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Hamstring Strains, Tears, and Everything in Between

Hamstring strains are perhaps one of the most frustrating injuries. They are annoying when they hurt because you can never get away from the muscle (you’re either using it to stand or sitting directly on it). Rehabilitating them can be difficult and finicky as they tend to flare up right when you thought they were getting better. And, long-term resolution of symptoms can often be elusive.

Hello, Dr. Sarah here. When it comes to blog posts, I typically write them from the second person point of view. This blog post will be a little different. I am choosing to write it from the first person point of view because I’ve strained both of my hamstrings rather badly (and at the same time unfortunately). Those same injuries then popped up later on in life during a period of high stress (gotta love physical therapy school). I’ve also treated many clients who have hamstring strains and watched them get better and get back to their sport of choice.

Essentially, I’ve got quite a bit of personal and professional experience when it comes to hamstring strains. I believe writing from my perspective will help articulate things more clearly. We’re going to dive into my experience and discuss how to recover from a hamstring strain. We’ll start off by discussing how to know if you’ve strained your hamstring. Then, we’ll talk about what to do immediately after the injury and how to progress from there. Lastly, we’ll finish with what to do if you simply can’t get rid of your discomfort. Ready? Let’s go!

Did I Strain My Hamstring?

Hamstring strains are one of the easier things to diagnose. Clinically, I look for three things – a specific mechanism, pain on the hamstring, and pain with using the hamstring.

A Specific Incident

A specific cause isn’t always present, but in the overwhelming majority of cases, it is. For me, this occurred while I was sprinting. When I was moving my leg forward, I felt a pop and fell to the ground. It was pretty obvious that something was wrong (especially because walking was rather difficult afterwards).

greater trochanteric pain - gluteus minimus
hamstring
When a specific cause isn’t present, it often looks like experiencing a nagging tug (or potentially nothing at all), and then waking up the next day or getting up after sitting and having pain. This is how my re-injury happened. Because my time was limited in PT school, I started running more for exercise. Over a period of 2-3 weeks, I always felt a nagging tug in my hamstring while running. It was mild, more of an annoyance than anything, so I ignored it. One day during a run, the annoyance turned into slightly altered running technique. Later that day, it turned into moderate discomfort, and the following day it was a significant limp due to pain.

It’s more difficult to discern a cause when the pain happens later and not in the moment. When that’s the case, it’s important to reflect over the previous 48 hours. More often than not there will be an activity that was new, a weird sensation, or a high volume of a specific activity. All those things can clue you in as to whether or not you’ve injured something.

Pain in the Hamstring

The second thing I look for is location of pain; the pain should be located in the hamstring. And, if you poke it, it should hurt more. When a strain is severe, it’s classified as a tear. When this happens, there is visible bruising. This bruising may be located in the hamstring or the lower leg. Bruising doesn’t always occur at the site of injury; it will depend where things travel to and how efficient the body is at clearing the damaged tissue.

Pain with Using the Hamstring

The last thing I look for is that when you use the hamstring, your pain increases. Using your hamstring involves actively bending your knee against resistance. The hamstring (leg curl) machine at the gym is a great example of this. Or, you can sit in a chair, push your heel into the floor, and try to pull your foot towards you. That is a pretty quick check to see if it hurts to use your hamstring or not.

So, there may or may not be a specific incident where you started to feel pain. However, if the hamstring muscle hurts, it hurts more when you poke it, and it hurts to use it, odds are it is a hamstring strain. The next question is then – what do you do about it?

Rehabilitating a Hamstring Strain

The first thing you don’t do is continue to use it. I can (unfortunately) tell you from personal experience that this does not go well. If you strain your hamstring while sprinting, you should not continue to sprint. (The sixteen year old version of myself was not the brightest bulb in the bunch and a bit too stubborn).

Instead, for the first 24 hours, do relative rest. Don’t push anything, avoid exercise that uses your hamstring, and let the inflammatory process start. During this time period heat often feels best. With injuries, ice will actually slow the inflammatory process and cause the injury to take longer to heal. With some injuries that have uncontrolled swelling, ice is indicated. However, a hamstring strain doesn’t present with uncontrollable swelling, so heat should be used. The heat will ease your discomfort and allow the muscle to relax and continue the healing process.

After the 24 Hour Period

After 24 hours is up, it’s time to start gradually loading the hamstring. This is the best way to flush the inflammation out and accelerate the healing process. Properly loading the hamstring can be a bit tricky depending on how severe the injury is. Ideally, you want to do as much load as possible without overloading the muscle.

