Conditions We Treat

Hamstring Strain

Reviewed by Dr Matthew Proctor · MTC(SA), ICCSP (FICS) · AHPCSA A10954

At a glance

A hamstring strain is a tear of the muscle fibres at the back of the thigh, usually while sprinting or overstretching into a kick or a slide. Most are managed well without surgery through a graded rehabilitation programme that progressively loads the muscle, and the main risk afterwards is doing it again. The rare exception is a tendon avulsion from the sitting bone, which needs prompt imaging and an orthopaedic opinion.

You are in the last few metres of a sprint, or reaching for a ball at full stretch, and something grabs at the back of your thigh. Some people feel a pop. Most pull up straight away, and by the evening walking feels stiff and sitting on a hard chair is uncomfortable.

The hamstrings are three muscles that run from the sitting bone to just below the knee. They work hardest when you run fast, which is why most strains happen at speed. A second type happens during slow, extreme stretches such as a high kick, a slide tackle or slipping into the splits, and these stretch-type injuries take noticeably longer to recover (Askling et al., 2013). In men's professional football, 22% of players have at least one hamstring injury a season (Ekstrand et al., 2016). We see the same pattern in the rugby players, runners, cricketers and padel players who come through our Sandton practice.

How you rehab the muscle makes a real difference. In a randomised trial of 75 elite Swedish footballers with MRI-confirmed hamstring injuries, players on a programme built around loading the muscle in lengthened positions returned to full training in an average of 28 days, compared with 51 days on a conventional exercise programme (Askling et al., 2013). A separate trial found that letting players train into a tolerable level of discomfort, rather than stopping at the first twinge, did not slow their return and left them with more hamstring strength (Hickey et al., 2020). Early, progressive loading guided by what the muscle can tolerate is the backbone of how we rehabilitate these injuries.

Treatment starts with a careful assessment: where the tear is, how it happened, how much strength you have lost and whether anything points to a more serious injury. In the first few days we follow the principles in our PEACE & LOVE guide, then move quickly into soft tissue work, mobilisation of a stiff lower back or pelvis where it is contributing and a staged exercise programme. Dry needling can form part of the soft tissue work where it suits you. The later stages rebuild speed, change of direction and sport-specific drills, so that returning to play is a planned step rather than a guess. Our sports injury page explains how we work with athletes more broadly.

Not every pain at the back of the thigh is a hamstring strain. Pain can be referred there from the lower back, the hip or the sacroiliac joint, and nerve tension tests such as the seated slump test help show whether the lumbar spine or sciatic nerve is involved (Chu and Rho, 2016). We check the lumbar spine routinely, and if the pain is coming from there, our sciatica approach is the better fit.

Re-injury is the real problem with hamstrings. A 2020 meta-analysis of 78 studies found that any previous hamstring strain raised the risk of another by 2.7 times and a recent one by 4.8 times, with older age the other strong risk factor (Green et al., 2020). That risk can be brought down. Including the Nordic hamstring exercise in prevention programmes roughly halved hamstring injury rates across 15 studies covering 8,459 athletes (van Dyk et al., 2019). We build it into the later stages of rehab and leave you with a maintenance routine to keep doing once you are back playing.

One injury needs to be picked up quickly. If the tendon pulls away from the sitting bone, it is called a proximal avulsion. Watch for an audible pop during an overstretch, bruising that spreads down the back of the thigh towards the knee and a gap you can feel in the muscle, which can point to a complete rupture. When an avulsion is suspected, imaging is needed to confirm it (Chu and Rho, 2016). A meta-analysis of 24 studies found that repaired proximal avulsions had better strength and patient satisfaction than those managed without surgery, and that early repairs did better than delayed ones (Bodendorfer et al., 2018). Chiropractors in South Africa are primary contact practitioners, so if we suspect an avulsion we can refer you directly for imaging and to an orthopaedic specialist without waiting for a separate referral.

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Common symptoms of a hamstring strain

Sudden sharp pain at the back of the thigh while sprinting or stretching
A pulling or popping feeling at the moment of injury
Pain when bending the knee against resistance
Tightness and pain when straightening the leg or bending forward
Tenderness to touch along the back of the thigh
Bruising that appears a day or two later
Limping or shortening your stride to protect the leg
Discomfort sitting on a hard chair
Weakness when trying to run or accelerate
A hamstring that keeps tightening up at the same spot

Hamstring strains recover best with early, guided loading. If you have pulled up with a sore hamstring, getting assessed early helps you start the right rehab sooner and plan a safe return to sport.

Located on Rivonia Road in Morningside, we treat patients from Sandton, Bryanston, Rivonia, Fourways and across Johannesburg.

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Frequently Asked Questions

How long does a hamstring strain take to heal?

It depends on where the muscle is torn and how it happened. In a trial of elite footballers with MRI-confirmed hamstring injuries, players on a programme built around loading the muscle in lengthened positions returned to full training in an average of 28 days. Injuries caused by an extreme stretch, such as a high kick or slipping into the splits, took longer than those that happened while sprinting. Milder strains often settle sooner, and a proper assessment gives you a realistic timeframe for your injury.

Should I stretch a pulled hamstring?

Not aggressively in the first few days. What helps is gentle movement early on, then progressively loading the muscle, including in lengthened positions. One trial found that allowing a tolerable level of discomfort during rehab exercises, rather than stopping at the first twinge, did not slow return to play and left players with more hamstring strength. We guide how far to push at each stage.

How do I stop my hamstring tearing again?

A previous hamstring strain is one of the strongest risk factors for another, and a recent one raises the risk most. Finishing rehab properly before going back to full speed matters, and so does keeping up strength work afterwards. Programmes that include the Nordic hamstring exercise have roughly halved hamstring injury rates across a meta-analysis of more than 8,000 athletes.

When is a hamstring injury serious?

Get assessed promptly if you felt a pop during an overstretch, if bruising spreads down the back of the thigh towards the knee or if you can feel a gap in the muscle. These can be signs of a more severe tear, including the tendon pulling away from the sitting bone, known as an avulsion. A suspected avulsion needs imaging and an orthopaedic opinion quickly, because early repair tends to give better results than delayed repair.

Is it my hamstring or my lower back?

Pain at the back of the thigh can be referred from the lower back, the hip or the sacroiliac joint, and this can feel a lot like a hamstring strain. Simple nerve tension tests, such as the seated slump test, help show whether the lumbar spine or sciatic nerve is involved. We check the lower back as part of every hamstring assessment, because the treatment is different.