Updated: Nov 9, 2020
Have you ever felt the back of your thigh spasm? Did you ever feel a pop and have difficulty with running or walking shortly after?
Have you noticed increased tightness in your posterior thigh that is limiting your stride? Does it feel weaker than your other leg? Ever noticed swelling or bruising?
If you answered "yes" to most of those questions, then you may have a hamstring strain.
Strains and bruising account for 90% of all muscle injuries according to Shruti Nambiar. Strains typically occur with higher-level physical activity like sprinting, or fast stop and go movement seen in basketball, football, soccer, and rugby. Strains are also commonly seen in runners.
Strains are classified into 3 grades:
Grade 1 Strain- Mild, only a few fibers have been injured. Walking will likely be unaffected, you may feel minimal symptoms with sprinting.
Grade 2 Strain- Moderate, a partial muscle tear up to half of the muscle. You may experience a limp with walking, and running may not be an option due to weakness and pain.
Grade 3 Strain- Severe, between half the fibers up to a complete rupture of the muscle belly or tendon. You may not be able to stand or walk. If there's a tear in the muscle, swelling and bruising is typically present. In a complete tear, there should be an observable deformity when comparing both legs.
Grades 1 and 2 are more manageable to treat non-surgically than grade 3. If you have a complete tear of your muscle belly, you need to get that reattached before you can rehab it.
Understanding what grade your injury is will set the pace for your return to activity.
How do you check for a hamstring strain?
1. The "Take Off Your Shoe Test" has the highest value in predicting what will show up on an MRI.
Are you able to perform the test without difficulty? Are you having any familiar posterior thigh symptoms with the test?
2. Check your range of motion.
Can you bring your heel to your bottom with just using your hamstrings? You can try this standing up, laying on your back, and on your stomach.
Compare both legs. Are you able to bend your symptomatic leg as far as your asymptomatic leg? Can you locate any tender areas on the symptomatic leg by touching the muscle? Does activating your hamstring aggravate your pain?
If you answer yes to most of those questions and you are able to rule out other types of injury, then you may have a hamstring tear.
What else causes posterior thigh pain?
1. The low back can also refer pain to the back of your lower leg, and one way to assess your low back is to check your lumbar range of motion.
Bend forward, backward, side to side, and rotate. Pay attention to how the back of your leg feels with each direction. Do any of the above motions aggravate your familiar symptoms in the back of your leg?
If yes, you should focus your attention on your back first. You want to treat the root cause of a problem, not a side effect.
2. The sciatic nerve also is another structure that can cause pain in the back of your thigh.
Sciatic pain can be dull to sharpshooting, like an electrical shock, and or burning down the path of the nerve as it travels down your leg. You may also have numbness, tingling, and weakness.
How do you assess nerve pain? Nerve pain is typically more irritable and less easy to calm down if it becomes flared up. It can be aggravated by too much or not enough movement. It also causes abnormal sensations like numbness and tingling.
Muscle pain can be aggravated by activating the painful muscle. You may have weakness and pain, but abnormal sensations should not be present. If you notice a bruise with a muscle deformity, I would not jump to the sciatic nerve first.
Another way to differentiate nerve pain from muscle pain is to stretch the tissue. The trick is that the stretch needs to bias more of a nerve or more of a muscle stretch. The purpose of stretching is to gently apply tension to the injured tissue and assess if it reproduces your familiar symptoms.
3. What if the strain is in another muscle that is next to the hamstrings?
An adductor muscle strain could also look and feel like a hamstring strain but with one major difference: It would hurt worse with bringing your leg toward the midline, not with bending your knee.
You also may notice bruising and swelling on the inner portion of your thigh and not strictly the back of it. A quad strain would present with more bruising and swelling on the front of your thigh. Also, activating your quads to straighten your knee would aggravate your symptoms. You may feel a painful pull with bending your knee all the way back, but the pain would be in the front of your thigh.
A doctor of physical therapy can thoroughly assess all of these possibilities so you can have the peace of mind to know exactly what you're dealing with. If your symptoms feel confusing, don't hesitate to contact a specialist for clarity.
Will the tear get worse?
Since the muscle has a tear, won’t contracting it make the tear worse? For the most part, absolutely not!
Our body is very strong and resilient. Our muscles are not like paper. Muscle fibers adapt to the load that is placed on them, when they are stressed appropriately they become stronger.
That being said, in the early stages of a strain, you need to respect a muscle tear. If you continue to overload an injured tissue, you can make it worse and delay the healing process. Gently activating your muscle will not make it worse. In the early stages of a tear, gentle activation can help promote healing in the muscle.
What can you do to treat a strain?
How you treat a strain depends on the grade.
Grade 1 strains will typically resolve on their own. However, the exercises listed below will make sure your hamstrings have fully recovered and help prevent reinjury. A risk factor for strains is having a previous strain!
Grades 2 and 3 need more time to heal. In the first month of injury be sure to avoid excessive stretching and heavy muscle activation. Adding more trauma to an acute tear can make the injury worse and prolong the healing process.
