What is the recommended management for a strained hamstring?

Management of Strained Hamstring

Implement the PRICE protocol (Protection, Rest, Ice, Compression, Elevation) immediately after injury, followed by early progressive rehabilitation with eccentric strengthening exercises once acute symptoms subside. 1

Acute Phase Management (First 48-72 Hours)

Initial RICE Protocol:

• Apply ice for 20-30 minutes, 3-4 times daily to reduce pain and swelling 1
• Use compression wraps to promote comfort while ensuring circulation is not compromised 1
• Elevate the injured limb to reduce swelling 1
• Protect the area from further injury with activity modification 1

Pain and Inflammation Control:

• NSAIDs can be used to reduce swelling and pain, and may decrease recovery time 1
• Avoid heat application during the acute phase 1

Critical Pitfall: Do not use prolonged immobilization, as this leads to muscle atrophy, loss of strength and extensibility, and poor functional outcomes 2. While a brief period of rest (typically 3-5 days) is needed initially to allow granulation tissue formation, extended immobilization is counterproductive 2, 3.

Subacute and Rehabilitation Phase

Functional Support:

• Use semirigid or lace-up supports rather than elastic bandages for functional treatment 1
• Continue support devices during return to activity, especially if there is a history of recurrent strains 1

Progressive Exercise Program:

• Begin mobilization exercises as soon as acute symptoms allow to prevent muscle atrophy and maintain strength 2
• Incorporate eccentric strength training, which has mounting evidence for reducing reinjury risk 4
• Include neuromuscular control exercises to address altered movement patterns 4
• Progress flexibility training to restore normal muscle extensibility 5, 3

Rehabilitation Progression Criteria: The length of immobilization should be optimized based on injury grade so the healing scar can bear pulling forces without re-rupture 2. Athletes should not return to sport until achieving:

• Complete return of muscle strength and endurance 5
• Full flexibility restoration 5
• Return of coordination and athletic agility 5
• Objective measures confirming musculotendon recovery 4

Major Pitfall: Inadequate rehabilitation is thought to be responsible for the high rate of recurrent hamstring injuries, with nearly one-third recurring within the first year 4. Traditional return-to-sport criteria may be insensitive to persistent deficits, resulting in premature return 4.

Special Considerations

Complete Ruptures:

• Complete ruptures with loss of function require surgical intervention 2
• Avulsion injuries at the ischial tuberosity need longer immobilization and may require operative treatment 2

Injury Prevention:

• Pre-exercise stretching and adequate warm-up are important preventive measures 2
• Address risk factors including poor flexibility, inadequate strength/endurance, and insufficient warm-up 5, 3
• Neuromuscular training programs should be considered for athletes at risk 6