Jump to content

Hamstring Strain


Original Editor - Bo Hellinckxas part of the Vrije Universiteit Brussel's Evidence-based Practice project


Top Contributors - Purnima Raikwar, Admin, Boddengeen Ben, Bo Hellinckx, George Prudden, Mandeepa Kumawat, Vinit Kothekar, Nupur Smit Shah, Shaimaa Eldib, Evan Thomas, Vidya Acharya, Uchechukwu Chukwuemeka, Rachael Lowe, Kim Jackson, Tomer Yona, Aminat Abolade, Alexandra Stead, Wanda van Niekerk, Fasuba Ayobami, Iris Roelandt, Shoko Otsuka, Jonathan Wong, Pacifique Dusabeyezu, Daphne Jackson, Livia Hoeben, 127.0.0.1, Claire Knott, Simisola Ajeyalemi, WikiSysop, Kai A. Sigel, Tania Appelmans and Tony Lowe
This article is currently under review and may not be up to date. Please come back soon to see the finished work! (24/08/2026)


Introduction

A hamstring strain is a stretch or tear of one or more muscles within the hamstring muscle complex, including the biceps femoris, semitendinosus, and semimembranosus, all located in the posterior thigh.[1] Hamstring strain injuries (HSI) are among the most prevalent musculoskeletal injuries in sport, accounting for 12–29% of all injuries in athletic populations, with recurrence rates exceeding 30%.[2] The injury typically occurs during the terminal swing phase of the gait cycle during sprinting, or during movements involve extreme hip flexion with simultaneous knee extension, such as in dance and gymnastics.[3] Due to their high incidence, significant recurrence rate, and potential to cause prolonged absence from sport, hamstring strain injuries represent a major clinical challenge for physiotherapists and sports medicine professionals. For the individual, these injuries can result in considerable impairment, activity limitation, and restriction from sports participation.[4]

Clinically Relevant Anatomy

The hamstring muscle complex consist of three muscles located in the posterior compartment of the thigh:[5]

  • Biceps Femoris — has a long head originating from the ischial tuberosity and a short head from the linea aspera of the femur. Both inserting via a common tendon into the head of the fibula. The long head of the biceps femoris is the most commonly injured muscle in sprint-type hamstring strains.
  • Semitendinosus — originates from the ischial tuberosity and inserts into the medial surface of the proximal tibia as a part of pes anserinus.
  • Semimembranosus — also arises from the ischial tuberosity and inserts primarily into the posterior aspect of the medial tibial condyle.

All three muscles are primarily supplied by the tibial division of the sciatic nerve ( L5–S2), and the short head of biceps femoris innervated by the common fibular division. The hamstrings cross two joints, acting as hip extensors and knee flexors. Their primary functional demand during dynamic activities is the eccentric deceleration of knee extension and hip flexion during the terminal swing phase of running.[5] This biarticular function, combined with the high eccentric loading demands of sprinting, places the musculotendinous junction under significant mechanical stress and accounts for the high injury incidence in this muscle group.[6]

The musculotendinous junction (MTJ) particularly the proximal myotendinous region of the biceps femoris long head, is the most common site of hamstring strain injury due to the high tensile strain and eccentric loading experienced during sprinting and rapid lengthening contractions.[7][8]

Epidemiology and Aetiology

The cause of a hamstring muscle strain is often multifactorial and not always clearly identifiable. In the second half of the swing phase, the hamstrings are at their greatest length and at this moment, they generate maximum tension.[9] In this phase, the hamstrings contract eccentrically to decelerate flexion of the hip and extension of the knee.[10] At this point, a peak is reached in the activity of the muscle spindles in the hamstrings. A strong contraction of the hamstring and relaxation of the quadriceps are needed. A breakdown in the coordination between these antagonist muscles may cause the hamstring to tear.[10] The greatest musculotendinous stretch is experienced by the biceps femoris, which may contribute to its tendency to be more often injured than the other 2 hamstring muscles (semimembranosus and semitendinosus) during high-speed running.[11]

Mechanism of Injury

Hamstring strain injuries are caused by the generation of high mechanical stress within the muscle, typically occurring in one of two clinical scenarios:[12]

Sprint-type (Type I) injuries These occur during high-speed running, specifically at the end of the swing phase when the hamstrings are generating maximal eccentric force to decelerate the extending knee whilst simultaneously the hip is in full flexion. The proximal portion of the long head of the biceps femoris is the most commonly affected site.[13]

Stretch-type (Type II) injuries These occur during movements requiring extreme muscle lengthening with concurrent hip flexion and knee extension — such as kicking, dancing, or sliding tackles. These injuries tend to involve the proximal free tendon or proximal musculotendinous junction and are more commonly associated with the semimembranosus or proximal biceps femoris tendon. Stretch-type injuries are generally associated with longer recovery times.[14]

Excessive anterior pelvic tilt places the hamstrings at greater resting length, and may increase susceptibility to strain injury during high-speed movements.[2][15] Neuromuscular fatigue, reduced eccentric strength, and uncoordinated muscle activation patterns also contribute to the mechanism of injury.[16]

Predisposing /Risk Factors

There are various proposed risk factors that may play a role in hamstring injuries can be divided into intrinsic and extrinsic risk factors: [17]

Intrinsic Factors

  1. Non- modifiable -
  • Older age
  • Male athletes are twice as likely to sustain hamstring injuries compared to female athletes.[18]
  • Ethnicity, with some evidence suggesting variation in injury rates across different ethnic groups. [19]
  • Genetic predisposition (IGF2 and CCL2 polymorphisms)[20]
  • Hamstring muscle architecture variations (short BFlh fascicles)[21]

