Treatment of Hamstring Strain
For a hamstring strain, immediately initiate rest, ice (20-30 minutes per application), compression, and elevation, followed by early mobilization within 1 week and progressive functional exercises emphasizing eccentric strengthening and neuromuscular control. 1, 2
Acute Management (First 48-72 Hours)
Initial treatment should focus on limiting secondary tissue damage:
- Apply ice and water mixture surrounded by a damp cloth for 20-30 minutes, 3-4 times daily to reduce pain and swelling, avoiding direct skin contact to prevent cold injury 1
- Apply compression wrap to promote comfort, ensuring it does not compromise circulation 1
- Elevate the injured extremity and avoid activities that cause pain 1
- Consider NSAIDs for pain relief and inflammation control, though recognize that some inflammation is necessary for optimal muscle fiber removal and healing 2
- Immobilization should be brief (less than 1 week even for severe strains) as prolonged rest delays recovery 2
Critical Pitfall to Avoid
Do not continue immobilization beyond 1 week, as this impairs proper alignment of regenerating muscle fibers and increases connective tissue fibrosis 2. The evidence strongly supports early mobilization over prolonged rest.
Rehabilitation Phase (After Initial Week)
Begin mobilization and functional exercises as soon as tolerable to properly align regenerating muscle fibers:
- Start with pain-free stretching exercises to regain flexibility 2, 3
- Progress strengthening in sequence: isometric → isotonic → isokinetic exercises 2
- Incorporate eccentric strength training, which has mounting evidence for reducing reinjury risk 3
- Add neuromuscular control exercises including balance, agility, and coordination work to minimize reinjury 3
- Functional exercises should be emphasized throughout rehabilitation 4, 5
Return to Sport Criteria
Athletes should meet objective criteria before returning to competition to avoid the 30% reinjury rate:
- Isokinetic testing must confirm:
When Surgery Is Indicated
Surgery is only indicated for complete rupture at the ischial tuberosity origin or distal insertion (either soft-tissue avulsion with large defect or bone avulsion with >2 cm displacement) 2. This represents a rare scenario, as most hamstring strains are partial injuries at the muscle-tendon junction 4.
Key Evidence Considerations
The 2024 American Heart Association guidelines provide the most recent evidence on acute soft tissue injury management, supporting cold application and compression for sprains/strains 1. However, these guidelines note that compression wraps have not been proven to improve recovery time or function—they primarily provide comfort 1.
The rehabilitation literature consistently emphasizes that traditional return-to-sport criteria may be inadequate, explaining the high reinjury rate 5, 3. The evidence strongly supports incorporating eccentric exercises and neuromuscular training rather than simple rest and stretching protocols 3.
The major clinical challenge is that nearly one-third of hamstring strains recur within the first year, with subsequent injuries often more severe 5, 3. This high rate suggests premature return to sport due to inadequate objective assessment 5.