When should a hamstring injury be referred to the emergency room (ER)?

From the Guidelines

A hamstring injury should be referred to the emergency room (ER) immediately if there are signs of severe damage, complications, or high-risk mechanisms of injury, as outlined in the field triage decision scheme 1. When evaluating a hamstring injury, it is crucial to assess the severity of the injury and the potential for complications. According to the guidelines for field triage of injured patients 1, patients with severe injuries, such as those with a Glasgow Coma Scale score of less than 14, systolic blood pressure less than 90 mmHg, or respiratory rate less than 10 or greater than 29 breaths per minute, should be transported to a trauma center.

• Key indicators for ER referral include:
  • Severe pain and inability to walk
  • Significant swelling or bruising that develops rapidly
  • Numbness or tingling in the leg
  • Inability to bear weight on the affected leg
  • Visible deformity in the thigh
  • Signs of compartment syndrome, such as extreme pain, tightness, paleness, or decreased sensation in the affected limb
• The field triage decision scheme 1 also recommends assessing the mechanism of injury and evidence of high-energy impact, such as falls from a height, high-risk auto crashes, or motorcycle crashes, to determine the need for trauma center care.
• While mild to moderate hamstring strains can be managed with rest, ice, compression, and elevation (RICE therapy), severe cases require prompt medical evaluation to prevent complications like permanent muscle damage or disability.
• In cases where there is doubt about the severity of the injury or the need for emergency care, it is always best to err on the side of caution and seek immediate medical attention 1.

From the Research

Hamstring Injury Referral to ER

• A hamstring injury should be referred to the emergency room (ER) in cases of severe trauma, such as a proximal hamstring avulsion injury or a high-grade musculotendinous tear 2.
• Patients presenting with ecchymoses, pain, and weakness should be evaluated, and magnetic resonance imaging (MRI) may be necessary to guide treatment 3.
• Acute surgical treatment of proximal hamstring injuries tends to be favorable, and distal hamstring injuries may initially be managed nonoperatively, although some cases may require surgical intervention 3.
• The decision to refer a patient to the ER should be based on the severity of the injury, the patient's overall condition, and the presence of any underlying medical conditions.

Indications for ER Referral

• Severe pain or swelling
• Difficulty walking or bearing weight
• Numbness or tingling in the affected leg
• Coldness or paleness of the affected leg
• Weakness or paralysis of the affected leg
• A history of previous hamstring injuries or underlying medical conditions that may affect healing 2, 4.

Diagnostic Evaluation

• MRI remains the gold standard for diagnosis and may help guide treatment 3.
• A thorough physical examination and medical history should be taken to determine the severity of the injury and the presence of any underlying conditions 2, 4.
• The use of ketorolac for pain management should be considered, as it has been shown to be effective in controlling postoperative pain without increasing the risk of bleeding 5.