cramping sensation down the back of your thighs and behind your knees. Very often hardness around the tear can be felt and usually mistaken for a ‘knot’ in the muscle and sharp pain when pressing over the tear. Pain when the hamstring is contracted like doing a leg curl or kicking your hip while running. Jumping up a step will also cause sharp stinging pain. In most cases there will be no bruising visible initially.

If there is internal bleeding a bruise will settle and discolor the skin in the folds at the back of the knee. In some cases where the tear is very deep, the bleeding will pool in the ankle and foot, mostly on the inside of the heel and between the toes. When stretched by just sitting and straightening your knee and pulling your toes up will bring on the pain. Even just sitting on the edge of a chair, the direct pressure on the hamstrings will produce severe pain. During recovery you will have to walk with crutches for 2 to 4 weeks.

Recovery Time: 4 Weeks back to running.

Full Recovery:  6 to 8 weeks.

Symptoms of a 2nd degree Hamstring muscle tear

• Hear a tear, pop or snap when it happens. Like material tearing (as if tearing your pants)
• Unable to continue playing (sport), have to stop moving (running, jumping)
• Painful to put weight on the leg when walking
• Pain through the range as you bend your knee to your buttocks
• Loss of muscle strength (Unable to bend the knee to your buttocks)
• Small bursts of pain in the back of the thigh during exercise
• Sharp pain when stretched (See the tests above)
• Little to severe swelling (Mainly around the back of the knee & ankle)
• Bleeding under skin ( bruise visible – blue)
• Able to pinpoint it to one specific spot

3rd Degree (Severe)

This is the most severe tear with a complete rupture of 50% or more of the the muscle fibers.

There is some hope that a longitudinal tear (tear along the fibers) is less severe than a transverse tear (tear across the fibers). You will be unable to put any weight on the leg as the muscle contracting will cause severe pain. Limping and keeping the knee bent at 90 degrees will be the most comfortable position to keep it in. When you try to extend your knee, the hamstrings will stretch and pull over the tear. When you feel the hamstring has lost its strength and you are unable to climb up a small step, you may have torn all the fibers in one of the hamstring muscles.

Recovery Time: 3 to 4 Months depending on the site of the tear

Symptoms of a 3rd degree Hamstring muscle tear

• Hearing a loud pop, snap when it happens.
• Unable to continue playing, have to stop moving
• Minimal or no pain
• Unbearable to walk
• Able to contract the muscle, but no movement occurs
• Severe pain when stretched
• Always swelling
• Always considerable amount of bruising under skin
• Able to pinpoint and see the two loose ends of the torn hamstring muscle
• Visible gap

Our physiotherapists are able to make a diagnosis through physical examination, by palpating and feeling over all the muscles and its tendon attachments. We test the different muscles by contracting and stretching them in different positions to exactly determine the location & severity of the tear.

This helps us form a clear picture where & how bad the tear is, and tell you how long it will take to recover. We’ll guide you through a rehabilitation program of gradual strengthening, lengthening and conditioning of the muscle.  Every session we monitor your progress to tell you when it is safe to get off crutches, start walking, climbing stairs and return to training.

On every visit we will test and measure the length of your hamstrings, until it is back to its normal state, seeing that this is the main concern to prevent the hamstrings from tearing again. In most cases other tests like X-rays, CT-scan or MRI scans are not necessary.

Sonar
(Diagnostic Ultrasound)

We can refer you for an ultrasound (diagnostic sonar) to determine the depth and length of the tear or rupture. This can provide a more detailed and accurate indication of how long the recovery may take.

X-ray

Unless we expect fractures or joint involvement, from either your hip, knee joint or lumbar spine, there will be no need for an X ray, because X rays only show us the bony structures, joint space and the integrity of the bones. If we may suspect a femur fracture, it must be done.

MRI

An MRI scan would be a bit excessive in this case, unless we think there might be a bigger problem.

If you are asking yourself ‘why is it taking so long for the pain to go away’ then you might want to consider the following. When the muscle tears the body attempts to repair the injured fibers by sending cells to reattach the torn ends of the fibers. It reacts similar to repairing an open wound. Like having a cut at the bottom of your foot. If you keep on walking on it, you will shear away the cells that are healing and closing the wound. The more you walk or run through the pain, the longer it will take to heal.