2. Modifiable -

  • Previous hamstring injury, Hamstring-to-quadriceps strength imbalance [22]
  • Fatigue[23]
  • Poor core stability and lumbopelvic control [24]
  • Previous calf injury, Previous substantial knee injury, or Osteitis pubis[25]
  • Neuromuscular coordination deficits [26]
  • Reduced flexibility or tight hip flexors - A 2020 systematic review (SR) suggested that flexibility and range of motion (ROM) had no significant association with the risk of hamstring strain injuries.[27][28] However, the evidence is conflicting, with some research showing limited hamstring flexibility[29] and tight hip flexors[30] may increase risk.
  • One study found that increased quadriceps flexibility was inversely associated with hamstring strain incidence in a group of amateur Australian Rules footballers.[31]
  • Lumbar spine abnormalities and postural dysfunction - Kicking and abdominal strengthening exercises performed with straight legs have been identified as possible contributory causes of lumbar lordosis. The anatomical reason seems to be that the iliopsoas muscle group is primarily involved in kicking and straight leg raising or straight leg sit-up exercises and contributes to strengthening this muscle'. Therefore, certain athletic activities and training methods that exacerbate postural defects may also predispose the athlete to injury.[32]
  • High eccentric loading during running and kicking[33]

Extrinsic Factors

  • High speed running and sprinting[34]
  • Sudden increase in training load[35]
  • Inadequate recovery and Poor warm-up[36]
  • Sports- specific demands[37]
  • Poor training periodisation[38]
  • Surface and environment conditions[39]
  • Congested competition schedules[40]

Classification

Traditional Grading System

Hamstring strains are commonly graded on a three-point scale based on the degree of muscle fibre disruption:[1]

  • Grade 1 (mild): Fewer than 10% of muscle fibres are disrupted. The person experiences localised pain and minimal swelling, with little loss of strength or range of motion. Return to sport typically within 1–3 weeks.
  • Grade 2 (moderate): A partial tear involving a greater proportion of fibres. The person presents with moderate pain, swelling, and ecchymosis, with a noticeable reduction in strength and range of motion. Return to sport typically 3–8 weeks.
  • Grade 3 (severe): A complete or near-complete tear. The person is unable to contract the muscle and experiences significant pain, swelling, and functional loss. Surgical consultation may be required. [41]

British Athletics Muscle Injury Classification (BAMIC)

The BAMIC system classifies muscle injuries based on both the site of injury (myofascial, musculotendinous junction, or intramuscular tendon) and the extent of injury (percentage of cross-sectional area involved and cranio-caudal length on MRI). [42] Injuries involving the intramuscular tendon (grade 3c and 4 injuries) are associated with prolonged return to play and higher reinjury risk, and are therefore of particular prognostic relevance.[43]

Munich Classification

The Munich Muscle Injury Classification is a comprehensive system integrating both functional and structural injury types, providing a common language for clinicians and researchers. It categorises injuries from functional muscle disorders (no structural damage) through to subtotal and complete muscle tears.[1]

These modern classification systems are increasingly preferred in clinical and research settings as they offer stronger prognostic value than the traditional grade 1–3 system alone.[44][45]

Clinical Presentation

Hamstring strain typically presents with sudden onset of sharp or pulling posterior thigh pain, most commonly during sprinting or a rapid stretching movement. Symptoms vary according to injury severity:[5]

  • Pain: Acute, localised pain in the posterior thigh; may range from mild discomfort to severe, debilitating pain preventing weight-bearing. A "popping" or tearing sensation may be reported at the time of injury.
  • Swelling and ecchymosis: May be delayed for 24–72 hours following injury and may track distally. Extensive bruising suggests a higher-grade injury.
  • Gait disturbance: Shortened stride length is common; inability to weight-bear suggests Grade 3.
  • Neurological symptoms: Numbness, tingling, or distal weakness are uncommon and, when present, should prompt investigation of sciatic nerve involvement or proximal hamstring avulsion.

Differential Diagnosis

The following conditions should be considered when assessing posterior thigh pain:[5]

  • Proximal Hamstring Tendinopathy usually presents with gradual onset deep pain near the sitting bone and is often aggravated by sitting, running, or loading activities.
  • Sciatic nerve injury or referred pain from the lumbar spine and piriformis region(piriformis syndrome) may mimic hamstring symptoms. Neurological signs or radiating symptoms may be present.
  • Ischial tuberosity apophyseal avulsion is more common in adolescents and may present with tenderness directly over the ischial tuberosity. Radiographs can help to confirm the diagnosis.
  • Adductor/groin strain may also cause pain around the medial thigh and can co-exist with hamstring injury.
  • Posterior thigh compartment syndrome, although uncommon, may present with diffuse tightness, pressure, and worsening pain.
  • Deep vein thrombosis (DVT) should be excluded when swelling, calf tenderness, or symptoms appear disproportionate to the mechanism of injury.
  • Pain may also be referred from the lumbar spine or sacroiliac joint.

A thorough subjective history (mechanism of injury, onset, location) combined with systematic physical examination will usually differentiate these conditions.

Diagnostic Procedures

Most acute injuries can be identified by obtaining a detailed history of how the injury occurred. To be sure they must do a little investigation of the hamstrings as well.

When the diagnosis is uncertain, the clinician may request medical imaging to exclude other pathologies. This will exclude all other possibilities.[33]

Radiographs

An advantage of radiography is that it can differentiate the aetiology of pain, distinguishing muscular pathology from bony injury such as stress fracture. It can differentiate in muscular disease (e.g. muscle strain) or a disease of the bone (e.g. Stress fracture).[46]

Ultrasound (US)

This modality is widely used due to its cost-effectiveness and ability to image muscles dynamically. It is also a good method because it has the ability to image muscles dynamically. A limitation of ultrasound is that accurate interpretation requires a skilled and experienced clinician. [47]

Magnetic Resonance Imaging (MRI)

MRI provides a detailed assessment of muscle injury. However, imaging findings should always be interpreted alongside the patient’s clinical history and physical examination, as MRI findings may occasionally be inconclusive.[48]

MRI can also help classify muscle injuries into two main groups:

  • Direct muscle injuries – caused by direct external trauma to the muscle.
  • Indirect muscle injuries – commonly related to excessive stretch or overload mechanisms.

Indirect muscle injuries are further classified into:

Functional muscle injuries: These injuries present with clinical symptoms without macroscopic evidence of muscle fibre tear on MRI. Functional injuries are often multifactorial and may be associated with overload or neuromuscular dysfunction.

