Hamstring Tears: Treatment

How a hamstring injury is treated depends on the location and severity of the tear. Patients with an injury to the myotendinous junction are treated differently than patients with hamstring avulsion-type injuries.

Treatment of myotendinous junction tears

The course of treatment for myotendinous junction tears is usually non-operative (conservative), in which rehabilitation is followed by a properly-timed return to play.¹Garrett W. Muscle strain injuries. Am J Sports Med 1996;24 S2-S8.^,2Silder A, Heiderscheit B, Thelen D, Enright T, Tuite M. MR observations of long-term musculotendon remodeling following a hamstring strain injury. Skeletal Radiol 2008;37:1101-9.^,3Heiderscheit B, Sherry M, Silder A, Chumanov E, Thelen D. Hamstring strain injuries: recommendations for diagnosis, rehabilitation, and injury prevention. J Orthop Sports Phys Ther 2010;40:67-81.^,4Thelen D, Chumanov E, Sherry M, Heiderscheit B. Neuromusculoskeletal models provide insights into the mechanisms and rehabilitation of hamstring strains. Exerc Sport Sci Rev 2006;34:135-41.^,5Clark B, Jaffe D, Henn R, Lovering R. Evaluation and imaging of an untreated grade III hamstring tear: a case report. Clin Orthop Relat Res 2011;469:3248-52. Conservative management is divided into three phases based on the phases of healing.³Heiderscheit B, Sherry M, Silder A, Chumanov E, Thelen D. Hamstring strain injuries: recommendations for diagnosis, rehabilitation, and injury prevention. J Orthop Sports Phys Ther 2010;40:67-81.^,4Thelen D, Chumanov E, Sherry M, Heiderscheit B. Neuromusculoskeletal models provide insights into the mechanisms and rehabilitation of hamstring strains. Exerc Sport Sci Rev 2006;34:135-41. Patients with a myotendinous junction injury typically have a faster recovery and a higher rate of return to prior level of function than those who experience an avulsion type injury. ⁶Askling C, Saartok T, Thorstensson A. Type of acute hamstring strain affects flexibility, strength, and time to return to pre-injury level. Br J Sports Med 2006;40:40-4.^,7Askling C, Tengvar M, Saartok T, Thorstensson A. Acute first-time hamstring strains during slow-speed stretching: clinical, magnetic resonance imaging, and recovery characteristics. Am J Sports Med 2007;35:1716-24.^,8Askling C, Tengvar M, Saartok T, Thorstensson A. Proximal hamstring strains of stretching type in different sports: injury situations, clinical and magnetic resonance imaging characteristics, and return to sport. Am J Sports Med 2008;36:1799-804.

Phase 1: Inflammatory phase

During the initial inflammatory phase of healing, the goal should be to control pain, decrease inflammation, and protect the tendon so scar tissue can develop.³Heiderscheit B, Sherry M, Silder A, Chumanov E, Thelen D. Hamstring strain injuries: recommendations for diagnosis, rehabilitation, and injury prevention. J Orthop Sports Phys Ther 2010;40:67-81.^,4Thelen D, Chumanov E, Sherry M, Heiderscheit B. Neuromusculoskeletal models provide insights into the mechanisms and rehabilitation of hamstring strains. Exerc Sport Sci Rev 2006;34:135-41. This stage may require crutches and taking weight off the injured leg in order to facilitate recovery, healing, and protection.

In addition, patients should:

• Avoid excessive stretching during this stage, because it may be detrimental to the recovery process.³Heiderscheit B, Sherry M, Silder A, Chumanov E, Thelen D. Hamstring strain injuries: recommendations for diagnosis, rehabilitation, and injury prevention. J Orthop Sports Phys Ther 2010;40:67-81.^,4Thelen D, Chumanov E, Sherry M, Heiderscheit B. Neuromusculoskeletal models provide insights into the mechanisms and rehabilitation of hamstring strains. Exerc Sport Sci Rev 2006;34:135-41.
• Use ice, elevation, rest, and non-steroidal anti-inflammatory medications (NSAIDs) as needed for inflammation and pain control.
• Limit exercising to a protected and pain free range of motion.³Heiderscheit B, Sherry M, Silder A, Chumanov E, Thelen D. Hamstring strain injuries: recommendations for diagnosis, rehabilitation, and injury prevention. J Orthop Sports Phys Ther 2010;40:67-81.