The best way to navigate this is to follow the pain stoplight. This means that anything that is mild discomfort (green light) is okay. Moderate discomfort (yellow light) is okay-ish but shouldn’t be continually pushed into. Severe discomfort (red light) means you’re doing too much and it will take the muscle longer to heal. (Need a more detailed explanation? Check out this blog post.)

The tricky part about the pain stoplight is that this is in regards to pain during, immediately after, and a full 24 hours after activity. For my first hamstring injury, this was obvious. I didn’t have any delayed pain and was easily able to make decisions. However, for my second hamstring injury, this was not obvious. I typically had no discomfort at the time, but the next few days I would limp around. This made it harder to discern how much load was too much and how much was okay.

Hamstring Loading

When it comes to loading the hamstring, discerning what to do can be a bit tricky. Here’s a few exercises (in order of difficulty) to help you work your way through things. Loading the hamstring should continue for at least 8-12 weeks beyond the initial injury.

Bridges

Single Leg Bridge with Bent Knee

Bridge Walk Outs

Nordic Hamstring Curl – Band Assisted

Nordic Hamstring Curl

Beyond Exercises

One of the most common mistakes people make with this injury is a lack of long-term follow through. Similar to how you want to take the full course of antibiotics even if you no longer have symptoms, you’ll want to continue to strengthen the hamstring well beyond when your symptoms go away. Just because you don’t have pain doesn’t mean there still isn’t dysfunction lurking under the surface.

During my second hamstring injury, this was the mistake I made. I would do hamstring strengthening, my symptoms would improve, and I would go back to running (and quit doing my exercises). My discomfort would predictably come back. This turned into a frustrating two year battle of not being able to consistently run without discomfort. Even to this day, I still try to do hamstring strength training at least one time per week. When I don’t, the discomfort does start to creep back in.

Because of how long I had symptoms for, what should have been a short-term injury turned into a chronic injury that now needs to be managed. The best advice I can give someone who has a hamstring strain (or any muscle strain really) is to make sure it fully heals up the first time around. When things aren’t properly healed, they turn into aches and pain (and sometimes future injuries) down the road. Speaking from experience, it’s not something I’d recommend.

Core Strength for Hamstring Strains

While it’s obvious that the hamstring should be strengthened, it may not be as obvious that core strength should be addressed as well. Improving core strength has been shown to be helpful in long-term resolution for hamstring strains. It’s a relatively new (past ten years) finding in research, but the stronger the core is, the less stress that is placed on the hamstrings. When you break down the anatomy, it makes sense.

The hamstrings start on the trunk and end on the leg. This means they use the trunk as a base, or platform, from which they contract to do their job. The more secure the platform, the easier it is for the hamstrings to produce force. It’s like doing a long jump. If you jump off a squishy pad, you’re not going to go nearly as far as if you were to jump off solid ground. When the core is strong, the hamstrings get to jump off solid ground.

Virtually any core strengthening will do the trick, but my personal favorite core exercise is the hollow hold. It challenges the upper and lower abdominal muscles at the same time, whereas most core exercises only work the upper or lower muscles. However, variety is also important, so mixing in planks, sit-ups, candlesticks, Russian twists, and more are all helpful.

When Your Hamstring Just Isn’t Getting Better

Last but not least, let’s chat about how to improve a chronically irritated hamstring. I’m going to assume that if you’ve made it thus far, you’re either really into learning about the human body or you have a hamstring that is not doing what you want it to do. When that’s the case, it’s time to pull out some other tips and tricks.

Exercise is an amazing treatment, but sometimes hands-on techniques are what you need to get over the hump. With my hamstring, my symptoms finally started to turn around when I got some good massage therapy and dry needling. This calmed my hamstring down to where I was able to load it more consistently and with less flare-ups.

When I get flare-ups now (which happens once or twice per year), one bout of cupping is enough to bring the pain down and get me back in the gym. The decreased pain allows me to continue loading my hamstring, which is what keeps the flare-ups from happening again. All that to say, exercises are awesome, but if you can’t tolerate exercise, it’s important to decrease pain so you can tolerate exercise. That’s where hands-on treatment comes in.

Wrapping Things Up

In conclusion, hamstring strains are typically pretty easy to identify. They do best with resting for 24 hours and then progressive load. This load should be moderate or less during, immediately after, and a full 24 hours after. Loading things over time and adding in some core strength typically gives full resolution of symptoms. However, if your hamstring just isn’t having it, hands-on techniques are great at bringing pain down so you can load your hamstring (and get back to doing what you love).

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