Hamstring Tear - Causes, Treatment And Recovery

A classic injury but one often not diagnosed well or treated properly and thus the hamstring tear has a reputation for recurrence. Find out from physio Mark Buckingham about the causes of hamstring injuries and how to treat them.

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The symptoms of a hamstring tear are a sharp pain or a rapid build-up of pain somewhere in the belly of the hamstring. It is often in the middle of the muscle but it can be higher towards the buttock or down to the knee and the stringy tendons. 

Sharp pain with the rapid onset ‘like the sniper got me’ is clear to diagnose and is almost certainly a tear. Occasionally it can be cramp but the fierce contraction in the muscle tissue from cramp causes damage as well.  

Gradual build up type of ache or tightness is less likely to be a full tear but micro tears in the tissue which combine over time to make a significant injury.

It is often associated with lower back and pelvis issues and the nerve irritation and/or inhibition caused by the back affects the hamstring, increasing the likelihood of injury. You should have the back assessed at the same time as the hamstring even if it is not symptomatic. It doesn’t have to be painful to be the cause.

Other factors are age – the older you are the more likely; weakness in the hamstring so that it cannot cope with the forces you apply to it; Lack of flexibility meaning you more easily overstretch the muscle; fatigue causing poor coordination.  

What happens in the muscle with a tear?

Muscle fibres, connective tissue (collagen) and blood vessels are ripped apart. The more that is torn the longer it takes to heal.    

With a lot of damage then bleeding a haematoma or internal blood clot will form. A lot of bleeding over a big area usually means the fibrous sheath around the muscle has been torn too. This does not necessarily mean a longer recovery though.  

The bruising will take about 2 weeks for the body to break down and disperse.  

Tissue Healing

Tissue repair phases

From the chart you can see how long it takes the body to repair and recover from injury. A full grade 3 tear will take the body around 6 months to return to a fully functioning strong muscle whereas a smaller issue will take only a week or two.

Simple self-tests

These tests are to determine the extent of the injury to the muscle. The rehab plan is for a hamstring muscle tear alone. Please see the SIJ, low back pain and nerve mobility sections to add to the picture.

Hamstring stretch and hamstring contraction

The stretch in Picture 1 will produce pain in the belly of the muscle with a tear. This is distinct from tightness. If it is just tight then it is less of a full tear than a small strain of the tissues. If there is pain at the end of the range then it is a small tear, if the pain begins half way up then you know you have a decent amount of tissue damage.

Picture 2 - You should try the contraction at different angles of knee flexion. Fully straight, knee at 45 degrees and 90 degrees bent. Take the leg to these positions and push into the hand as shown. You can do it yourself by pushing into a chair. It may not be sore on all of these but if pain is reproduced again it adds evidence that there is a tear in the muscle.

What to do if you suffer a hamstring injury?

A history of sudden pain and pain to stretch and contract are the signs of a torn muscle. If there is a distinctly painful spot then there is a smaller grade tear. If there is a gap then it is a much bigger issue.    

Grade 1 – No pain to stretch or contract and is a general ache – it is a fatigue based or delayed onset muscle soreness issue. Rest and easy stretching will ease it over a few days.  

Grade 2 – No specific time of injury noted. There is tightness to stretch and to press but no contraction pain or distinctly painful spot shows there is increased tension in the muscle. This could be from the spine or it could be local tissue damage on a small scale. Rest, stretching, massage and easy exercise – bike/walk will ease it over a few days.  

Grade 3a – Sharp pain at the time of injury followed by pain to stretch, variable pain to contract dependent on extent and tender spot to palpate. This needs to be rested for 5 days and treated with ice and anti-inflammatories. Then follow the Rehab as below. If in doubt and if the pain continues to be there after 5 days then seek help from your physio.  

Grade 3b – This is the ‘sniper shot’. These are proper injuries with sharp pain on stretch and contraction, plenty of bleeding and swelling and you are unable to really use the leg. It needs to be rested to stop further damage, to reduce the amount of bleed and to allow healing. 

The initial knitting of the fibres takes at least 5 days but they are still very weak. Rest and do not do anything that causes pain in the muscle or you will slow the healing – it is like picking a scab. Treat it like a badly cut finger! It is the same process. These really need to input of your physio to guide the process and to determine the extent of the injury.

Rehab for hamstring tears

After the first 5 days you can start to ease into stretching the muscle but avoid sharp pain. At this point there should be no sharp pain, just low grade ache. If there is sharp pain to stretch it needs more rest. Stretch 5 times a day for a couple of minutes but carefully. Cross training like bike and pool work are fine as long as they are not painful. Gentle massage and rolling is also good.  

At day 8 or once there is no pain to stretch and contract you can start to jog. This has to be within pain and build to 1 km at a very steady pace over 3 -5 days.

Once a km is comfortable you can start to increase the pace by adding some short runs. Build up as shown. The rest days are important.  

 

Jog

Run

Jog

Reps

Day 1

20m

20m

20m

6

Day3

20m

30m

20m

6

Day 4

10m

40m

10m

7

Day 6

10m

60m

10m

8

Day 7

5m

80m

5m

7

Day 9

5m

100m

5m

8

Once you have completed this you will be somewhere like day 18 post injury and you can increase the training as pain allows. It is now vital that you continue to strengthen the hamstring and the tear.

Specific exercises and weights are essential to restore the torn fibres to better than their previous strength and look to prevent recurrence. If it was weak enough to tear once it is more likely to again now it has been damaged. To help prevent recurrence you have to accept that it clearly was not strong enough before to do what you asked and thus it has to be improved, regardless of any spinal/pelvic issues.  

There are many useful hamstring exercises. Here are some that are easily accessible. Pure gym weights machines are appropriate as they are straight forward methods of hamstring muscle strengthening so should not be overlooked. Both sitting and prone hamstring curl machines are in all gyms and ideally both should be used 3 times a week, 4 sets of 8 reps to fatigue but not pain.

Using a pulley machine or a theraband to work in a running action is a functional strengthening exercise (see Picture 3.) Start with 1 x 25 at a weight that fatigues then 4 sets of 8 at a higher weight, then 1 x 25 again.

Pulley hamstring

Running involves a lot of eccentric control of the hamstring (contraction whilst lengthening). This is tough for the muscles tissues and needs to be trained. Use a gym ball as shown in Picture 4 in a slow controlled roll in and out for 3 sets of 12 reps

Eccentric hamstring

Other protocols like Nordic exercises for hamstrings are an excellent way to build strength further and will be covered in the specific Preventative strength exercise section.

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