Have You Suffered A
Hamstring Injury?

If you currently or have ever had a hamstring injury, you understand how limiting this injury can be. What exactly is a pulled hamstring? How can you tell if you have one? And most importantly, what are your best treatment options for a pulled hamstring and how long will the recovery take?

Hamstring Anatomy

The hamstring is a group of muscles located at the back of the thigh. There are three muscles that make up the hamstring: the semimembranosus, semitendinosus, and the biceps femoris. These muscles all attach to the ischial tuberosity of the pelvis. Two of these muscles insert on the medial or inside aspect of the tibia and one inserts on the lateral or outside aspect of the fibula. Because these muscles cross both the hip and the knee, they function in providing both hip extension and knee flexion or bending.

hamstring anatomy

What Is A Hamstring Injury?

A pulled hamstring is the most common muscle injury in sports or activities that involve explosive running. Because the hamstring is a muscle, a hamstring injury, is considered a muscle strain. Muscle strains have three levels of severity: first degree (mild), second degree (moderate), and third degree (severe).

A first degree pulled hamstring is classified as a stretching and possibly slight tearing of the muscle tissue. A second degree strain involves partial tearing of muscle tissue. A strain is classified as a third degree strain where there is a complete rupture of the muscle. This rupture can occur either in the muscle itself or at the tendon attachment. A tendon attaches a muscle to a bone thus the tendon itself can become detached from the bone causing a complete rupture or detachment of the muscle. Occasionally muscle tendon ruptures can pull a portion of the bone off. When this occurs it is classified as an avulsion fracture of the bone in association with a third degree tendon rupture.

hamstring injury Determining the severity of the muscle strain can be done by both the history of the symptoms and a physical examination. Hamstring injuries occur generally with some type of explosive activity such as running or can also occur when the hamstring is overstretched. Most often the most common complaint is pain in the back of the back of the thigh or lower buttocks region, pain or difficulty extending the knee straight, difficulty walking, and occasionally swelling and/or bruising.

The difference between first and second degree strains is generally the amount of pain, swelling, and limitation in strength, range of motion, and function. With first degree strains there is some pain but generally strength of hip extension and knee flexion are maintained and the individual is generally able to walk. Second degree strains will involve greater pain, reduced strength, limited range of motion, and frequently results in a significant limp with walking.

With a third degree hamstring injury or rupture, most people feel a significant “pop” when the injury occurs. The ability to extend the hip and bend the knee will be significantly reduced or unable to occur. If a third degree strain is suspected, an MRI may be performed in order to confirm the diagnosis.

Treatment Options

As a pulled hamstring generally occurs from some type of an acute onset, the best initial treatment should follow acute muscle strain protocols. For an acute injury, the RICE method should be followed: Rest, Ice, Compression, and Elevation. Rest should come in the form of avoiding use of the hamstring muscle. The severity of the injury will determine whether crutches are recommended and to what extent weight should be allowed to be placed on the leg. Compression can be applied in the use of a compression wrap like an ACE wrap. The compression wrap should be worn at all times to minimize swelling.

For a severe hamstring injury, seek medical attention. An orthopedic physician is best qualified to determine the extent of the injury. An x-ray and/or MRI may be ordered to determine the extent of the injury. If a complete rupture has occurred, surgery is the best treatment option.

For a first and second degree pulled hamstring, after acute treatment is initiated, physical therapy should be implemented. Although physical therapy is effective in assisting with muscle healing, research has not identified the best treatment options. The key goals with respect to hamstring injury rehabilitation include: reduce swelling, and restore flexibility, strength, and function.

Generally, modalities such as electric stimulation, ultrasound, and shock wave therapy are all reasonable treatment options. In addition to modalities, soft tissue massage can also be of benefit to help minimize scar tissue thickening.

Strengthening is also a key component of rehabilitation. Some research points to the benefit of emphasizing eccentric muscle strengthening in helping reduce the risk of reinjury. Some evidence also points to the need to address not only the muscles around the knee (hamstrings and quadriceps) but muscles that also attach to the pelvis and lumbar spine. Thus, as part of the overall rehabilitation process, doing core stabilization exercises should be incorporated.

hamstring stretch

Finally, flexibility and range of motion exercises should also be a part of the treatment process. Because the hamstring crosses both the hip and the knee, exercises should address both areas. Care should be taken to avoid stretching at end range early in the healing process as this may influence tissue healing.

A first and second degree hamstring injury can take 6-8 weeks to heal. Because reinjury of a pulled hamstring is common caution should be used when determining return to sports and/or running activity.


• Hamstrings are the most commonly injured muscle in running related sports.

• A hamstring injury is classified by severity: grade I (mild), II (moderate), or III (severe/rupture).

• Acute treatment for a pulled hamstring should include rest, ice, compression, and elevation.

• No strong evidence points to the best treatment options but the use of modalities, soft tissue massage, stretching, and strengthening incorporating eccentric loads and core stabilization exercises are part of a typical rehabilitation program.

• Care should be used with both the progression of exercise and return to sport as reinjury is common.

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Am J Sports Med. 2011 Jan;39(1):146-53. Epub 2010 Sep 20.Shockwave therapy for the treatment of chronic proximal hamstring tendinopathy in professional athletes.Cacchio A, Rompe JD, Furia JP, Susi P, Santilli V, De Paulis F.

J Orthop Sports Phys Ther. 2010 Feb;40(2):67-81.Hamstring strain injuries: recommendations for diagnosis, rehabilitation, and injury prevention.Heiderscheit BC, Sherry MA, Silder A, Chumanov ES, Thelen DG.

Cochrane Database Syst Rev. 2007 Jan 24;(1):CD004575.Rehabilitation for hamstring injuries.Mason DL, Dickens V, Vail A.

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