What is the initial management and rehabilitation for a hamstring tear?

Hamstring Tear Work-Up and Initial Management

For acute hamstring tears, immediately initiate RICE (rest, ice through wet towel for 10-minute periods, compression, elevation), start NSAIDs for pain control, and begin eccentric strengthening exercises as soon as tolerated—avoiding complete immobilization to prevent atrophy. 1

Initial Clinical Assessment

Key Physical Examination Findings to Document

• Location and extent of pain/tenderness along the hamstring musculotendinous unit 2
• Palpable defect or gap (suggests complete rupture requiring surgical consideration) 3
• Degree of functional impairment during active knee flexion and hip extension 4
• Amount of retraction if partial or complete avulsion suspected (>2 cm retraction with ≥2 tendons involved warrants surgical referral) 3

Injury Grading and Prognosis

• Grade 1-2 injuries: Complete healing typically occurs within 50 days 1
• Grade 3-5 injuries: Complete healing takes approximately 75 days 1
• Overall timeline: 84% of patients show complete healing by 2-2.5 months regardless of severity 1

Immediate Management Protocol

First 72 Hours

• Apply ice through a wet towel for 10-minute periods to provide acute pain relief 1
• Relative rest (not complete immobilization) to prevent further damage while avoiding muscle atrophy 1
• NSAIDs for pain control: Topical formulations eliminate gastrointestinal hemorrhage risk associated with oral NSAIDs 1
• Compression and elevation to minimize swelling 1

Early Rehabilitation Phase (Days 3-14)

Begin eccentric strengthening exercises early—these have been shown to reverse degenerative changes and are the cornerstone of hamstring rehabilitation 1. The evidence strongly supports avoiding prolonged immobilization, as inadequate rehabilitation is the primary cause of recurrent hamstring injuries 2, 4.

• Gradually increase activity while monitoring pain response 1
• Address flexibility deficits through progressive stretching programs 2, 4
• Maintain cardiovascular fitness with non-aggravating activities 4

Imaging Considerations

When to Image

• Suspected complete rupture or palpable defect 3
• Proximal avulsion injuries in young, active patients 3
• Failure to progress with conservative management 3

Imaging Timeline

• 6 weeks post-injury: Most patients show significant healing on imaging 1
• 3 months post-injury: Complete healing of almost all grades typically observed 1

Return to Sport Criteria

Do not clear athletes until ALL criteria are met—premature return is a major cause of reinjury 2, 5:

• Full pain-free range of motion 1
• Complete return of muscle strength (hamstring peak torque ≥95% of baseline or hamstring-to-quadriceps ratio ≥0.55-0.60) 1, 5
• Functional hop testing demonstrates symmetry 1
• Return of coordination and athletic agility 2
• Minimum 4-6 weeks before returning to sport activities, with full competitive return typically at 6-12 weeks depending on severity 1

Critical Pitfalls to Avoid

• Complete immobilization: Leads to muscle atrophy and prolonged recovery 1
• Premature return to sport: Most recurrent injuries result from inadequate rehabilitation before the initial injury fully healed 2, 4
• Neglecting eccentric strengthening: This is the most evidence-based intervention for reversing degenerative changes 1
• Missing surgical indications: Complete 3-tendon ruptures, partial avulsions with ≥2 tendons and >2 cm retraction in young active patients require surgical referral 3

Surgical Indications

Refer immediately for surgical evaluation if: 3

• Complete proximal avulsion (3-tendon rupture)
• Partial avulsion with ≥2 tendons injured with >2 cm retraction in young, active patients
• Chronic tendinosis or partial avulsion that failed 3-6 months of appropriate conservative management

Evidence Limitations

The evidence base for hamstring rehabilitation lacks high-quality randomized controlled trials, with most recommendations based on lower-level evidence and expert consensus 4, 6. However, the principles of early mobilization, eccentric strengthening, and objective return-to-sport criteria are consistently supported across multiple sources and represent current best practice 1, 2, 5.