What is the initial treatment for a pulled hamstring?

Initial Treatment for a Pulled Hamstring

Begin immediate RICE protocol (Rest, Ice, Compression, Elevation) with specific ice application of 10-minute intervals using melting iced water through a wet towel, repeated multiple times rather than continuous application. 1, 2

Immediate First Aid (First 48-72 Hours)

Ice Application Protocol

• Apply melting iced water through a wet towel for 10-minute intervals, not continuously 2
• Target temperature reduction of 10-15°C in the muscle tissue 2
• Use repeated 10-minute applications rather than prolonged continuous icing to sustain reduced muscle temperature while allowing superficial skin temperature to normalize 2
• This prevents skin compromise while maintaining therapeutic cooling at deeper muscle levels 2

Rest and Protection

• Immediately cease the activity that caused the injury 1, 3
• Avoid weight-bearing or activities that reproduce pain 4, 3
• Immobilization should be brief (only as long as needed for initial scar formation between ruptured myofibers), typically 2-5 days maximum depending on severity 3

Compression and Elevation

• Apply compression bandaging to control swelling 1, 3
• Elevate the affected leg above heart level when possible 1, 3

Pain Management

• Acetaminophen is the preferred first-line analgesic for mild to moderate pain, up to 4 grams daily 5
• NSAIDs may be considered as an alternative, though they carry higher risk of gastrointestinal, platelet, and nephrotoxic effects, particularly in older patients 5
• Avoid high-dose NSAIDs for prolonged periods 5

Critical Timing Considerations

Early Mobilization (After Initial 2-5 Days)

• Begin early mobilization as soon as the scar can bear pulling forces without rerupture 3
• Prolonged immobilization beyond what is necessary causes rapid inactivity-induced atrophy, loss of strength, and loss of extensibility 3
• Early mobilization promotes proper adhesion and orientation of regenerating muscle fibers, revascularization, and resorption of connective tissue scar 3

Rehabilitation Focus

• Initiate functional exercises emphasizing both stretching and strengthening once acute phase resolves 1, 4
• Address hamstring strength, flexibility, and gradual return to activity 4
• The rehabilitation model should target the aetiological factors: strength deficits, flexibility limitations, and fatigue 4

Important Caveats

Post-Ice Activity Restriction

• Avoid athletic activity for 30 minutes after ice treatment as reflex activity and motor function are impaired, increasing susceptibility to reinjury 2
• This is a commonly overlooked risk factor for secondary injury 2

Avoid Over-Immobilization

• Prolonged immobilization beyond 2-5 days is counterproductive and leads to muscle atrophy and stiffness that is difficult to reverse 3
• The optimal immobilization length depends on injury grade but should never exceed what is necessary for initial scar stability 3

Recurrence Risk

• Hamstring strains have a high recurrence rate with often prolonged rehabilitation and persistent disability 1, 6
• Most injuries occur at the muscle-tendon junction of a single muscle 1
• Prevention of reinjury requires addressing underlying risk factors during rehabilitation 4, 6

When to Consider Advanced Imaging

• MRI can help pinpoint extent and location of injury when diagnosis is unclear or to guide management decisions 1
• Most hamstring injuries can be diagnosed by history and physical examination alone 1