What is the best approach to manage hamstring pain in a young to middle-aged adult with a history of musculoskeletal injuries during physical therapy?

Management of Hamstring Pain During Physical Therapy

For hamstring pain occurring during physical therapy in young to middle-aged adults, continue with a structured exercise-based rehabilitation program for a minimum of 3 months, emphasizing eccentric strengthening exercises, while modifying activities that provoke severe pain but avoiding complete rest. 1

Immediate Management Approach

Pain Control Strategy

• Apply ice, compression, and elevation to control acute inflammation when pain flares occur during therapy 1
• Use acetaminophen or NSAIDs for short-term pain relief (maximum 3-7 days) if needed 1
• Implement relative rest by reducing activities that provoke pain, but do not stop all physical activity, as complete immobilization leads to muscle atrophy and worse functional outcomes 1, 2

Activity Modification

• Strategic rest periods should be incorporated between exercise sessions to allow for recovery 2, 3
• During acute pain flares, reduce the intensity or load of exercises that aggravate symptoms rather than eliminating them entirely 2
• Pain during exercise is acceptable at mild levels, but pushing through severe pain can exacerbate inflammation and should be avoided 2, 3

Essential Rehabilitation Program Components

Duration and Supervision Requirements

• The rehabilitation program must be at least 3 months in duration—shorter programs consistently show suboptimal results and higher recurrence rates 4, 1, 3
• A minimum of 12 supervised physical therapy sessions is mandatory to ensure proper technique and appropriate progression 1, 2
• Programs shorter than 3 months should be considered inadequate and a common pitfall to avoid 1, 3

Core Exercise Elements

• Eccentric strengthening exercises are the most critical component and should be prioritized, as they address the underlying pathophysiology of hamstring injuries 1
• Progressive loading with gradual increases in resistance and complexity throughout the 3-month period is essential 4, 1
• Hip and trunk strengthening, particularly targeting the gluteus medius muscle, must be included to support hamstring function 1, 2, 3

Exercise Prescription Specifics

• Specify load magnitude, number of repetitions and sets, duration of contractile elements, time under tension, rest between repetitions and sessions, and range of motion 4, 3
• Include exercises focusing on hip and pelvis motor control, particularly in single-leg support positions 3
• Gradually introduce sport-specific movements and high-level tasks as tolerance improves 4

Monitoring Treatment Response

Assessment Tools

• Use patient-reported outcome measures (PROMs) such as the Copenhagen Hip and Groin Outcome Score (HAGOS) or International Hip Outcome Tool (IHOT) to monitor progress 4
• Measure physical impairments including range of motion, hip muscle strength, movement quality, and functional task performance 4
• Assess psychosocial factors that may influence recovery 4

Return to Activity Criteria

• Return to full activity should only occur when the individual is pain-free with sport-specific movements 1
• Use the return to sport continuum: first return to participation (lower level), then return to sport (preferred sport but not desired level), finally return to performance (preinjury level or above) 4
• Ensure the patient can safely and confidently tolerate high loads in the hip joint before returning to demanding activities 4

Critical Pitfalls to Avoid

• Inadequate rehabilitation duration: Programs shorter than 3 months consistently show worse outcomes and higher recurrence rates (14-63% risk) 1, 3, 5
• Neglecting eccentric strengthening: This is the most evidence-based component and should never be omitted 1
• Complete rest beyond initial 48-72 hours: This leads to muscle atrophy, joint stiffness, and worse functional outcomes 1, 2
• Stopping therapy due to pain: Pain during rehabilitation is common and does not necessarily indicate treatment failure 4

When to Escalate Care

• Consider specialist referral if there is no improvement after 2-3 weeks of conservative treatment 1
• High-grade injuries (complete or near-complete tears) may require surgical consultation, as nonoperative management is associated with poor return to function and high recurrence risk 5
• Persistent weakness or functional compromise despite 3 months of appropriate rehabilitation warrants surgical evaluation 5

Patient Education and Shared Decision-Making

• Discuss patient expectations regarding treatment outcomes, including the likely extent of improvement and anticipated duration 4, 3
• Explain that morphological findings on imaging are often present in asymptomatic individuals and do not always correlate with symptoms 3
• Collaborate with the patient to develop sport or activity-specific goals and implement strategies to achieve them 4
• Emphasize that physical activity (including sport) is recommended for people with hip-related pain and should not be completely avoided 4