If the pain returns every time you start running again, you have missed the most vital aspect of the cause of the muscle tear. The muscle length must return to its normal length before you return to participating. If you take a few days off and the pain in the thigh is gone (usually 3 days) and try running again, the pain just returns. If the muscle length is not restored, you will rip the wound wide open and have to start from the beginning again. This is the most common reason why patients consult us.

Some medications slows the healing

If you are taking anti-inflammatory medication for the hamstring muscle tear, STOP taking them. Inflammation is the body’s natural way of healing the injured muscle fibers. The medication is preventing this process from taking place. Anti-inflammatory medication also masks the effects of the trauma on the tissue if you return to running while still taking anti-inflammatory medication.

Hamstring injuries have a high risk of recurring under the best circumstances. The risk is even higher if you return to sport too early. Even though the pain may disappear, it is worth while to get it checked out. Without any treatment complications will increase your risk for reinjury. 12 – 48% of English football players had a recurrence of their injury, and that is with full time training and access to physiotherapy services. So be very careful.

Complications include tight scar tissue (which cannot lengthen) and muscle weakness due to compensation, to avoid using the muscle. This is a fear-avoidance pattern that emerges during a hamstring injury. Hamstring Syndrome may develop, where scar tissue from the injured site traps your sciatic nerve, causing nerve pain similar to sciatica.

We see a common trend where emergency services, first aid responders or even general practitioners assess the thigh muscles, and due to the excessive bleeding (bruise under the skin) they are mainly concerned to exclude a fracture (which can be life threatening). They refer the patient for X-rays, to find that there are no fractures. They send the patient off to buy crutches and instruct them to keep the weight off the leg until it is comfortable to start walking on the leg, approximately 2 weeks.

After 2 weeks there has been considerable amount of scar tissue that formed over the tear. The patients rarely move the leg in fear of pain, and when trying to get off the crutches, they start to experience the same pain, or even worse. The knee is kept bent, which results in the hamstring muscles repairing in its most shortened position. This causes even more complications due to the muscles of the whole leg weakening from inactivity and severe loss of muscle length.

Patients arrive at our practice, in most cases TOO LATE. Only 4 – 6 weeks after the initial injury. We have much to do and teach you as the healing process takes place within those first weeks, not to mention how much shorter the recovery time is when we guide you through the progress.

Physiotherapists are equipped to effectively treat a hamstring strain. The main concern being to regain the full muscle length and strength. Our role as physiotherapists play a vital role in monitoring your progress, preventing any complications, and guiding you to optimal health in as little time as possible.

If you are uncertain, rather let us have a look at it and tell you what to do.

We use a combination of the following treatment machines and techniques to accelerate the healing process of a hamstring muscle tear.

• Ultrasound
• Strapping and Taping to support and protect the hamstring from further injury.
• Acupuncture or Dry Needling
• Laser when the tear occurs at the musculo-tendinous junction.
• Electrotherapy
• Massage and Soft tissue mobilization
• Myofascial release of the Hamstring muscles
• Dynamic, static and ballistic stretches
• Compression braces
• Crutches to immobilize the hamstrings for the first few days or weeks.

We will guide you through a gradual progression of rehabilitation exercises to regain full function of the hamstring muscles.

PRICE protocol

1st Phase: Protection and initial Healing

During the first 72 hours after the injury the PRICE (Protection, Rest, Ice, Compression, Elevation) regiment is the most crucial to initiate optimal healing. Give us a call to set up a consultation to determine the extent of the damage. If you think you may have a mild hamstring injury (strain) you should follow the PRICE protocol:

P

Protect.

We have found that patients tend to continue walking on the injured leg with a limp. The muscle still contracts every time that weight is put onto the leg. It is better to get crutches and keep the load off your hamstring. The main concern is to prevent your hamstring muscles from tearing even further.

R 

Rest.

No weight on the injured leg. Use crutches to take the load off the muscle.

As soon as there’s no pain, don’t test it. Give it time to fuse completely.

I

Ice.

Ice cubes wrapped in a towel, tied around the Hamstring reduces pain & inflammation and speeds up the healing process. For at least the first 3 days or until the swelling goes down, apply an ice pack for 20 minutes every two hours. Always keep a towel between the ice and your skin (to prevent a clod burn), and press the ice pack firmly against your hamstring.

C

Compress.

Use strapping (Leukotake S) or elastic compression bandage to keep the muscle supported and prevent blood pooling in your hamstring. This can be done either with taping or tube grip bandage and helps to control swelling.