Structural muscle injuries: These injuries demonstrate macroscopic evidence of muscle fibre tearing and structural damage on MRI. Structural injuries commonly occur at the musculotendinous junction, which is considered a biomechanically vulnerable region.[49]

Some studies evaluating athletes following hamstring injuries reported that normalisation of increased MRI signal intensity may not be necessary before a successful return to play (RTP).[50]

Hamstring injuries can be classified based on the mechanism of injury, clinical presentation, and MRI findings. The table below summarises the different categories of hamstring injuries, including direct, indirect functional, and structural injuries, along with their associated MRI characteristics.[51]

Type of injury Definition MRI
Direct Contusion: blunt trauma from external factors, with intact muscle tissue

Laceration: blunt trauma from an external factor with muscular rupture

Hematoma
Indirect :Functional 1A: fatigue-induced muscle disorder Muscle stiffness

1B: delayed onset muscle soreness Acute inflammatory pain

Type 2: muscle disorder of neuromuscular origin

2A: spine-related neuromuscular muscle disorder Increased muscle tone due to neurological disorder

2B: muscle-related neuromuscular muscle disorder Increased muscle tone due to altered neuromuscular control

Negative

Negative or isolated edema

Structural Type 3: Partial muscle tear

3A: minor partial muscle tear: tear involving a small area of the maximal muscle diameter

3B: moderate partial muscle tear: tear involving moderate area of maximum muscle diameter

Type 4: (sub)total muscle tear with avulsion:

Involvement of the entire muscle diameter, muscle defect

Fiber rupture

Retraction and hematoma

Complete discontinuation of fibers

Outcome Measures

  • FASH: The FASH(Functional assessment scale for acute Hamstring injuries) questionnaire is a self-administered questionnaire which now can only be used in Greek, English and German languages. Because hamstring injuries represent the most common football injury, they tested the validity and reliability of the FASH-G (G = German version) questionnaire in German-speaking footballers suffering from acute hamstring injuries. The FASH-G is a valid and reliable instrument to assess and determine the severity of hamstring injuries in a population of athletes.[52][53]
  • LEFS: Lower Extremity Functional Scale is a patient-reported outcome measure used to assess functional ability in patients with lower extremity musculoskeletal conditions, including hamstring injuries.[54]
  • SFMA: The Selective Functional Movement Assessment (SFMA) is a clinical assessment system designed to identify musculoskeletal dysfunction by evaluation of fundamental movements for limitations or symptom provocation.[55]
  • PSFS: The Patient Specific Functional Scale is a self-report outcome measure in which patients identify and rate activities they find difficult due to their injury, making it useful for individualised rehabilitation goal-setting.[56]
  • VAS: The Visual Analog Scale is a unidimensional measure of pain intensity, commonly used to track symptom progression throughout hamstring injury rehabilitation.[57]
  • NPRS: The Numerical Pain Rating Scale is an 11-point scale (0–10) used to quantify pain severity, where 0 indicates no pain and 10 indicates the worst imaginable pain.[58]

Clinical Examination

There are multiple components need to assess for a hamstring strain injury. A structured clinical examination includes subjective assessment, observation, gait assessment, palpation, range of motion testing, strength assessment, neurological screening, and special clinical tests.[59]

Subjective History

  • Mechanism of injury (sprint-type vs stretch-type injury)
  • Onset, location, and severity of pain
  • Previous history of hamstring injury
  • Sport-specific and activity demands
  • Presence of pain during running, sprinting, stretching, or sitting.

Observation and Gait Assessment

Observation: It includes assessment of posture, gait, and visible soft tissue changes.

  • Walking gait assessment may reveal protective limping, shortened stride length, reduced stance time, or reduced hip extension during terminal stance.
  • Running gait assessment may be included in athletic populations, particularly during later stages of rehabilitation or return-to-sport assessment. Athletes may demonstrate reduced stride length, altered pelvic control, or pain during terminal swing phase.
  • Swelling, bruising, or ecchymosis may not be visible immediately after injury and can appear several days later.
  • The posterior thigh should be inspected for asymmetry, swelling, deformity, muscle wasting, or visible ecchymosis.[60]

Palpation

Palpation is useful for identifying the injured structure and reproducing symptoms.[61]

  • Examination is commonly performed in prone with the knee slightly flexed to reduce passive tension on the hamstrings.
  • The posterior thigh should be palpated systematically from the ischial tuberosity distally through the muscle belly toward the distal musculotendinous junction.
  • The clinician should assess the location and quality of tenderness, symptom reproduction, swelling, and the presence of any palpable defect within the musculotendinous unit.

A more proximal site of maximal tenderness near the ischial tuberosity has been associated with longer recovery time and delayed return to sport.[11]

Range of Motion

Range of motion assessment should include both active and passive testing of the hip and knee joints.

Commonly used tests include:[62]

  • Passive straight leg raise (SLR)
  • Active straight leg raise
  • Active knee extension (AKE) test at 90° hip flexion

These tests help assess hamstring flexibility, muscle length, pain provocation, and side-to-side asymmetry. In acute injuries, range of motion may be limited by pain and muscle guarding. Bilateral comparison is recommended.

Strength Testing

Strength assessment should evaluate pain, weakness, and asymmetry compared with the contralateral limb.

Common assessments include:

  • Resisted knee flexion in prone or supine
  • Resisted hip extension
  • Isometric knee flexion strength testing

Internal or external rotation of the lower leg during testing may help bias the medial or lateral hamstring muscles and assist in identifying the involved structure.[63]

Neurological Screening

Neurological examination should be performed to exclude referred pain or neural involvement.

Assessment may include:

  • Sensory changes or paraesthesia
  • Pain radiating below the knee
  • Neural tension tests
  • Signs of sciatic nerve involvement. [64]

Clinical tests

A systematic review by Reiman et al examined clinical tests for hamstring injuries.[65] The review included patients that presented with hamstring or posterior thigh pain but excluded those with pathology that was associated with a condition that originated elsewhere that referred pain to the hamstring/posterior thigh (i.e. the lumbar spine), The results are listed below[65]:

  • Puranen-Orava test – Actively stretching the hamstring muscles in standing position with hip flexed at about 90 degrees, the knee fully extended and foot on a solid surface. Positive – exacerbation of symptoms.
  • Bent-Knee stretch test
  • Modified Bent-knee stretch test
  • Taking off the shoe test/hamstring-drag test
  • Active ROM test
  • Passive ROM test
  • Resisted ROM test

+LR: The probability that an individual with the target disorder tests positive, divided by the probability that an individual without the disorder tests positive. A higher value indicates greater diagnostic utility.