The length of this phase depends on the severity of injury, but typically lasts 3 to 7 days.³Heiderscheit B, Sherry M, Silder A, Chumanov E, Thelen D. Hamstring strain injuries: recommendations for diagnosis, rehabilitation, and injury prevention. J Orthop Sports Phys Ther 2010;40:67-81.^,4Thelen D, Chumanov E, Sherry M, Heiderscheit B. Neuromusculoskeletal models provide insights into the mechanisms and rehabilitation of hamstring strains. Exerc Sport Sci Rev 2006;34:135-41.^,9Sharma P, Muaffulli N. Tendon Injury and Tendinopathy: Healing and Repair. JBJS 2005;87:187-202. A qualified clinician should make decisions about progression to the next phase based on the patient’s clinical examination and function.

Generally, a patient is considered ready to progress to the second phase of healing and treatment when he or she can tolerate a normal walking gait, an isometric contraction at 50% to 70% maximal, and a very low-speed jog without pain.³Heiderscheit B, Sherry M, Silder A, Chumanov E, Thelen D. Hamstring strain injuries: recommendations for diagnosis, rehabilitation, and injury prevention. J Orthop Sports Phys Ther 2010;40:67-81.^,4Thelen D, Chumanov E, Sherry M, Heiderscheit B. Neuromusculoskeletal models provide insights into the mechanisms and rehabilitation of hamstring strains. Exerc Sport Sci Rev 2006;34:135-41. An isometric contraction literally means without movement. An example of this would be a clinician holding the heel while a patient tries to bend (flex) the knee, but not allowing it to bend. While the muscle contracts, it does not shorten.

Phase 2: Reparative phase

During the reparative phase of treatment, the patient should try to regain full range of motion, with continued caution to avoid overaggressive stretching.³Heiderscheit B, Sherry M, Silder A, Chumanov E, Thelen D. Hamstring strain injuries: recommendations for diagnosis, rehabilitation, and injury prevention. J Orthop Sports Phys Ther 2010;40:67-81.^,4Thelen D, Chumanov E, Sherry M, Heiderscheit B. Neuromusculoskeletal models provide insights into the mechanisms and rehabilitation of hamstring strains. Exerc Sport Sci Rev 2006;34:135-41. Over time, the patient can do more challenging exercises as tolerated, remembering always to do these in a pain-free manner.

This phase can last from 6 to 8 weeks, but depends on the patient and the severity of the initial injury.³Heiderscheit B, Sherry M, Silder A, Chumanov E, Thelen D. Hamstring strain injuries: recommendations for diagnosis, rehabilitation, and injury prevention. J Orthop Sports Phys Ther 2010;40:67-81.^,4Thelen D, Chumanov E, Sherry M, Heiderscheit B. Neuromusculoskeletal models provide insights into the mechanisms and rehabilitation of hamstring strains. Exerc Sport Sci Rev 2006;34:135-41.^,9Sharma P, Muaffulli N. Tendon Injury and Tendinopathy: Healing and Repair. JBJS 2005;87:187-202. Progression to the third phase of healing and treatment requires full strength and range of motion, with the ability to tolerate a backward jog at 50% maximal speed.³Heiderscheit B, Sherry M, Silder A, Chumanov E, Thelen D. Hamstring strain injuries: recommendations for diagnosis, rehabilitation, and injury prevention. J Orthop Sports Phys Ther 2010;40:67-81. It is recommended that a qualified clinician evaluate the patient and guide the therapy appropriately.

