What is a hamstring injury?

A hamstring injury occurs when 1 or more of the 3 hamstring muscles or tendons (a type of soft tissue connecting the muscle to the bone) tear. It is 1 of the most common injuries of the lower body, particularly affecting athletes participating in sports such as football, soccer, or track. After tearing a hamstring muscle, a person is 2 to 6 times more likely to suffer a subsequent injury. Surgery is required to treat the most severe cases. However, in most cases, hamstring injuries are managed with physical therapy.

What are common causes of a hamstring injury?

The hamstrings make up the primary muscle group responsible for straightening (extending) the hip and bending (flexing) the knee. It includes a group of 3 muscles along the back of the thigh that connect the pelvis to the leg. The three muscles are the:

• Semitendinosus
• Semimembranosus
• Biceps femoris

Hamstring injuries occur when excessive force is placed across the muscles. This typically happens during sudden starts or stops when running, a rapid change of direction with “cutting” or jumping maneuvers, or when the muscle is overstretched by activities such as sprinting, hurdling, kicking, or heavy lifting.

The common structures involved in hamstring injuries are:

• Hamstring muscle(s) and/or tendon (a type of soft tissue that connects muscle to bone)
• Bursa (a fluid-filled sack that sits between bones and soft tissues to limit friction), usually irritated with recurring hamstring injuries
• Ischial tuberosity (the “sit-bone”), which in rare cases can be fractured by traumatic injury

Risk factors for hamstring injuries include:

• A history of prior hamstring injury
• Muscle imbalances (particularly hamstring weakness)
• Poor flexibility (muscle tightness)
• Inadequate warm-up before activity
• Muscle fatigue

Where does it hurt?

In most cases of hamstring muscle pain and injury, patients report pain right in the middle of the hamstring muscle. This is the most common site of hamstring muscle strains. There are many different causes of hamstring pain: hamstring syndrome, chronic hamstring tightness and even your low back can cause hamstring pain. Because of this, it’s possible to feel the pain in other parts of your body. This is called referred pain. Understanding the root cause of your pain is fundamental to treating your pain in the long run & will decrease your dependence on painkillers or treatment that only addresses the symptoms.

What are common symptoms of a hamstring injury?

When a person injures a hamstring muscle, the symptoms are related to the severity of the injury. Mild hamstring strains often just feel like a pulled or cramping muscle; you might not even realize you have pulled your hamstring until you stop performing the activity, or until the next day, when you might have soreness, tightness, or bruising. However, more involved injuries can be painful, and your symptoms might include:

• A sudden, sharp pain in the buttocks or back of the thigh
• A feeling of a “pop” or tearing in the muscle
• Bruising within hours or days after the injury
• Swelling
• Tenderness to touch
• Difficulty sitting comfortably, lifting the leg when lying down, or straightening the knee
• Difficulty walking, resulting in a limp

Can a hamstring injury be treated?

Yes, hamstring pain can be treated and with great results. Even better, many times it can be treated conservatively without needing injections, pain medications, or surgeries if you can address it early enough. The key to treatment is to solve the root cause of your pain so you can get the best results and along-term outcome.

Some root causes of hamstring pain can be:

• Decreased hip range of motion
• Poor posture in sitting causing hip tightness
• Hip arthritis and labral tear
• Weak hip and glute muscles
• Poor patella tracking
• Poor lifting and running biomechanics
• Hip flexor problems
• Leg length discrepancy
• Previous leg or hip injury
• Tight low back and hip joints
• Poor biomechanics with sports
• Trigger points in hip and thigh muscles
• Lack of ankle range of motion

If you have failed multiple treatment approaches already, your clinician missed the real root cause of your pain and was just chasing the symptoms. The pain or symptom is the effect, not the cause. What do I mean by this? Say your fire alarm goes off in your house. Its purpose is to protect you and make you aware that something is wrong, i.e., that there is a fire in your house. The “alarm” is like your pain (your body’s way of telling your something is wrong) and the “fire” is the root cause. When the fire alarm goes off, you don’t run upstairs and just turn it off, right? You run through the house with the fire extinguisher, trying to find the room where the fire is at. You try to find out what caused the alarm to go off so you can put it out. Once the fire is out, then the fire alarm can go off. Solve the “root” cause of your pain, and then the pain (“the effect”) eventually goes away.