-LR: The probability that an individual with the condition tests negative, divided by the probability that an individual without the condition tests negative. A lower value indicates a better ability to rule out the condition.

Tests Summary
Test Sensitivity Specificity +LR -LR
Puranen-Orava 0.76 0.82 4.2 0.29
Bent-Knee stretch  0.84 0.87 6.5 0.18
Modified Bent-knee stretch 0.89 0.91 9.9 0.12
Taking off the shoe 1.00 1.00 280 0.00
Active ROM 0.55 1.00 154.6 0.50
Passive ROM 0.57 1.00 160.6 0.43
Resisted ROM 0.61 1.00 170.6 0.40

Medical Management

Non-steroidal anti-inflammatory drugs (NSAIDs) may be used for short-term pain management, however, evidence for their benefit in acute muscle injury is limited. Platelet-rich plasma (PRP) injections have been investigated, but current evidence does not support routine use. Surgical management (tendon repair) is indicated for complete proximal hamstring avulsion injuries and is ideally performed within 4–6 weeks of injury.[1][66]

Surgical intervention is rarely indicated following a hamstring strain and is usually reserved for complete hamstring rupture. In a study by Cross et al.[67] most patients reported subjective improvement following surgery. Approximately 91% were satisfied with the outcome and rated their satisfaction as 75% or higher. Post-operative hamstring strength ranged from 45% to 88% of the contralateral limb, while endurance testing ranged from 26% to 100%.[68] Follow-up examination demonstrated that all surgical repairs remained intact.[69]

Platelet-poor plasma, blood flow restriction training, extracorporeal shockwave therapy, and injection therapies have shown potential benefits in return to play outcomes. However, further high-quality research is required before these interventions can be routinely recommended.[70]

Prognosis

Many factors impact prognosis in terms of recovery times such as:[71] [72]

  • Number of days with daily life impairments due to the injury,
  • Degree of muscle function loss or disability,
  • Physical activity performed by the patient and/or physical examination (pain provocation, flexibility deficit, strength deficit and functional impairment)

Prognosis remains challenging for each patient. This is because of significant variations in recovery times even within muscle injury types (for example, hamstring strains in professional football have a median recovery period of two weeks, with 80% of athletes recovering within a few days to five weeks.[73] Currently, accurate estimations of recovery time for individuals after sustaining muscle injuries remain inaccurate.[73] That said, subsequent reassessments during the rehab period may enable more accurate determinations of recovery time and time to return to activities.[71]

Physiotherapy Management

The primary objective of physiotherapy is to restore full function and facilitate return to sport at the pre-injury level with minimal risk of reinjury.[5]

Acute Phase (Days 0–7)

Initial management follows PEACE & LOVE principles (Protection, Elevation, Avoid anti-inflammatory modalities, Compression, Education; Load, Optimism, Vascularisation, Exercise) rather than the outdated RICE model:[74]

  • Protect: Unload and restrict movement for 1–3 days to minimise bleeding and prevent aggravation.
  • Elevate: Elevate the limb above heart level to reduce swelling.
  • Avoid anti-inflammatories: Inhibiting inflammation may impair tissue healing in the early stages.
  • Compress: Apply external mechanical pressure to reduce swelling.
  • Educate: Promote active recovery and set realistic return-to-sport expectations.

Then progress to:

  • Load: Optimal loading using pain as a guide, without exacerbating symptoms.
  • Optimism: Maintain a positive outlook on recovery.
  • Vascularisation: Pain-free cardiovascular exercise commenced early.
  • Exercise: Restore mobility, strength, and proprioception without pain provocation.

Rehab Goals:

  • Reduce pain and oedema
  • Protect healing tissue
  • Maintain cardiovascular fitness.

Management:

  • Pain-free range of motion exercises
  • Isometric hamstring and gluteal contractions
  • Low-intensity cardiovascular activity (e.g. pool walking, cycling at low resistance)
  • Cryotherapy and compression for oedema management

Progression Criteria: Pain-free walking at normal speed, pain ≤2/10 on NPRS with daily activities.[75]

Subacute Phase (Loading Phase - Days 7–21)

Rehab Goals:

  • Progressive loading of the hamstring
  • Restore strength and range of motion.

Management:

  • Progressive pain-free eccentric loading commencing at low load and increasing in range and speed
  • Nordic hamstring curls — introduction dependent on pain levels and injury grade
  • Hip extension and knee flexion strengthening, Romanian deadlift
  • Lumbopelvic stabilisation exercises
  • Low-speed running reintroduction when pain-free walking is achieved
  • Sport-specific movement patterns at submaximal intensity
  • Progression Criteria: Full pain-free range of motion, strength symmetry ≥70% compared to uninjured limb on isokinetic or handheld dynamometry.[76]

Rehabilitation and Return-to-Sport Phase (Weeks 3–12+)

Goals

  • Restore full hamstring strength
  • Improve neuromuscular control and lumbopelvic stability
  • Increase tolerance to high-speed running and sport-specific movements
  • Prepare the athlete for safe return to sport

Management

The rehabilitation programme during this phase focuses on progressive eccentric strengthening, plyometric training, neuromuscular control, and sport-specific loading. Exercise intensity and running speed should be progressed gradually according to symptoms, strength recovery, and functional performance.

Eccentric Strengthening Exercises

  • Eccentric backward steps
  • Eccentric lunge drops
  • Eccentric forward pulls
  • Single-leg deadlifts
  • Double-leg deadlifts
  • Split-stance deadlift (good morning)

Plyometric and Agility Exercises

  • Squat jumps
  • Split jumps
  • Bounding
  • Depth jumps
  • Single-leg bounding
  • Backward skips
  • Lateral hops
  • Lateral bounding
  • Zigzag hops
  • Plyometric box jumps

Sport-Specific Rehabilitation

  • Progressive straight-line sprinting
  • Acceleration drills
  • Deceleration drills
  • Change-of-direction activities
  • Running mechanics and movement retraining when required

Neuromuscular Control Exercises Exercises targeting balance, coordination, trunk stability, and lower-limb control should be included throughout rehabilitation.

