What is the treatment and management for acute hamstring sprain/strain in athletes?

Treatment and Management of Acute Hamstring Sprain/Strain in Athletes

The mainstay of treatment for acute hamstring strains in athletes involves immediate implementation of the PRICE protocol (Protection, Rest, Ice, Compression, Elevation), followed by a progressive functional rehabilitation program that includes range of motion exercises, strengthening, and proprioceptive training. 1

Initial Management (First 24-72 hours)

• Implement the PRICE protocol immediately after injury:

  • Protection: Avoid activities that cause pain and limit use of the injured area 1
  • Rest: Limit activity that causes pain but avoid complete immobilization 2
  • Ice: Apply cold therapy (ice and water in a damp cloth) for 20-30 minutes, 3-4 times daily to reduce pain and swelling 1
  • Compression: Apply a compression wrap to promote comfort, ensuring circulation is not compromised 1
  • Elevation: Keep the injured area elevated to reduce swelling 3

• Pain management: Nonsteroidal anti-inflammatory drugs (NSAIDs) can help reduce swelling and pain after injury and may decrease recovery time 1

Functional Rehabilitation (Begin within 48-72 hours)

• Early mobilization is preferred over immobilization to properly align regenerating muscle fibers and limit connective tissue fibrosis 2, 4

• Progressive exercise program:

  • Begin with pain-free isometric exercises 2, 4
  • Progress to isotonic and then isokinetic strengthening exercises as tolerated 2, 4
  • Include eccentric strengthening exercises which have shown particular benefit for hamstring rehabilitation 4, 5
  • Incorporate neuromuscular control and proprioceptive exercises to reduce reinjury risk 4, 5

• Stretching:

  • Begin gentle, pain-free stretching exercises to regain flexibility 2, 6
  • Gradually increase intensity as healing progresses 4

Support Devices

• Semirigid or lace-up supports are recommended over elastic bandages for functional treatment 1, 3
• Consider continued use of support devices during return to activity, especially for athletes with history of recurrent strains 1, 3

Return to Sport Criteria

• Readiness for return to competition should be assessed using objective measures:
  • Isokinetic testing to confirm muscle-strength imbalances have been corrected 2
  • Hamstring-quadriceps strength ratio should be 50% to 60% 2
  • Strength of injured leg restored to within 10% of unaffected leg 2, 4
  • Full range of motion and flexibility 6, 4
  • Restoration of sport-specific movement patterns and agility 6, 4

Special Considerations

• Location of injury affects prognosis and treatment approach:

  • Injuries at the myotendinous junction (most common) typically respond well to conservative treatment 2, 7
  • Proximal tendon injuries near the ischial tuberosity may require longer recovery 7
  • Complete ruptures or avulsions with >2cm displacement may require surgical intervention 2, 7

• MRI is the gold standard for diagnosis and can help guide treatment decisions for more severe or complex cases 7

Common Pitfalls to Avoid

• Inadequate rehabilitation is a major factor in recurrent hamstring injuries, which can be more severe than the initial injury 6, 4

• Premature return to sport before complete rehabilitation increases reinjury risk 6, 4

• Prolonged immobilization should be avoided as it shows no benefits compared to functional treatment 2, 6

• Failure to address all components of rehabilitation (strength, flexibility, endurance, coordination, and agility) 6, 4

• Heat application is not recommended for acute hamstring injuries 3