Additionally, there is a common root cause which many clinicians misdiagnose. They treat the hamstring pain with a cookie cutter approach, hoping it will work, and treat it as a simple muscle problem. They tend to rely on stretching, ultrasound, massage, and focus treatment directly on the hamstring muscle. However, often the root cause is missed and the symptoms return. There is probably something else adjacent to the knee, like the hip or ankle, that is overloading or stressing the knee to cause your pain. Other neighboring joints can influence your primary complaint area causing your pain. So many healthcare clinicians treat pain like this and thus show poor treatment outcomes which results in the pain coming back. Why? They missed the root cause of your hamstring pain. This is also the case when patients turn to injections, nerve blocks and other surgeries which are still not effective because the actual problem still is not solved, their treatment was just chasing the pain.

The first step in treatment is to identify the root cause of your pain. A specific and individualized treatment approach for your type of pain can lead to a successful outcome for you and resolve your symptoms for the long term. This is why you can’t rely on a standard cookie cutter approach; you need a customized and individualized treatment approach specifically for your type of hamstring pain.

“It is with great pleasure that I highly recommend Dr. Ron Miller as your next Physical Therapist! I have suffered for years with plantar fasciitis in both feet, hip problems, a chronic hamstring strain and, most recently, pain in my Achilles. Dr. Miller believed in me, and in my ability to begin running again pain free. He is thorough, thoughtful, intelligent, and capable.“

Meredith B.
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What happens if it goes untreated?

Minor case – If it is a minor case of hamstring pain, research shows that many acute cases of pain may spontaneously go away in 4-8 weeks. The key to prevent from becoming a more severe chronic case is to solve the root cause of the hamstring pain and determine what actually is causing it. Many times, it’s not really a knee pain and the problem is somewhere else. But who wants to wait 8 weeks to get pain free? Let’s try to solve the root cause of your pain in 2-3 weeks and address all of the risk factors present (so it never returns!) and get you back to your favorite activities faster! We still recommend that you get it checked out by one of our board-certified physical therapists to ensure that it is just a minor case, to solve all risk factors, and to get the optimal outcome in the fewest visits needed. Most minor cases resolve on their own in time or get better with some stretching and strengthening. But, the sooner you take action, the sooner you are pain-free. (And research supports this!)

Severe case – If it’s more of a severe and chronic case of hamstring pain, your pain will probably start to worsen and increase because the root cause and underlying risk factors of the pain are not being treated. Many people turn to pain medication and injections at this time but this only blocks the pain for short term. You may not feel the pain when taking pain medications, but the underlying problem is still there. Many people say after the pain medication and injection wears off, then usually the pain returns and sometimes it returns even worse. Many cases like this, the hamstring is not the problem, but the effect. It is just the result of another predisposing injury or risk factor. Once the root cause is addressed, then we can start decreasing your pain, regardless of how chronic and severe the pain is. This is the crucial first step. It just may take more time to recover from a chronic case. Usually with chronic and severe cases, the longer you have your pain and injury, the longer it takes to resolve.

What outcome can you expect from treatment?

As we’ve discussed, the first step is to solve the root cause of your hamstring muscle pain. This is the most essential step to plan a treatment specialized for you and your unique type of pain. Your root cause will guide your treatment and dictate what is the best way to treat your pain. This, along with identifying risk factors that may be predisposing you to have your pain and injury, will allow you to start getting pain free again. The next step is to start decreasing pain, modifying activities, and start addressing all of the impairments causing your pain which we discovered during your evaluation. With each session, pain should start to decrease and you should start to regain range of motion with less pain and symptoms. Any radicular and referred pain should resolve fast as well. At this point, we begin light and basic strengthening only if it does not increase pain. Treatment will consist of a lot of manual therapy and light exercises.

The next step is to achieve full range of motion, (which should correlate to being pain-free) and now we can start progressive strengthening. Strengthening the muscles is crucial and research shows that this gives you the best long-term outcome! As you start to get stronger and maintain your mobility, your pain will continue to decrease if it is not already gone. Your increased strength will allow you to perform more activities and prevent flare-ups. This usually does take up to 4 weeks. As you clear our goals, then we can start easing you back into sport, golf, running, and whatever your favorite activities are. This is when we start winding down treatments and getting you back into functional strengthening, sport specific training, return to run programs, golfing, and whatever your goals are. In the end, we reassess everything, making sure we achieved all of our goals, your goals, that all risk factors are gone, and finalize your long-term home exercise program. There are many factors which can influence your outcome, but 85-90% of our patients respond well to our treatment approach and achieve a successful outcome when completing their plan of care.

How is it diagnosed?