Progression Criteria Progression toward return to sport should consider:

  • Limb symmetry index ≥90% for eccentric hamstring strength
  • Pain-free completion of sport-specific drills
  • Full range of motion without symptom provocation
  • Psychological readiness to return to sport.[77]

Nordic Hamstring Exercise

[78]

Prevention

Evidence-based prevention of hamstring strain injury should include the following strategies:[2]

  • Nordic Hamstring Exercise: The most well-evidenced intervention for reducing hamstring injury incidence. A systematic review and meta-analysis (Al Attar et al., 2017) demonstrated a 51% reduction in hamstring injury rates in football players when the Nordic hamstring exercise was incorporated into training programmes.[79] Compliance remains a barrier to implementation.[80]
  • Progressive eccentric strengthening: General eccentric hamstring loading programmes reduce injury risk independent of the Nordic exercise.[81]
  • Graduated return to high-speed running: Progressive GPS-monitored sprint load exposure reduces reinjury risk.[82]
  • Structured Warm-up programmes: The FIFA 11+ warm-up programme has demonstrated effectiveness in reducing overall lower limb injury rates in football and includes hamstring-specific components.[83]
  • Training load monitoring and management: Avoiding sudden spikes in training volume and intensity, Progressive increases in high-speed running volume should not exceed 10% per week.[84] Adequate recovery and appropriate load management are important for reducing the risk of hamstring injury.[85]
  • Addressing modifiable risk factors: Correcting musculoskeletal control, and addressing strength asymmetries.- Lumbopelvic Stabilisation: Exercises targeting the gluteal muscles and deep trunk stabilisers reduce anterior pelvic tilt and improve hamstring neuromuscular control. [86]- Hip Flexor Flexibility: Restricted hip flexor length is associated with increased anterior pelvic tilt and compensatory hamstring overload; regular flexibility work is recommended.[87]

Prevention programmes should be implemented at least twice per week for optimal effect.

Return to Sport

Return to sport following hamstring strain should criteria-based rather than purely time-based. According to the JOSPT Clinical Practice Guidelines (2022):[5]

  • Clinicians should account for previous hamstring injury history before clearing an athlete, as this is the strongest predictor of reinjury.
  • Athletes who have not completed a comprehensive rehabilitation programme incorporating eccentric exercises should be progressed cautiously.
  • Key criteria to assess before return to sport include:
    • Full, pain-free range of motion
    • Hamstring strength symmetry (≥90% limb symmetry index on isokinetic or isometric testing)
    • Successful completion of sport-specific running and change-of-direction tasks
    • Pain-free performance of high-speed running
    • Ability to perform the Askling H-test pain-free

Prognostic indicators of longer return-to-play times include: significant pain at time of injury, inability to walk pain-free within the first 48 hours, MRI evidence of intramuscular tendon involvement (BAMIC Grade 3c/4), and proximal location of injury.

Typical return-to-sport timelines (should be used as guidance only):[88]

  • Grade 1: 1–3 weeks
  • Grade 2: 3–8 weeks
  • Grade 3 (structural): 8–16+ weeks
  • Complete proximal avulsion with surgical repair: 6+ months

Resources

Resources

[89]
[90]
[91]

