What is the best course of treatment for a persistent hamstring strain (pulled hamstring) lasting 2-3 months?

Management of Persistent Hamstring Strain (2-3 Months Duration)

At 2-3 months post-injury without complete healing, you need to reassess for inadequate rehabilitation, consider imaging to evaluate for structural complications, and implement an aggressive eccentric strengthening program—most hamstring strains should show complete healing by 2-2.5 months, so persistent symptoms warrant investigation for incomplete recovery or reinjury. 1

Why This Duration is Concerning

• 84% of hamstring injuries show complete healing by 2-2.5 months regardless of initial severity, making your 2-3 month timeframe a critical decision point 1
• Grade 1-2 injuries typically heal completely within 50 days, while even severe Grade 3-5 injuries heal within 75 days 1
• Persistent symptoms beyond this timeframe suggest either inadequate initial rehabilitation, premature return to activity causing reinjury, or a more severe structural injury than initially recognized 2, 3

Immediate Assessment Required

Physical examination findings to document:

• Localized tenderness on palpation at the specific injury site 4
• Pain reproduced by maneuvers simulating tendon loading (resisted knee flexion, straight leg raise) 4
• Muscle atrophy compared to the contralateral side (indicates chronic injury) 4
• Asymmetry in muscle bulk or contour 4
• Limited range of motion on the symptomatic side 4

Obtain MRI imaging now to evaluate for:

• Extent of tendon retraction (>2 cm retraction of 2+ tendons requires surgical consideration) 5
• Central tendon involvement (associated with prolonged recovery) 6
• Scar tissue formation or incomplete healing 5
• Complete versus partial tear differentiation 5

Treatment Protocol for Persistent Injury

Conservative Management (First-Line)

Structured rehabilitation program:

• Eccentric strengthening exercises are mandatory—these reverse degenerative changes and are the cornerstone of treatment 1
• Perform hamstring strengthening specifically in lengthened positions 6
• Nordic hamstring exercises have proven efficacy in reducing reinjury incidence 6
• Gradually increase activity while monitoring pain response 1

Pain management:

• NSAIDs effectively relieve pain and reduce swelling 1
• Topical NSAIDs eliminate gastrointestinal hemorrhage risk associated with oral formulations 1
• Ice application through wet towel for 10-minute periods for acute pain flares 1

Activity modification:

• Relative rest to prevent further damage, but avoid complete immobilization which causes atrophy 1
• No return to sport until objective criteria are met (see below) 1

Surgical Consideration Threshold

Proceed to surgical consultation if:

• 2-tendon injury with >2 cm retraction on MRI 5
• 3-tendon injury of any severity 5
• No improvement after 6 months total of appropriate nonoperative management 5
• Complete rupture at ischial tuberosity origin or distal insertion with >2 cm displacement 7

Return to Activity Criteria (Critical—Do Not Skip)

You cannot clear for return to sport based on time alone. Functional testing is required: 1

• Functional hop testing to assess dynamic stability 1
• Isokinetic testing showing hamstring-to-quadriceps ratio of 50-60% 7
• Strength of injured leg restored to within 10% of unaffected leg 7
• Complete return of flexibility (equal to contralateral side) 2
• Pain-free performance of sport-specific movements 3

Common Pitfalls Causing Persistent Symptoms

The high recurrence rate (nearly one-third within first year) is directly attributable to: 3

• Premature return to activity—the most common error causing reinjury 2, 3
• Inadequate eccentric strengthening during rehabilitation 6
• Failure to address strength deficits before clearance 6
• Using time-based rather than objective criteria for return to sport 3
• Incomplete restoration of hamstring-quadriceps strength ratio 7

Expected Timeline from This Point

• With appropriate aggressive rehabilitation, expect an additional 1-3 months before return to full activity 1
• Total recovery timeframe of 3-6 months from initial injury is typical for complete healing 1, 2
• If no improvement within 6 months total (meaning 3-4 more months from now), surgical evaluation is indicated 5

The fact that you're at 2-3 months without resolution indicates either the initial injury was more severe than recognized, rehabilitation has been inadequate, or premature activity has caused reinjury—address these factors immediately to prevent chronic disability.