Diagnosis of hamstring injuries starts with a thorough understanding of your health history and the cause of the injury. The questions your therapist may ask include:

• If you have had a similar injury before
• What you were doing when you first felt the pain
• Where you felt the pain, and if you felt a “pop”
• If you noticed any swelling or bruising in the first 24 hours after the injury
• What you were able to do immediately following the injury, and how you have been functioning since the injury (walking, sleeping, lifting your leg, etc.)

Your physical therapist will also perform a clinical evaluation, including some of the following observations and tests to determine the nature of your injury:

• Observation:To note any discoloration or bruising
• Pain: To identify your current pain level, and the activities that make your pain better or worse
• Palpation: To pinpoint the location and size of the tender area through touch, which will help determine the severity of the injury
• Range of motion: To compare the motion of your injured leg with your healthy leg
• Muscle strength: To determine the strength of the hamstring muscles when bending or straightening your knee and hip
• Gait analysis: To note any limping or pain when walking

Typically, hamstring injuries are classified as Grade I – III depending on the severity of the injury.

• Grade I: Mild strain with minimal tearing; usually feels like a pulled or cramping muscle
• Grade II: Moderate strain with partial tearing; may cause a stinging or burning sensation at the back of the thigh
• Grade III: A severe, complete muscle tear; may result in a “lump” on the back of the thigh where the muscle has torn

If your physical therapist suspects a severe injury, you will likely be referred to an orthopedic physician for medical diagnostic imaging, including x-ray and MRI, to evaluate the extent of the injury. In the event of a fracture of the ischial tuberosity (sit-bone) and/or a complete rupture of the muscle, surgery might be recommended.

Do you need an X-ray and MRI imaging for hamstring muscle pain?

For most common orthopedic cases, imaging is not needed and the diagnosis can be made with a simple physical therapy evaluation. No need to waste thousands of dollars on unwarranted diagnostic imaging. We also have clinical tests which we can perform to help rule in and rule out pathologies that correlate to MRI findings (which is WAY cheaper than an MRI!). An expensive MRI may just tell us what we already know. Also, often times the positive findings found on x-rays, MRIs, and EMGs may not actually be the root cause of your pain. What does that mean? Many positive findings on an MRI are also found in asymptomatic (pain-free) individuals, so diagnostic imaging may not be able to tell us what is actually causing your pain. For example: many people have a herniated disc in their low back but do not have any low back pain. So if herniated discs can cause no pain, just because someone with low back pain has a herniated disc does not mean that is what’s causing their pain. The key is to find out if your clinical evaluation findings during your evaluation at Pursuit match the MRI findings. If so, then we can decide what is the best way to treat it.

How can a Physical Therapist treat it?

Your physical therapist will design an individualized treatment program specific to the exact nature of your injury and your goals.

Physical therapy may include:

• Resting the injured area by avoiding aggravating activities, such as walking or working out. If you are having notable difficulty walking, crutches may be recommended.
• Applying ice to the injured area 3-4x/day for 15-20 minutes (with a towel placed between your skin and the ice).
• Applying a compression wrap to the area to aid in decreasing swelling and pain.
• Referral to another health care provider for further diagnostic testing (if needed).

Range of motion
It is common for muscles and joints to become stiff after an injury. As your pain decreases, your physical therapist will begin gentle flexibility exercises, such as stretching your hamstring muscles.

Muscle strength
Hamstring strengthening will be an essential part of your rehabilitation program. Your physical therapist will compare the strength of the muscle groups in each leg, and prescribe specific exercises to target areas of weakness.

Manual therapy
Many physical therapists are trained in hands-on “manual” therapy to move and manipulate muscles and joints to improve motion, flexibility, and strength. These techniques can target areas that are difficult to treat on your own.

Functional training
As you regain the flexibility and strength in your hamstrings, it will be important to teach your body how to move so you no longer put excessive stress on the previously injured area. Your physical therapist will develop a functional training program specific to your desired activity.

In the event that the severity of your hamstring injury requires surgical treatment, a physical therapist will guide your postoperative rehabilitation. Your physical therapist will communicate with your surgeon to ensure complete and consistent postoperative care.

“After at least three years of doctor-hopping […] looking for someone to alleviate my constant dizziness and neck pain, I finally found Dr. Miller. I have more energy and less pain, and have halved my dependence on painkillers. He shouldn’t be the last stop on your road to recovery, he should be the first.”

Lisa B.
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How long does it take for recovery?

