Hamstring Strain: Prevention & Rehabilitation (Part 2)

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Guest blog by Paul Head

Paul holds a BSc Sports Therapy degree from University of Central Lancashire (UCLAN) and is a pre reg physiotherapy student. He received first Class Honours Classification (78% average) and  an award for Academic Excellence in the field of sports therapy / physiotherapy from DJO UK. Find out more about Paul here…

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They could feel a tear or a popping sensation at the back of their leg during high speed running, sprinting, change of direction, deceleration or kicking, overstretching activity. Sudden onset with pain and swelling on the posterior thigh.


Walking gait, functional tests

Clear joints above and below: Lumbar spine with active movements and passive overpressure if active is pain free. Pelvis and Ankle with active and passive range of motion

Active Range of Motion

Prone knee flexion; hip extension with the leg extended, will be painful, reduced strength

Straight leg raise (SLR); hip flexion with knee extension with internal and external rotation of the tibia, will show reduced ROM and pain

Passive Range of Motion

SLR with ankle in plantarflexion to limit neural involvement, will be painful, reduced ROM

Hip flexion with knee extension and internal / external tibial rotation

Manual Muscle Tests (MMT)

Knee flexion at 15 and 90 degrees of flexion with internal and external rotation of the tibia to help differentiate what muscle is injured

Hip extension with knee extended, could show reduced strength and pain

Palpation from ischial tuberosity down the muscle, most pain usually felt up to the musculotendinous junction and mid belly of the muscle.


This concept acknowledges the role that altered neural motion and physiology may have in the production of soft tissue dysfunction. During human motion the nervous system moves against adjacent tissue and is subjected to compressive and tensile forces. An alteration in the ability of the neural system to tolerate these forces has been suggested as a contributing factor in musculoskeletal dysfunction.


The patient lies supine and the clinician passively raises the patient’s leg, keeping the patient’s knee in extension. At the point of slight discomfort, the clinician adds in sensitising manoeuvres that further increase the mechanical and physiological stress on the neural tissue but which, theoretically, do not change the stress in the hamstring tissue.

These are: cervical flexion, internal rotation of the hip and ankle dorsiflexion.

Slump test

The patient sits on the edge of the couch. The clinician asks the patient to slump their spine whilst keeping their head up and looking forwards. The clinician then passively extends the patient’s knee to the point of mild discomfort. The clinician adds in sensitising manoeuvres that further increase the stress on the neural tissue but these are: cervical flexion, internal rotation of the hip and ankle dorsiflexion.

These two neurodynamic tests are important in trying to resolve the issue of whether a patient’s posterior thigh pain/hamstring pain is hamstring or neural in origin.

(Hunter and Speed, 2007)

Differential Diagnosis

Posterior thigh pain from sciatic nerve damage

Piriformis syndrome causing radicular posterior thigh pain

SIJ dysfunction

Adductor strain; due to adductor magnus having a hamstring portion that shares the same origin at the ischial tuberosity and nerve supply from the tibial nerve.

Isokinetic Testing can be helpful in quantifying reductions in strength and differences in strength between injured and non injured hamstrings and eccentric hamstring / quadriceps ratio

MRI and Diagnostic Ultrasound to help determine size of lesions and whether full healing has occurred prior to return to play.

Hamstring Strain Classification

According to the Munich consensus muscle strains can be categorized into functional and structural strains (Mueller-Wohlfahrt et al. 2013). Functional strains show no physical signs of muscle fibre damage on ultrasound or MRI scans but present with increased hamstring tone on palpation and the person reporting a feeling of tightness in the posterior thigh. This type of injury normally resolves in a week with treatment consisting of methods to decrease hypertonicity, decrease swelling and increase function. On the other hand structural strains show muscle fibre damage on MRI and ultrasound, pain on palpation and take longer to resolve.

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