E

Elevate.

Lying on your back with your foot on a chair (your leg must be higher than your heart to allow gravity to assist in draining the pooled blood in your leg.) Raise your leg for 15 minute intervals during the day.

2nd Phase: Regain Full Range of Movement & Isometric Strengthening

The most important component of our rehabilitation is to regain full length of the muscle fibers. The scar tissue that forms inside the site of the tear must be lengthened and orientated to allow the muscle to contract without any restrictions. Physiotherapy treatment uses massage, stretches and neurodynamic mobilizations to achieve full range of movement. This will also prevent future re-occurrence.

Our Physios will use a variety of taping techniques including: Strapping (to prevent you from overextending the hamstring muscles) and compression bandages to stabilize the hamstring against the femur.

At every session we re-test the progress that you’ve made, and guide you to continue to use crutches until it’s safe to start walking without limping.

Hamstring exercises to help hasten the process? You may begin:

1. Bridges with your knee flexed at 60 degrees without pain.
2. Deep water pool jogging aim for 20 minutes. You should not feel any pain.
3. Indoor cycling for 20 minutes at low resistance. Stop if you feel pain.
4. Active knee extension within your pain-free range while sitting on a chair.
5. Core stability and glute exercises.

3rd Phase: Eccentric Hamstring Strength

A muscle contraction works in two directions: One where the muscle is contracted and it shortens like with a leg curl (concentric), and controlling the descent going down from a leg curl (eccentric). This loads the muscle fibers while it’s being lengthened. These type of exercises are vital for conditioning the muscle fibers to absorb force.

4th Phase: Concentric Hamstring Strength

Shortening of the muscle during a contraction involves strength and power exercises that will gradually be progressed as your injury healing allows. This will be tested frequently to determine if you can progress from non-weight bearing to full weight bearing (walking without crutches). The physiotherapist will guide and monitor the hamstring muscle’s reaction to normal forces like walking, climbing stairs and driving.

In this stage you should be able to:

• Go up and down stairs without pain
• Perform single leg bridges with your knee flexed at 60 degrees without pain
• Performed straight leg raises

Other Hamstring Exercises you may begin:

1. Gentle stretches of your quadriceps, adductors, hamstrings, gastrocnemius, soleus and gluteus muscles.
2. Low intensity sidewalk drills such as sidestep
3. Interval cycling at medium-high intensity
4. Box step ups
5. Low level running

5th Phase: High Speed & Power, Proprioception

The hamstring muscles must be tested under a high load and speed to ensure that the muscle will be able to keep up with the demand of your body. During this phase the physiotherapist will guide you to return to normal activities, as well challenge the muscle past its ‘normal’ boundaries to determine how it reacts to different forces and prepare you to return to participating in sports.

6th Phase: Sport Specific Training

Depending on your sport, the physiotherapist will tailor specific exercises that will help strengthen the muscle and surrounding muscle groups, to assist the hamstring. A successful outcome is when you have gained knowledge throughout the rehabilitation program and can participate at full power and speed, with the ability to minimize your chance of future injury.

Recovery Time

Recovery time will be directly influenced by the severity of your injury. The quicker you seek treatment, the less time you’ll spend in rehabilitation and the quicker you can get back onto the field/track/road. If we can start your treatment in the acute phase, we will see you twice in the first two weeks and then follow up once weekly to modify your exercises. Tending to this injury fast and loading the muscle enough at the right time will greatly decrease your risk of injuring the hamstring again.

In the case of a grade 1 strain, recovery may take 3 weeks. A moderate hamstring strain, grade 2, will need 6 – 8 weeks. Full rupture of the hamstring muscle may require surgery, after which your recovery time may be 4 to 6 months.

Medical management

In some severe cases you may need analgesics that need to be prescribed by your GP. In this case, analgesics will be more beneficial, due to research showing a delay in the healing process when anti-inflammatories are taken.

Surgery of Torn Hamstring Muscles

Clear cut, isolated injuries of the hamstring muscles would not be surgically repaired, as stitches do not hold in skeletal muscle fibers.

If your hamstring injury does not respond to physiotherapy treatment you may be referred to a Orthotist to put your leg in a brace and advise you to rest for 4 – 6 weeks until the muscle has healed. Surgery to the hamstring muscle is very rare due to the procedure causing more fibrous tissue deposits. This makes the likelihood of developing nerve entrapment of the sciatic nerve much more likely.