Phase 3: Remodeling phase

During the third phase of treatment, it is important to customize the rehabilitation to the patient’s specific needs. Sport or activity-specific exercise and agility drills are recommended to promote tissue remodeling and help prepare the patient for return to his or her previous level of function.³Heiderscheit B, Sherry M, Silder A, Chumanov E, Thelen D. Hamstring strain injuries: recommendations for diagnosis, rehabilitation, and injury prevention. J Orthop Sports Phys Ther 2010;40:67-81.^,4Thelen D, Chumanov E, Sherry M, Heiderscheit B. Neuromusculoskeletal models provide insights into the mechanisms and rehabilitation of hamstring strains. Exerc Sport Sci Rev 2006;34:135-41. Drills that emphasize quick movements and change of direction, such as plyometric exercises, are ideal and will help prepare the patient for return to activities.³Heiderscheit B, Sherry M, Silder A, Chumanov E, Thelen D. Hamstring strain injuries: recommendations for diagnosis, rehabilitation, and injury prevention. J Orthop Sports Phys Ther 2010;40:67-81. As in the previous phases of healing, it is important to have a qualified clinician involved to guide the rehabilitation and recovery.

Treatment of proximal hamstring avulsions

A proximal hamstring avulsion refers to when the tendon has torn away from where it inserts into the pelvic bone, possibly pulling away a small bone fragment with the tendon. Advanced imaging is important in cases of proximal injuries in order to expedite surgical consultation and possibly improve outcomes and return to play.¹⁰Lempainen L, Sarimo J, Mattila K, Vaittinen S, Orava S. Proximal hamstring tendinopathy: results of surgical management and histopathologic findings. Am J Sports Med 2009;37:727-34.^,11Sarimo J, Lempainen L, Mattila K, Orava S. Complete proximal hamstring avulsions: a series of 41 patients with operative treatment. Am J Sports Med 2008;36:1110-5.

If surgery is not required, conservative treatment of proximal hamstring avulsions will follow the same phases 1 through 3 described above, though the exact protocol (e.g. stretches and exercises) may differ.

If a proximal hamstring avulsion has more than 2 mm of displacement, a surgical consultation for reattachment is recommended.¹²Folsom G, Larson C. Surgical treatment of acute versus chronic complete proximal hamstring ruptures: results of a new allograft technique for chronic reconstructions. Am J Sports Med 2008;36:104-9.^,14Domb B, Linder D, Sharp K, Sadik A, Gerhardt M. Endoscopic repair of proximal hamstring avulsion. Arthrosc Tech 2013;2:e35-9. Early surgical repair can yield superior results over both conservative treatment and delayed surgical repair of proximal hamstring avulsions.¹²Folsom G, Larson C. Surgical treatment of acute versus chronic complete proximal hamstring ruptures: results of a new allograft technique for chronic reconstructions. Am J Sports Med 2008;36:104-9.^,14Domb B, Linder D, Sharp K, Sadik A, Gerhardt M. Endoscopic repair of proximal hamstring avulsion. Arthrosc Tech 2013;2:e35-9.

The recovery process following surgical repair can take from 6 to 12 months or longer, depending on the severity of the initial injury and required surgical intervention.¹²Folsom G, Larson C. Surgical treatment of acute versus chronic complete proximal hamstring ruptures: results of a new allograft technique for chronic reconstructions. Am J Sports Med 2008;36:104-9.^,15Cohen S, Bradley J. Acute proximal hamstring rupture. J Am Acad Orthop Surg 2007;15:350-5.^,16Harris J, Griesser M, Best T, Ellis T. Treatment of Proximal Hamstring Rupture- A Systemic Review. Int J Sports Med 2011;32:490-5.^,17Sarimo J, Lempainen L, Mattila K, Orava S. Complete proximal hamstring avulsions: a series of 41 patients with operative treatment. Am J Sports Med 2008;36:1110-5.^,18Askling C, Tengvar M, Saartok T, Thorstensson A. Proximal hamstring strains of stretching type in different sports: injury situations, clinical and magnetic resonance imaging characteristics, and return to sport. Am J Sports Med 2008;36:1799-804. It is important that patients follow the surgeon’s instructions during rehabilitation and recovery.