References

  1. ↑ 1.0 1.1 1.2 1.3 Larson JH, Fenn TW, Allahabadi S, Nho SJ. Hamstring strains: classification and management. Sports Health. 2024 Jul;16(4):661-3.
  2. ↑ 2.0 2.1 2.2 Wing C, Bishop C. Hamstring strain injuries: Incidence, mechanisms, risk factors, and training recommendations. Strength Cond J. 2020;42(3):40–57.
  3. ↑ Wing C, Bishop C. Hamstring strain injuries: Incidence, mechanisms, risk factors, and training recommendations. Strength Cond J. 2020;42(3):40–57.
  4. ↑ Thorborg K, Krommes KK, Esteve E, Clausen MB, Bartels EM, Rathleff MS. Effect of specific exercise-based football injury prevention programmes on the overall injury rate in football: a systematic review and meta-analysis of the FIFA 11 and 11+ programmes. Br J Sports Med. 2017;51(7):562–571.
  5. ↑ 5.0 5.1 5.2 5.3 5.4 5.5 Hickey JT, Opar DA, Weiss LJ, Heiderscheit BC. Hamstring Strain Injury Rehabilitation. J Orthop Sports Phys Ther. 2022;52(3):CPG1–CPG44.
  6. ↑ Heiderscheit BC, Sherry MA, Silder A, Chumanov ES, Thelen DG. Hamstring strain injuries: recommendations for diagnosis, rehabilitation, and injury prevention. J Orthop Sports Phys Ther. 2010;40(2):67–81.
  7. ↑ Evangelidis PE, Kellis E. Localized strain patterns within the proximal myotendinous junction during eccentric hamstring contractions. ''Eur J Appl Physiol''. 2025. doi:10.
  8. ↑ Danielsson A, Horvath A, Senorski EH, et al. The mechanism of hamstring injuries – a systematic review. ''BMC Musculoskeletal Disorders''. 2020;21:641. doi:10.
  9. ↑ Cattrysse E, Provyn S, Scafoflieri A, Van Roy P, Clarijs J.P, Van Noten P, et al. Compendium Topografische en Kinesiologische Ontleedkunde; Vrije Universiteit Brussel; Brussel; 2015-2016
  10. ↑ 10.0 10.1 Sperryn PN. CE KLAFS and DD ARNHEIM “Modern Principles of Athletic Training”. British Journal of Sports Medicine. 1983 Jun;17(2):116.
  11. ↑ 11.0 11.1 Heiderscheit BC, Sherry MA, Silder A, Chumanov ES, Thelen DG. Hamstring strain injuries: recommendations for diagnosis, rehabilitation, and injury prevention. journal of orthopaedic & sports physical therapy. 2010 Feb;40(2):67-81.
  12. ↑ Huygaerts S, Cos F, Cohen DD, et al. Mechanisms of hamstring strain injury: Interactions between fatigue, muscle activation and function. Sports. 2020;8(5):1–15.
  13. ↑ Kenneally-Dabrowski CJB, Brown NAT, Lai AKM, Perriman D, Spratford W, Serpell BG. Late swing or early stance? A narrative review of hamstring injury mechanisms during high-speed running. ''Scand J Med Sci Sports''. 2019;29(8):1083-1091. doi:10.1111/sms.13437
  14. ↑ Askling CM, et al. Acute First-Time Hamstring Strains during Slow-Speed Stretching. Am J Sports Med. 2007.
  15. ↑ Mendiguchia J, Gonzalez A, Mendez-Villanueva A, et al. Training-induced changes in anterior pelvic tilt: potential implications for hamstring strain injuries management. ''J Sports Sci''. 2021;39(2):232-241. doi:10.1080/02640414.2020.1845439
  16. ↑ Bayrak A, Patlar S. Increased anterior pelvic tilt angle elevates the risk of hamstring injuries in soccer player. ''Res Sports Med''. 2025;33(2):129-145. doi:10.1080/15438627.2024.2430662
  17. ↑ Opar DA, Williams MD, Shield AJ. Hamstring strain injuries. Sports medicine. 2012 Mar;42(3):209-26.
  18. ↑ Edouard P, Feddermann-Demont N, Alonso JM, Branco P, Junge A. Sex differences in injury during top-level international athletics championships: surveillance data from 14 championships between 2007 and 2014. British journal of sports medicine. 2015 Apr 1;49(7):472-7.
  19. ↑ Prior M, Guerin M, Grimmer K. An evidence-based approach to hamstring strain injury: a systematic review of the literature. Sports Health. 2009;1(2):154–164.
  20. ↑ Cupeiro R, González-Lamuño D, Amigo T, et al. Influence of the IGF2 and CCL2 genes on the risk of muscle injuries in professional soccer players. Gene. 2016;590(1):69–74.
  21. ↑ Timmins RG, Bourne MN, Shield AJ, Williams MD, Lorenzen C, Opar DA. Short biceps femoris fascicles and eccentric knee flexor weakness increase the risk of hamstring injury in elite football (soccer): a prospective cohort study. Br J Sports Med. 2016;50(24):1524–1535.
  22. ↑ Yeung SS, Suen AM, Yeung EW. A prospective cohort study of hamstring injuries in competitive sprinters: preseason muscle imbalance as a possible risk factor. Br J Sports Med. 2009;43(8):589–594.
  23. ↑ Small K, McNaughton L, Greig M, Lovell R. The effects of multidirectional soccer-specific fatigue on markers of hamstring injury risk. J Sci Med Sport. 2010;13(1):120–125.
  24. ↑ Kibler WB, Press J, Sciascia A. The role of core stability in athletic function. Sports Med. 2006;36(3):189–198.
  25. ↑ Gabbe BJ, Finch CF, Bennell KL, Wajswelner H. Risk factors for hamstring injuries in community level Australian football. Br J Sports Med. 2005;39(2):106–110.
  26. ↑ Schuermans J, Van Tiggelen D, Danneels L, Witvrouw E. Biceps femoris and semitendinosus-teammates or competitors? New insights into hamstring injury mechanisms in male football players: a muscle functional MRI study. Br J Sports Med. 2014;48(22):1599–1606.
  27. ↑ Green B, Bourne MN, van Dyk N, et al Recalibrating the risk of hamstring strain injury (HSI): A 2020 systematic review and meta-analysis of risk factors for index and recurrent hamstring strain injury in sport. British Journal of Sports Medicine 2020;54:1081-1088.
  28. ↑ van Doormaal MC, van der Horst N, Backx FJ, Smits DW, Huisstede BM. No Relationship Between Hamstring Flexibility and Hamstring Injuries in Male Amateur Soccer Players: A Prospective Study. Am J Sports Med. 2017 Jan;45(1):121-126. doi: 10.1177/0363546516664162. Epub 2016 Oct 1. PMID: 27582278.
  29. ↑ Tokutake G, Kuramochi R, Murata Y, Enoki S, Koto Y, Shimizu T. The risk factors of hamstring strain injury induced by high-speed running. Journal of sports science & medicine. 2018 Dec;17(4):650.
  30. ↑ Prior M, Guerin M, Grimmer K. An evidence-based approach to hamstring strain injury: a systematic review of the literature. Sports health. 2009 Jan;1(2):154-64.