In the first few weeks of a significant tear, respect your injury. You should focus on reducing pain and maintaining range of motion. Be gentle with your stretching, gentle with strengthening, and aggressive with activity modification. As your injury recovers, you can start more aggressive stretching, aggressive strengthening, and gentle activity. Depending on the grade of your strain, this is usually best done under the guidance of a physical therapist.
Hamstring Strain Recovery
1. Rolling out the hamstrings will help relieve any increased tension that has developed pre and post-injury. As you spend 3-5 mins rolling your hamstring muscle belly, be on the lookout for tight and painful spots. It should feel more like a "hurt so good" type of feeling, it should not feel excruciating!
Once you find a symptomatic spot, sit on it, and relax your breathing. You can also tac and stretch that spot by bending and straightening your leg slowly. You need to be sitting in a chair or on a table with your ankle hanging off to tac and stretch. Remember to change the angle of your thigh and rotate it out or in to get different portions of the muscle belly.
2. Another aspect of the hamstring you need to check is the range of motion. Are you able to straighten your leg under tension without pain?
Heel slides on the wall is a good way to check for that. Find a doorway and lay on your back with the injured leg on the door frame. It helps to wear a sock on your injured leg. Keep your opposite leg straight on the floor. Start with the knee bent and slowly slide the heel up the door frame.
Take note of how it feels, is it painful? Is it getting worse or staying the same? Keep your pain to a tolerable level as you perform 10 reps. If the pain is no worse, rest and try another 2 sets of heel slides.
Adjust how close your bottom is to the door frame. The closer your bottom is the more difficult the heel slide will feel. Take your time as you work a little into your painful range.
With your leg fully straight, contract your quad muscle for a few seconds before lowering your heel. Try performing 3 sets of 10, 2 times a day.
If doing heel slides against the door is too hard, try them while lying on the floor. The purpose of this exercise is two-fold: to regain any lost range of motion and to normalize that motion. We want full pain free range of motion with this exercise.
3. Deadlifting is a great way to introduce load to your hamstrings.
Good form is very important with this exercise to properly target your hamstrings. Your feet need to be shoulder-width apart and pointed straight ahead. Keep your back straight, hinge at your hips, and bend your knees to go deeper into the deadlift.
Start without weight and assess how just bodyweight feels. If bodyweight is intolerably painful, do not add weight. If bodyweight feels easy and mostly asymptomatic, you may begin to add weight. Start light and gradually build up.
Remember to control the weight as you push through your legs. Keep those knees in neutral. Whenever you add weight, make sure you are able to control the entire movement while maintaining good form. Find a weight that will challenge you with 3 sets of 10.
4. Nordic hamstring curls have been frequently researched in rehabilitating lower leg injuries. Some studies indicate that they help with reducing the risk of hamstring strains.
I include nordic hamstring regression variations as a part of a hamstring strain rehab program because nordic hamstring curls are very difficult to do.
The first exercise demonstrated is a curl with a push-up. Remember to activate your core and slow your descent with your hamstrings. As you touch the floor enter your push up position. Apply enough force with your pushup to aid your hamstrings as you curl them up into the starting position.
The second exercise is a nordic hamstring curl with a ball roll out. Keep that core activated and your back straight as you roll the ball out. Your hamstrings need to be on the whole time. Keep your movement slow and controlled.
Both of these exercises will be very taxing for your hamstrings--- This should feel like a workout. Choose one of the above and try performing 3 sets of 8, adding these variations to your strength training. These regressions will give your hamstrings some good contraction under tension.
The goal of these exercises is to bulletproof your hamstrings
Proper rehab for a strain injury is crucial.
Just because you are not experiencing pain does not mean that your hamstring has fully healed and is ready for any load or stress placed on it.
It's crucial that you have a strategic and comprehensive plan in order to get your hamstring back to where it was before your injury so that you can stay active in the long run! One of the risk factors for getting a strain is a previous strain, so you want to make sure that your muscle rebounds from this strain and is as strong and resilient as possible to help prevent future strains.
We have many years of experience helping Memphis athletes recover from all manner of hamstring strains, and we can guide you through a step-by-step plan that will give you the confidence that your hamstring is healing properly.
We'll spend time gradually loading and stressing your hamstring in order to promote a strong and healthy muscle while also making sure you have a full range of motion and good strength in that range of motion.
As your hamstring heals, we'll acclimate your leg to impact and fast/slow dynamic movements to prepare you for more high-impact sports like running so that this injury won't slow you down for very long!
Hamstring rehab can be a complicated process, let us help simplify it for you.
We help Memphis athletes stay active for a lifetime.
Ishøi, Lasse, et al. “Infographic. Diagnosis, Prevention, and Treatment of Common Lower Extremity Muscle Injuries in Sport—Grading the Evidence: a Statement Paper Commissioned by the Danish Society of Sports Physical Therapy (DSSF).” British Journal of Sports Medicine, 2020, doi:10.1136/bjsports-2020-102119.