Recovery time for hamstring muscle pain depends on multiple factors:

• The severity and chronicity of your pain
• Whether your pain is an easy or complex case
• If the root cause of your pain was solved or if it was missed (this is the key to getting a great recovery!)
• How long you have been in pain for and when you need to be pain-free by
• Other therapies and treatments you have tried
• Which medical professional(s) you saw prior to seeing us
• How active you are in trying to resolve your pain
• Which treatment approach is chosen and if it is proven to work for your pain

There are many factors that influence your recovery time and every patient’s recovery time is different. If you do nothing and don’t pursue treatment, it could gradually get better on its own, you could continue to have the same pain persist, or it could continue to get worse. As stated earlier, most acute cases may or may not resolve in 4-8 weeks. If you get expert treatment that solves the root cause of your pain, some cases resolve in 1-3 weeks! Then you can get back to sports, exercise, and your favorite activities without flare-ups and recurrences. Some of our patients are pain-free in 1-3 visits and back to 100% in 2 weeks!

If it is a complex case with chronic pain, your recovery may take longer, but you can still get a good outcome. Some chronic cases can resolve as fast as 2 months but can take as long as 4-6 months. It varies with every patient because every case of hamstring muscle pain is different. Every patient’s recovery varies depending on the factors listed above. After a thorough evaluation here at Pursuit Physical Therapy, you will know your exact timeline of recovery, your prognosis, and when you should reach your goals.

How much does it cost?

The average cost of care for a case of spine pain in the US is $1800-$6600. This high price is due to many factors: the over-inflated cost of healthcare, the over expensive cost of unwarranted imaging (x-rays, CT scans, and MRIs) that is not needed, over-utilization of care (which increases the number of visits needed to be treated, requiring multiple visits to different doctors and physical therapists for the same diagnosis), and getting billed for unnecessary and unproven treatments that you don’t even need. All of these factors increase cost and this is why healthcare is so expensive. We strive to end that unnecessary, expensive cycle. In fact, we are currently publishing our first-year data with the University of Central Florida that shows the cost-effectiveness of our treatment approach.

This year, the average cost of our care was shown to be $814-$1141. Some of our patients get even as low as $315 for the full treatment! So if you have a deductible of $3,000-$10,000 and you have to pay out of pocket for your treatment, we can save you lots of money.

Remember, every case of pain is different and not all hamstring muscle pain is the same. It is hard to predict exactly how much your treatment is going to cost you. But after a thorough evaluation, we can tell you exactly what is causing your pain, how long it is going to take, what the best way to treat it will be, and exactly how much it is going to cost. We have no hidden fees, no co-pays, and no miscellaneous bills that you will be surprised by 3 months after you receive treatment. Your pain, your diagnosis, your goals, and what is best for you dictate your treatment and how much it will cost, and while it varies for every patient, treatment at Pursuit is still much more affordable than standard healthcare.

How long are sessions?

Our evaluations are always one-on-one with one of our board-certified specialists and 60-90 minutes long. We like to perform thorough evaluations so we can solve the root cause of your pain, identify all risk factors, and make sure that we do it right. After the evaluation, you will know your diagnosis, the root cause of why you have your pain and symptoms, your prognosis, an expected timeline of when you should see results, what the best way to treat your pain is, how much it will cost, and your expected recovery outcome. We want you to fully understand everything about your pain and injury. What is best for you and will get you the best outcome is what will dictate your care and treatment. There will be plenty of time for you to ask questions so we can make sure you fully understand why you have your pain and what the best way to treat it will be. After the evaluation is completed, all treatment sessions are 60 minutes going forward and still one-on-one with your physical therapist. You and your physical therapist will design a customized treatment plan that works for you and that will achieve your goals.

How can it be prevented?

You can decrease your risk of a hamstring injury in the following ways:

• Always warm up before participating in athletic activities.
• Avoid starting a new activity too quickly; gradually increase the frequency and intensity of the activity so that your body may adapt to the new movement patterns.
• Listen to your body after you work out (and stretch, apply ice, rest as needed) prior to engaging in the same routine again.
• Use proper lifting and squatting techniques, particularly when maneuvering heavy objects.

What are the next steps?

Getting started is simple. The first step, and the key to getting you pain-free again is to solve the root cause or your case of pain. Remember, not all pain is the same. Your pain is different than someone else’s pain, even though it may be in the same area. If you’re ready to get pain free, give us a call at (407) 494-8835 or fill out the form below. The next step is to schedule your evaluation so we can solve the root cause for you. We’re happy to answer any questions you may have and we would love the opportunity to help you.