  31. ↑ Gabbe BJ, Bennell KL, Finch CF, Wajswelner H, Orchard JW. Predictors of hamstring injury at the elite level of Australian football. ''Scand J Med Sci Sports''. 2006;16(1):7-13. doi:10.1111/j.1600-0838.2005.00441.
  32. ↑ Hennessey L, Watson AW. Flexibility and posture assessment in relation to hamstring injury. British Journal of Sports Medicine. 1993 Dec 1;27(4):243-6.
  33. ↑ 33.0 33.1 Brockett CL, Morgan DL, Proske UW. Predicting hamstring strain injury in elite athletes. Medicine & Science in Sports & Exercise. 2004 Mar 1;36(3):379-87.
  34. ↑ Askling CM, Tengvar M, Saartok T, Thorstensson A. Acute first-time hamstring strains during high-speed running: a longitudinal study including clinical and magnetic resonance imaging findings. Am J Sports Med. 2007;35(2):197–206.
  35. ↑ Woods C, Hawkins RD, Maltby S, Hulse M, Thomas A, Hodson A. The Football Association Medical Research Programme: an audit of injuries in professional football—analysis of hamstring injuries. Br J Sports Med. 2004;38(1):36–41.
  36. ↑ Dupont G, Nedelec M, McCall A, et al. Effect of 2 soccer matches in a week on physical performance and injury rate. Am J Sports Med. 2010;38(9):1752–1758.
  37. ↑ Woods C, Hawkins RD, Maltby S, Hulse M, Thomas A, Hodson A. The Football Association Medical Research Programme: an audit of injuries in professional football—analysis of hamstring injuries. Br J Sports Med. 2004;38(1):36–41.
  38. ↑ Gabbett TJ. The training—injury prevention paradox: should athletes be training smarter and harder? Br J Sports Med. 2016;50(5):273–280.
  39. ↑ Orchard J. Is there a relationship between ground and climatic conditions and injuries in football? Sports Med. 2002;32(7):419–432.
  40. ↑ Bengtsson H, Ekstrand J, Waldén M, et al. Match congestion increases the injury rate in professional football players. Br J Sports Med. 2013;47(12):743–747.
  41. ↑ Troyer WD, Phrathep D, Pagan-Rosado R, Hung CM, Kruse RC, Rosario-Concepcion R. Diagnosis and Management of Hamstring Muscle Injuries in Athletes. Curr Phys Med Rehabil Rep. 2026;14(1):3.
  42. ↑ Patel A, Chakraverty J, Pollock N, Chakraverty R, Suokas A, James SLJ. British athletics muscle injury classification: clinical and MRI predictors of return to play following hamstring injury in elite athletes. ''Br J Sports Med''. 2015;49(21):1388-1395. doi:10.1136/bjsports-2014-094131
  43. ↑ Zein MI, et al. Baseline clinical and MRI risk factors for hamstring reinjury. Br J Sports Med. 2024;58(14):766–76.
  44. ↑ Mueller-Wohlfahrt HW, Haensel L, Mithoefer K, et al. Terminology and classification of muscle injuries in sport: the Munich consensus statement. ''Br J Sports Med''. 2013;47(6):342-350. doi:10.1136/bjsports-2012-091448
  45. ↑ Valle X, Alentorn-Geli E, Tol JL, et al. Muscle injuries in sports: a new evidence-informed and expert consensus-based classification with clinical application. ''Sports Med''. 2017;47(7):1241-1253. doi:10.
  46. ↑ Hirahata Y, Yasui Y, Sasahara J, et al. Role of Ultrasonography and MRI in Acute Hamstring Strains: Diagnostic and Prognostic Insights. Diagnostics. 2025;15(9):1053. Available from: MDPI Diagnostics⁠.
  47. ↑ Muscle Injuries. Physiopedia. www.physio-pedia.com/Muscle_Injuries
  48. ↑ Hirahata Y, Yasui Y, Sasahara J, et al. Role of Ultrasonography and MRI in Acute Hamstring Strains: Diagnostic and Prognostic Insights. Diagnostics. 2025;15(9):1053. Available from: MDPI Diagnostics⁠.
  49. ↑ Ernlund L, Vieira LD. Hamstring injuries: update article. Revista brasileira de ortopedia. 2017 Aug;52(4):373-82.
  50. ↑ Reurink G, Goudswaard GJ, Tol JL, Almusa E, Moen MH, Weir A, Verhaar JA, Hamilton B, Maas M. MRI observations at return to play of clinically recovered hamstring injuries. British journal of sports medicine. 2014 Sep 1;48(18):1370-6.
  51. ↑ Mueller-Wohlfahrt HW, Haensel L, Mithoefer K, et al. Muscle injuries in sport: a one-stop guide for classification based on a comprehensive clinical and imaging approach. Br J Sports Med. 2013;47(6):342-350.
  52. ↑ Malliaropoulos N, Korakakis V, Christodoulou D, Padhiar N, Pyne D, Giakas G, Nauck T, Malliaras P, Lohrer H. Development and validation of a questionnaire (FASH—Functional Assessment Scale for Acute Hamstring Injuries): to measure the severity and impact of symptoms on function and sports ability in patients with acute hamstring injuries. British Journal of Sports Medicine. 2014 Dec 1;48(22):1607-12.
  53. ↑ FASH (Functional Assessment Scale for Acute Hamstring Injuries) questionnaire for German-speaking athletes. Br J Sports Med. 2011;45(13):1056–1063.
  54. ↑ Mehta SP, Fulton A, Quach C, Thistle M, Toledo C, Evans NA. Measurement properties of the Lower Extremity Functional Scale: a systematic review. ''J Orthop Sports Phys Ther''. 2016;46(3):200-216. doi:10.2519/jospt.2016.6205
  55. ↑ Glaws KR, Juneau CM, Becker LC, Di Stasi SL, Hewett TE. Intra- and inter-rater reliability of the selective functional movement assessment (sfma). Int J Sports Phys Ther. 2014 Apr;9(2):195-207.
  56. ↑ Horn KK, Jennings S, Richardson G, Vliet DV, Hefford C, Abbott JH. The Patient-Specific Functional Scale: psychometrics, clinimetrics, and application as a clinical outcome measure. ''J Orthop Sports Phys Ther''. 2012;42(1):30-42. doi:10.2519/jospt.2012.3727
  57. ↑ Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). ''Arthritis Care Res (Hoboken)''. 2011;63(S11):S240-S252. doi:10.1002/acr.20543
  58. ↑ Childs JD, Piva SR, Fritz JM. Responsiveness of the Numeric Pain Rating Scale in patients with low back pain. ''Spine''. 2005;30(11):1331-1334. doi:10.1097/01.brs.0000164099.92112.29
  59. ↑ Brukner P, Khan K. Brukner & Khan’s Clinical Sports Medicine. 5th ed. Sydney: McGraw-Hill Education; 2017.
  60. ↑ van der Horst N, Backx FJG, Goedhart EA, Huisstede BMA. Return to play after hamstring injuries: a qualitative systematic review of definitions and criteria. Sports Medicine. 2016;46(6):899-912.
