What is the assessment and treatment approach for a suspected hamstring tear?

Assessment and Treatment of Hamstring Tear

Begin with clinical examination focusing on posterior thigh pain location, palpable tenderness, and functional testing, then proceed to MRI without contrast for definitive diagnosis when imaging is warranted—particularly for suspected proximal tendon avulsions or when surgical decision-making is needed.

Clinical Assessment

Key History Elements

• Sharp or stabbing pain in the posterior thigh that increases with activity, may subside after warm-up in early stages, and becomes progressively more severe with rest pain in advanced cases 1
• Mechanism of injury: typically forceful eccentric contraction during sprinting or kicking activities 2
• Location matters for prognosis: proximal tendon injuries at the ischial tuberosity versus muscle belly versus distal insertion injuries have different healing timelines and treatment implications 2, 3

Physical Examination Findings

• Inspection: Look for visible swelling, ecchymosis, and asymmetry compared to the contralateral side 4, 1
• Palpation: Well-localized tenderness corresponding to the pain location experienced during activity 4, 1
• Functional testing: Pain reproduction with maneuvers that simulate hamstring loading (resisted knee flexion, passive hip flexion with knee extension) 4, 1
• Strength assessment: Manual resistance testing often reveals weakness, though this has limited diagnostic accuracy as a standalone test 5

Diagnostic Test Performance

• Single special tests demonstrate high specificity (up to 1.00) but variable sensitivity (0.55-1.00), meaning they are better at ruling in injury when positive than ruling out when negative 5
• Composite clinical assessment (combining multiple tests) shows stronger sensitivity than specificity, making it useful for screening but less definitive 5
• Clinical examination alone has limitations—only one high-quality study exists validating specific hamstring tests 5

Imaging Strategy

When to Image

MRI is indicated for:

• Suspected proximal hamstring tendon avulsions (2-tendon injuries with >2 cm retraction, any 3-tendon injury) 2, 6
• Persistent symptoms despite 6 months of conservative management 2
• High-level athletes requiring precise injury characterization for return-to-sport decisions 2, 7
• When surgical decision-making is being considered 4

MRI Without Contrast: The Gold Standard

MRI without IV contrast is the definitive imaging modality for hamstring injuries, with near-perfect detection rates 4, 2

Key advantages:

• 100% detection rate for proximal hamstring avulsions in direct comparison studies 4
• Classifies location, extent, degree (partial versus complete), and chronicity of injury—all critical for treatment planning 4, 2
• Identifies associated injuries including other soft tissue pathology that may complicate recovery 4

Ultrasound: Limited Role

Ultrasound has insufficient evidence to support its use as the primary imaging modality for hamstring injuries 4

Critical limitations:

• Only 58.3% detection rate for proximal hamstring avulsions compared to MRI's 100% 4
• Limited utility for return-to-play decisions in athletes 4
• Operator-dependent with variable accuracy 4

Appropriate ultrasound use: Image-guided interventions (injections) rather than primary diagnosis 8

Treatment Algorithm

Non-Operative Management

Indicated for:

• Muscle belly injuries without significant tendon involvement 2, 6
• Partial-thickness proximal tendon tears 6
• Proximal hamstring tendinopathy 6

Treatment components:

• Relative rest: Reduce repetitive loading while avoiding complete immobilization to prevent atrophy 4
• Eccentric strengthening exercises: Proven beneficial for hamstring injuries with strong evidence 4, 3, 7
• Neuromuscular control exercises: Reduce reinjury risk when combined with eccentric training 3
• Extracorporeal shock wave therapy: Option for refractory tendinopathy 6
• Platelet-rich plasma injections: Currently under investigation with inconclusive long-term evidence 2, 7

Surgical Management

Indicated for:

• Acute proximal hamstring injuries: 2-tendon injuries with >2 cm retraction, any 3-tendon injury 2, 6
• Failed conservative management: No improvement after 6 months of appropriate non-operative treatment 2, 6
• Complete ruptures: Non-operative treatment yields unsatisfactory outcomes with residual weakness and poor return-to-sport rates 6

Surgical approach:

• Acute repair preferred over delayed/chronic repair for better functional outcomes and strength recovery 6
• Endoscopic or open approaches depending on injury pattern 2
• Distal biceps femoris injuries frequently managed surgically with faster return to sport 2

Critical Pitfalls to Avoid

• Do not rely on clinical examination alone for complete tears—sensitivity of individual tests is inadequate, and MRI changes management in proximal avulsions 5, 4
• Do not use ultrasound as primary diagnostic imaging when MRI is available—it misses >40% of proximal avulsions 4
• Do not delay MRI in high-level athletes or when proximal tendon avulsion is suspected—early surgical repair yields superior outcomes to delayed repair 6, 2
• Do not assume muscle belly injuries are benign—nearly one-third recur within the first year, suggesting inadequate rehabilitation or premature return to sport 3
• Do not use traditional return-to-sport criteria alone—they may be insensitive to persistent deficits; incorporate objective measures of musculotendon recovery 3