What is the best course of treatment for a 14-year-old patient presenting with hamstring pain?

Hamstring Pain in a 14-Year-Old

For a 14-year-old with hamstring pain, initiate relative rest with activity modification, followed by a structured exercise-based rehabilitation program lasting at least 3 months, focusing on progressive strengthening and eccentric exercises of the hamstring muscles.

Initial Management

First 48-72 Hours

• Apply RICE protocol immediately: Rest, ice (melting ice water through wet towel for 10-minute periods), compression, and elevation to control acute inflammation and pain 1
• Relative rest is essential: Reduce activities that provoke pain, particularly running and sprinting, but avoid complete immobilization which leads to muscle atrophy and weakness 1, 2
• Short-term pain control: Use acetaminophen as first-line for mild-to-moderate pain, or NSAIDs for short-term relief (3-7 days maximum) if not contraindicated 1

Diagnostic Considerations

• Assess injury severity clinically: Look for localized tenderness at the hamstring muscle belly or ischial tuberosity insertion, pain with resisted knee flexion, and pain with passive straight leg raise 2, 3
• Determine if imaging is needed: Plain radiographs are indicated if there's concern for avulsion fracture at the ischial tuberosity (common in adolescents during growth spurts), especially if pain is severe or there's a palpable defect 4, 3
• Consider MRI only if: Complete rupture is suspected, symptoms don't improve with conservative treatment after 2-3 weeks, or there's diagnostic uncertainty 3

Exercise-Based Rehabilitation Program (Primary Treatment)

Duration and Structure

• Minimum 3-month program is mandatory: Shorter programs lead to suboptimal results and higher recurrence rates 1, 5
• Include at least 12 supervised sessions: Initial supervision ensures proper technique and appropriate progression 5

Exercise Components

Phase 1 (Weeks 1-2): Pain Control and Gentle Mobilization

• Begin gentle pain-free range of motion exercises within 2-3 days of injury 3
• Avoid stretching into pain during this acute phase 1
• Light isometric hamstring contractions (holding 6-7 seconds) without resistance 1

Phase 2 (Weeks 2-6): Progressive Strengthening

• Eccentric strengthening is critical: This specifically addresses hamstring injury pathophysiology and may reverse degenerative changes 1
• Progress from isometric to concentric to eccentric exercises 2, 3
• Include hip and trunk strengthening, particularly gluteus medius, as these support hamstring function 1, 5
• Specify load magnitude, repetitions (typically 3 sets of 10-15), rest periods (2-3 minutes between sets), and time under tension 1

Phase 3 (Weeks 6-12): Functional Training and Return to Activity

• Progress to sport-specific activities that mimic the demands of the adolescent's activities 1
• Include agility drills, acceleration/deceleration training, and dynamic balance exercises 1
• Ensure full strength, flexibility, and coordination are restored before return to full activity 2, 6

Critical Exercise Principles

• Avoid pushing through severe pain: This can exacerbate injury and prolong recovery 5
• Progressive loading is essential: Gradually increase resistance and complexity over the 3-month period 1, 5
• Do not interrupt the program before 3 months: This is a common error leading to recurrence 5

Flexibility and Warm-Up

• Address flexibility deficits: Poor hamstring flexibility is a major risk factor for injury and recurrence 2, 6
• Implement proper warm-up protocols: Pre-exercise stretching and adequate warm-up are important for prevention of re-injury 3, 6
• Stretching should be pain-free and performed after muscles are warmed up, not on cold muscles 1

Return to Sport Criteria

Do not permit return to full activity until ALL criteria are met:

• Complete return of hamstring strength (should be equal to contralateral side) 2, 6
• Full flexibility and range of motion restored 2, 6
• Pain-free with sport-specific movements 1
• Coordination and agility returned to pre-injury level 2

Common Pitfalls to Avoid

• Premature return to activity: This is the leading cause of recurrent hamstring injuries, which can be devastating for young athletes 2, 7
• Inadequate rehabilitation duration: Programs shorter than 3 months consistently show worse outcomes 1, 5
• Neglecting eccentric strengthening: This is the most evidence-based component of hamstring rehabilitation 1
• Complete rest beyond initial 48-72 hours: Prolonged immobilization leads to muscle atrophy and worse functional outcomes 1, 3

When to Consider Specialist Referral

• Immediate orthopedic referral if: Complete rupture suspected (palpable defect, severe weakness, inability to bear weight) 3, 7
• Refer if no improvement after 2-3 weeks of conservative treatment 1
• Consider physical therapy referral for supervised exercise program if resources allow 1, 5