  61. ↑ Hamstring protocol apsetar. Available from:http://www.aspetar.com/AspetarFILEUPLOAD/UploadCenter/636209313253275549_Aspetar%20Hamstring%20Protocol.pdf (assessed 10 July 2018)
  62. ↑ Askling C. Hamstring muscle strain. Karolinska Institutet (Sweden); 2008.
  63. ↑ Tol JL, Hamilton B, Eirale C, Muxart P, Jacobsen P, Whiteley R. At return to play following hamstring injury the majority of professional football players have residual isokinetic deficits. British Journal of Sports Medicine. 2014;48(18):1364-1369.
  64. ↑ StatPearls Publishing. Hamstring Injury. StatPearls. Treasure Island (FL): StatPearls Publishing; 2024.
  65. ↑ 65.0 65.1 Reiman MP, Loudon JK, Goode AP. Diagnostic accuracy of clinical tests for assessment of hamstring injury: a systematic review. journal of orthopaedic & sports physical therapy. 2013 Apr;43(4):222-31.
  66. ↑ Bodendorfer BM, Curley AJ, Kotler JA, et al. Outcomes after operative and nonoperative treatment of proximal hamstring avulsions: a systematic review and meta-analysis. ''Am J Sports Med''. 2018;46(11):2798-2808. doi:10.
  67. ↑ Cross MJ, Vandersluis R, Wood D, Banff M. Surgical repair of chronic complete hamstring tendon rupture in the adult patient. The American Journal of Sports Medicine. 1998 Nov;26(6):785-8.
  68. ↑ Cross MJ, Vandersluis R, Wood D, Banff M. Surgical repair of chronic complete hamstring tendon rupture in the adult patient. The American Journal of Sports Medicine. 1998 Nov;26(6):785-8.
  69. ↑ Ravich JW, Zvijac JE, Vargas LA, Schurhoff MR, Yurubi M, Moya Diaz RK, et al. Functional Outcomes of Proximal Hamstring Tendon Repair in Patients Over 40 Treated Without Postoperative Bracing. Orthop J Sports Med. 2025;13(4):23259671251326604. doi:10.1177/23259671251326604. PMID: 40291626; PMCID:
  70. ↑ Troyer WD, Phrathep D, Pagan-Rosado R, Hung CM, Kruse RC, Rosario-Concepcion R. Diagnosis and Management of Hamstring Muscle Injuries in Athletes. Current Physical Medicine and Rehabilitation Reports. 2026 Dec;14(1):3.
  71. ↑ 71.0 71.1 Jacobsen P, Witvrouw E, Muxart P, Tol JL, Whiteley R. A combination of initial and follow-up physiotherapist examination predicts physician-determined time to return to play after hamstring injury, with no added value of MRI. British Journal of Sports Medicine. 2016 Apr 1;50(7):431-9.
  72. ↑ Guillodo Y, Here-Dorignac C, Thoribé B, Madouas G, Dauty M, Tassery F, Saraux A. Clinical predictors of time to return to competition following hamstring injuries. Muscles, Ligaments and Tendons Journal. 2014 Nov 17;4(3):386.
  73. ↑ 73.0 73.1 Ekstrand J, Krutsch W, Spreco A, Van Zoest W, Roberts C, Meyer T, Bengtsson H. Time before return to play for the most common injuries in professional football: a 16-year follow-up of the UEFA Elite Club Injury Study. British journal of sports medicine. 2020 Apr 1;54(7):421-6.
  74. ↑ Dubois B, Esculier JF. Soft-tissue injuries simply need PEACE and LOVE. Br J Sports Med. 2020;54(2):72–73.
  75. ↑ Heiderscheit BC et al. J Orthop Sports Phys Ther. 2010;40(2):67–81.
  76. ↑ Hickey JT, Timmins RG, Maniar N, Rio E, Hickey PF, Pitcher CA, Williams MD, Opar DA. Pain-free versus pain-threshold rehabilitation following acute hamstring strain injury: a randomised controlled trial. J Orthop Sports Phys Ther. 2020;50(2):91–103.
  77. ↑ Hickey JT, Timmins RG, Maniar N, Rio E, Hickey PF, Pitcher CA, Williams MD, Opar DA. Pain-free versus pain-threshold rehabilitation following acute hamstring strain injury: a randomised controlled trial. J Orthop Sports Phys Ther. 2020;50(2):91–103.
  78. ↑ FourFourTwo. Micah Richards gym workout | How to do the Nordic hamstring curl | Injury prevention. Available from : https://www.youtube.com/watch?v=TO47AQuYphE [last accessed 24 August 2022]
  79. ↑ Al Attar WSA, et al. Effect of injury prevention programs that include the nordic hamstring exercise on hamstring injury rates in soccer players: a systematic review and meta-analysis. Sports Med. 2017;47(5):907–16.
  80. ↑ Al Attar WSA et al. Sports Med. 2017;47(5):907–916.
  81. ↑ Al Attar WSA, et al. Effect of injury prevention programs that include the nordic hamstring exercise on hamstring injury rates in soccer players: a systematic review and meta-analysis. Sports Med. 2017;47(5):907–16.
  82. ↑ Utilizing GPS technology to identify and manage hamstring injuries during high-speed running: A scoping review — Miller E, Surber B, Vrooman L, et al. Sci J Sport Perform. 2025;4(2):162–176. doi:10.55860/IIGA8100
  83. ↑ Thorborg K, Krommes KK, Esteve E, et al. Effect of specific exercise-based football injury prevention programmes on the overall injury rate in football. Br J Sports Med. 2017;51(7):562–571.
  84. ↑ Green B et al. Br J Sports Med. 2020;54(18):1081–1088.
  85. ↑ Green B, Bourne MN, van Dyk N, Pizzari T. Recalibrating the risk of hamstring strain injury (HSI): a 2020 systematic review and meta-analysis of risk factors for index and recurrent hamstring strain injury in sport. Br J Sports Med. 2020;54(18):1081-1088. doi:10.1136/bjsports-2019-100983.
  86. ↑ Heiderscheit BC et al. J Orthop Sports Phys Ther. 2010;40(2):67–81.
  87. ↑ Heiderscheit BC et al. J Orthop Sports Phys Ther. 2010;40(2):67–81.
  88. ↑ Green B, Bourne MN, van Dyk N, Pizzari T. Recalibrating the risk of hamstring strain injury (HSI): a 2024 framework for return to sport. Sports Medicine. 2024. Available from: https://link.springer.com/journal/40279⁠.
  89. ↑ www.sportsinjuryclinic.net. How long does it take a Hamstring Strain to heal? Available from : https://www.youtube.com/watch?v=1BjlA8xIgWI [last accessed 24 August 2022]
  90. ↑ ATLXtv. Common Sports Injuries: Hamstring Pull. Available from : https://www.youtube.com/watch?v=EPYQgwA15Aw[last accessed 24 August 2022]
  91. ↑ Bob & Brad. Top 3 Treatments for Hamstring Injury or Tear- It is not what you think. Available from : https://www.youtube.com/watch?v=tUQ86Ok69gY[last accessed 24 August 2022]
Retrieved from "https://www.physio-pedia.com/w/index.php?title=Hamstring_Strain&oldid=382262"