Hamstring injury

Updated January 28, 2024

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of hamstring injury are prepared by our editorial team based on guidelines from the American Physical Therapy Association (APTA 2022), the National Institute for Health and Care Excellence (NICE 2020), and the Italian Society of Muscles, Ligaments and Tendons (ISMuLT 2014).

Screening and diagnosis

Diagnosis: as per APTA 2022 guidelines, diagnose hamstring strain injury in patients presenting with a sudden onset of posterior thigh pain during activity, with pain reproduced when the hamstring is stretched and/or activated, muscle tenderness with palpation, and loss of function.

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Diagnostic investigations

Physical examination: as per APTA 2022 guidelines, use a handheld or isokinetic dynamometer to quantify knee flexor strength following hamstring strain injury.

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Medical management

Analgesics: as per NICE 2020 guidelines, offer acetaminophen or topical NSAIDs (such as ibuprofen gel) as first-line therapy for pain management. Consider offering oral NSAIDs (such as ibuprofen) if needed. Consider offering short-term codeine as an 'add-on' medication.

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Nonpharmacologic interventions

Conservative management: as per NICE 2020 guidelines, advise on initial 'PRICE' self-management strategies for the first 48-72 hours after injury:

Situation

Guidance

Protection

Protect from further injury (for example, by using a support or high-top, lace-up shoes)

Rest

Avoid activity for the first 48-72 hours following injury

Ice

Apply ice wrapped in a damp towel for 15-20 minutes every 2-3 hours during the day for the first 48-72 hours following the injury (not left on whilst asleep)

Compression

Apply snug (but not tight) compression with a simple elastic bandage or elasticated tubular bandage to help control swelling and support the injury (remove before going to sleep)

Elevation

Keep the injured area elevated and supported on a pillow until the swelling is controlled

Avoid prolonged periods with the leg not elevated if the leg is injured

Consider offering a short period of immobilization for a few days after injury for severe sprains and strains

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Preventative measures

Injury prevention: as per APTA 2022 guidelines, offer the Nordic hamstring exercise as part of a hamstring strain injury prevention program, along with other components of warm-up, stretching, stability training, strengthening, and functional movements (sport-specific, agility, and high-speed running).

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Follow-up and surveillance

Clinical follow-up

As per APTA 2022 guidelines:

Obtain objective measures of the patient's ability to walk, run, and sprint when documenting changes in activity and participation over the course of treatment.

Use the Functional Assessment Scale for Acute Hamstring Injuries before and after interventions, intended to alleviate the impairments of body function and structure, activity limitations, and participation restrictions in patients diagnosed with an acute hamstring strain injury.

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