Emergency and Urgent Care - Thigh Injury - Hamstrings

There are two main groups of muscles in the thigh that can be injured:

Quadriceps: consist of the vastus lateralis, vastus medialis, vastus intermedius, and the rectus femoris.

Hamstrings: consists of three separate muscles – Semitendinosus, Semimembranosus, Biceps femoris.

What is a pulled hamstring?

A ‘pulled’ hamstring (also known as hamstring tear or hamstring strain) is when the hamstring muscle group, on the back of the thigh, is torn. Physiotherapy is an important treatment for a pulled hamstring.

How does a pulled hamstring happen?

A 'pulled' hamstring usually occurs when the hamstring muscle is contracted in a stretched position. This often occurs during running or sprinting; or stretching such as in gymnastics or martial arts.

Sprint related hamstring strains

• During sprinting the hamstring muscles work extremely hard. In particular, at a point just before the foot strikes the ground, they decelerate the tibia (shin) very quickly. It is at this point that the hamstring is most likely to tear
• Sprint related hamstring injuries usually occur lower down the biceps femoris muscle. More specifically, where the muscle joins to the tendon. They often feel worse initially but recover more quickly

Stretch related hamstring strains

• Stretch related injuries usually occur higher up at the back of the thigh. Most commonly the in the tendon of the semi- membranous muscle
• These injuries may take longer to heal because the blood supply to the tendon is not as good

Referred pain

• Referred pain is caused by problems elsewhere such as the lower back and hip but is felt at the back of the leg
• These may increase the likelihood of suffering a hamstring strain and should always be considered, particularly if you suffer from recurrent hamstring strains

What are the symptoms of a pulled hamstring?

The first sensation felt when a hamstring muscle is torn is sudden pain. This pain is normally felt in the back of the thigh. At the same time, you may also experience a ‘tearing’ sensation in the back of your thigh. In minor tears you may be able to continue participating with slight pain. However, as the muscle cools down, your pain may gradually worsen as bleeding and swelling occurs within the injured muscle. Other symptoms include:

• Spasm
• Weakness
• Swelling/inflammation
• Reduced range of movement

What should I do if I have a pulled hamstring?

The first 24–48 hours are important in the management of a pulled hamstring muscle. Swelling is necessary in the normal healing process; however, too much swelling can slow healing and cause further tissue damage:

P - Painkillers: it is important that you take regular painkillers to reduce the pain and help you keep moving around. Paracetamol and ibuprofen are effective painkillers if they are taken regularly and can be taken at the same time. These medications can be easily purchased over the counter at supermarkets and pharmacies. Please carefully read the instruction leaflet with the medication and only take the recommended dose; there may be reasons why you cannot take these medications, a pharmacist will be able to help you with this.

R - Rest: will help prevent further injury and allow the healing process to begin. For the first 2 days reduce the amount of walking you do and gently exercise your leg to prevent stiffness. Avoid forceful and strenuous activity, such as running, until you can walk without it causing pain.

I - Ice: can help reduce swelling and reduce pain. Make an ice pack by wrapping a small bag of frozen peas or some crushed ice cubes in a damp towel – DO NOT put ice pack directly onto skin. Put the ice pack on back of thigh for up to 20 minutes every 2 hours for the first 3 days after the injury. Then use the ice pack 3 times a day until the swelling has gone down. DO NOT eat food that has been thawed and refrozen.

M - Mobilisation: early weight bearing (putting weight on your injured leg) has been shown to help sprains to heal more quickly. Always try to walk normally, with your heel striking the floor first, then rocking forward onto your foot and pushing off with your toes. Using the exercises in this leaflet will help you to regain movement and build up strength and balance in your injured leg.

E - Elevation: keeping your injured leg raised above the level of your hips for the first 2 days after your injury. This will help to decrease the swelling and pain.

What shouldn’t I do if I have a pulled hamstring?

In the first few days after pulling your hamstring you should not perform activities that increase blood flow to the site of the injury. These include hot showers, hamstring stretches, heat rubs, massage, consumption of alcohol and excessive use of your leg.  These can prolong muscle bleeding and exaggerate swelling resulting in further pain and an extended recovery.

Physiotherapy treatment for a pulled hamstring

Physiotherapy is very important in the treatment of a pulled hamstring. Initially, your physiotherapist can advise you on the exact tissue/s damaged and the extent of the damage. Following your assessment, your physiotherapist can provide you with advice on how long your injury will take to heal and an appropriate treatment plan can be developed.

Treatment plans usually involve a number of treatment techniques, such as manipulations and electrotherapy, to reduce your pain and swelling and enhance the healing of the injured structures. Other treatment includes:

• Manipulation and mobilisation
• Massage
• Sports injury rehabilitation
• Hydrotherapy

Could there be any long-term effects?

With the correct treatment, most hamstring muscle strains heal in up to eight weeks. A proportion of injuries do, however, cause longer-term effects. This is usually if the initial management of the injury is poor or if the muscle damage is significant. When the hamstring muscle is torn significantly, a number of structures in and around the muscle can also be injured, delaying recovery. Poor management of a hamstring injury can lead to a tight or weakened hamstring muscle group that is prone to re-injury when returning to activity.

Hamstring strain exercises

Both stretching and strengthening exercises are important. After the initial acute stage, very gentle static stretching exercises can begin as long as they are pain-free. As your injury heals, dynamic stretching which involves movement is introduced and eventually sports-specific drills.

Strengthening exercises also begin gently with isometric contractions and progress through to advanced hamstring exercises.

Hamstring stretching exercises

During the acute stage immediately following a hamstring strain injury no stretching should be done at all, only rest.

How long this stage lasts for will depend on the severity or what grade the injury is but is usually 2 to 4 days. You can usually begin stretching exercises when daily activities such as normal walking are pain-free.

Straight leg hamstring stretch

The aim here is to get a little bit of elasticity to the healing tissue, not increase flexibility. This stretch can also be done sitting down.

• Place your foot on a table or similar and lean into the stretch, keeping your leg straight and chest up
• Take the stretch as far as is comfortable and hold relaxing into the stretch. Aim to stretch forward from the hip rather than the shoulders
• A gentle stretch should be felt at the back of the leg, but it should not be painful
• Perform 3 sets of 10 seconds once or twice a day

Bent leg hamstring stretch

• Bent leg hamstring stretch on the back targets the muscle fibres closer to the hip whereas the straight leg hamstring stretch targets the fibres nearer the knee
• Lie on your back and pull the leg over keeping the knee very slightly bent until a gentle stretch is felt at the back of the leg. Again, this should not be painful
• Perform 3 sets of 10 seconds once or twice a day

Hamstring strengthening exercises

Below are a number of progressively more difficult hamstring exercises. They should always be done pain-free. Where you start and how fast you progress will depend on how bad your injury is and how long ago it was injured.

Standing knee flexion

• Stand on one leg and bend the other one using just gravity as resistance
• This can be done gently and slowly to start with as an early- stage exercise
• Aim for 3 sets of 10 repetitions once a day, building to 4 sets of 20 reps
• Ankle weights can be used to increase the load further
• During the later stages when you begin running again, this exercise can be performed more explosively

Hamstring catches

 

The leg is allowed to fall, and the hamstring muscle catches the leg before it falls to the horizontal. It may take a while to get used to this one.

• Stay relaxed as your leg falls under the influence of gravity
• Only contract the hamstring muscles to prevent the foot landing
• This starts to work the hamstring muscles eccentrically, with a very light dynamic training effect
• Again, begin with 1 set of 10 reps and build up each day to 3 sets of 15 reps. An ankle weight can be used to increase the load on the muscle

Bridge exercises

• Lie on your back, knees bent and push the hips upwards to work the gluteal muscles and hamstrings
• Use both feet on the floor pushing up, to begin with
• Hold the position briefly and then lower
• Begin with 3 sets of 8 reps building to 3 sets of 12 reps then progress the exercise to single-leg bridges
• Single leg bridges are done in the same way ensuring you squeeze the gluteal muscles and aim to maintain a straight line from the shoulder on the ground to the knee at the top point of the exercise

Seated hamstring curl

• This is a deceptively difficult exercise that works the hamstring muscles specifically in a very contracted close range of movement
• One end of a resistance band is tied to a fixed point or held by a partner and the other end secured to the foot
• Pull your heel into the buttocks, contracting the hamstring muscle to do so
• Aim for 3 sets of 8 reps to begin building up to 3 sets of 12 or 15

Returning to physical activity

• Returning to sport and work will depend on the demands of your job or chosen sport
• Recovery is faster if you stay at work, or go back to work as early as possible
• If you are on your feet all day you may need to gradually return to work, do light duties initially, or have regular breaks to elevate your leg
• Once you have regained movement, strength and balance you can slowly start to increase your activity back to your previous level

Driving

It is important that you contact your insurance company to let them know about your injury. You may be able to drive once you are able to perform an emergency stop safely and fully operate your vehicle.

Physiotherapy

If you are unsure about what to do and feel you need support with your rehabilitation, then you can always go to see a Physiotherapist.

If you live in the Heywood, Middleton and Rochdale area, you can refer yourself by using the following link: www.physiodirect.northerncarealliance.nhs.uk

Work

If you do not feel capable of working either due to pain or reduced movement/mobility, you are able to self-certify sickness for the first 7 days.

You must complete a self-certification form found on the government website and give this to your employer. This entitles you to statutory sick pay from your employer for up to 7 days.

To access the self-certification form, follow this link:
https://www.gov.uk/government/publications/statutory-sickpay- employees-statement-of-sickness-sc2

If you feel you need longer than 7 days off work, you must contact your GP for a sick note. The Urgent Treatment Centre does not issue sick notes.

Possible complications

If follow up has been arranged, you should attend this.

If your injury does not require, follow up you will have been given an approximate recovery time during your visit to the Urgent Treatment Centre.

• If the pain is ongoing despite treatment and analgesia
• You experience tingling/change in sensation to your leg or foot
• You develop signs of a DVT such as hard swelling, redness to calf or thigh
• You develop chest pain please contact Rochdale Urgent Treatment Centre on 01706 517023 or return to the department.