eMedicine Specialties > Sports Medicine > Lower Limb
Hamstring Injury: Treatment & Medication
Updated: Jun 16, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Acute Phase
Rehabilitation Program
Physical Therapy
Treatment of hamstring injuries varies according to the severity of the injury. Patients with minor strains may progress quickly to strengthening exercises, whereas those with full-thickness ruptures require surgery. Up to 1 week after a minor injury, the focus of therapy is to limit pain, inflammation, and swelling. Rest, ice, compression, and elevation (RICE) are recommended. Elastic thigh bandages can be useful for compression. Icing for 20 minutes, 4 times per day, provides pain relief.
Most patients may begin active range of motion (AROM) exercises within their pain tolerance after 1-2 days. Individuals with more serious injuries benefit from immobilization in knee extension for 1-5 days to prevent contracture formation and further damage. Crutches enable ambulation while resting the injured leg.
After several days, most patients may begin pain-free submaximal isometrics, pool therapies, and upper-body exercises. Isometric exercises are performed at various knee angles in increments of 20°. Patients hold the contraction for 5-15 seconds, and perform 3 sets at each angle.
Related eMedicine topic:
Therapeutic Exercise
Medical Issues/Complications
If patients return to their usual activities too soon, delayed healing or reinjury may result. In more serious injuries, compartment syndrome can result from an extending hematoma. The most common symptom of compartment syndrome is increasing pain.
Surgical Intervention
Surgery is rarely performed for large hematomas; on the other hand, it is performed in more than 50% of cases of muscle belly tears, with consideration given to the patient's activity demands. However, surgery is generally indicated for bony avulsions only.
Consultations
In cases of severe hamstring injuries, consultation with a sports medicine specialist or an orthopedic surgeon may be indicated. Physiatrists may be consulted to oversee rehabilitative therapies and to help prevent further injuries.
Related eMedicine topic:
Adult Physiatric History and Examination
Recovery Phase
Rehabilitation Program
Physical Therapy
Generally, treatment 1-6 weeks postinjury focuses on patient strengthening, improving range of motion (ROM), and flexibility.
Passive static stretching may begin at this stage. Moist heat may be used to warm up the muscle tissues before stretching and exercising. Electrical stimulation may be used in conjunction with ice for added pain relief.
Being pain free throughout the entire ROM is not required before strengthening exercises may be initiated. The patient may exercise, preferably with a therapist, to strengthen the muscle within the available pain-free ROM.
Next, the patient begins isotonic exercises with resistance, increasing the program gradually as tolerated. As healing continues, high-speed, low-resistance isokinetic exercises are started. Resistance is increased gradually, while exercise speed is decreased. Over time, the patient progresses from concentric to eccentric strengthening exercises. Before the athlete returns to play, sports-specific training maximizes recovery and minimizes the chances for additional injury.
Related eMedicine topic:
Therapeutic Exercise
Medical Issues/Complications
Reinjury and delayed healing result if the therapy is too aggressive or if activity limitations are not followed.
Maintenance Phase
Rehabilitation Program
Physical Therapy
From 1 month postinjury onward, the patient continues stretching and strengthening exercises to maintain flexibility and an adequate hamstring-to-quadriceps strength ratio.
Medication
Although some inflammation may theoretically be desirable to facilitate clearing of necrotic tissue and to initiate healing, nonsteroidal anti-inflammatory drugs (NSAIDs) are usually started right away. However, NSAIDs are ideally used for only 3-7 days, given the evidence that their use may delay complete healing.
Acetaminophen or a narcotic may be administered in addition to an NSAID for most continuing pain. However, narcotics (eg, Vicodin) are usually reserved for those with serious injuries and extreme pain.
Some animal model studies show some evidence that anabolic steroids may aid in the healing of injured muscles. Animals that have been treated with anabolic steroids are able to generate greater forces through injured muscles than those that have not been treated with these agents. However, there is not enough evidence to recommend the use of anabolic steroids to promote faster healing.
Related eMedicine topics:
Anabolic Steroid Use and Abuse
Corticosteroid-Induced Myopathy
Toxicity, Acetaminophen
Toxicity, Narcotics
Toxicity, Nonsteroidal Anti-inflammatory Agents
Resource Center Adverse Drug Events Reporting
Resource Center Pain Management: Advanced Approaches to Chronic Pain Management
Resource Center Pain Management: Pharmacologic Approaches
Nonsteroidal Anti-inflammatory Agents
NSAIDs have analgesic and antipyretic activities. The mechanism of action of these agents is not known, but NSAIDs may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation and various cell membrane functions. Treatment of pain tends to be patient specific.
Naproxen (Aleve, Anaprox, Naprelan, Naprosyn)
Relieves mild to moderate pain. Inhibits inflammatory reactions and pain probably by decreasing the activity of the enzyme cyclooxygenase, which results in decreased prostaglandin synthesis.
Adult
250-500 mg PO bid; may increase to 1.5 g/d for limited periods; not to exceed 1.25 g/d
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Coadministration with aspirin increases the risk of inducing serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of the drug.
Analgesics
Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who have sustained trauma or who have sustained injuries.
Acetaminophen (Feverall, Tempra, Tylenol)
DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, in those diagnosed with upper GI disease, or in those taking oral anticoagulants.
Adult
650-1000 mg PO q4-6h
Pediatric
15 mg/kg/dose PO q4h
Rifampin can reduce the analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity.
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity can occur in those with chronic alcoholism with various dose levels of acetaminophen; severe or recurrent pain or high or continued fever may indicate a serious illness.
Hydrocodone bitartrate and acetaminophen (Vicodin, Vicodin ES)
Drug combination indicated for moderate to severe pain.
Adult
1-2 tab or cap PO q4-6h prn
Pediatric
<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d acetaminophen
>12 years: 750 mg acetaminophen PO q4h; not to exceed 10 mg hydrocodone bitartrate per dose or 5 doses/24h
Coadministration with phenothiazines may decrease the analgesic effects; toxicity increases with CNS depressants or tricyclic antidepressants
Documented hypersensitivity; elevated intracranial pressure
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
The tablets contain metabisulfite, which may cause allergic reactions; caution in the presence of severe renal or hepatic dysfunction
More on Hamstring Injury |
| Overview: Hamstring Injury |
| Differential Diagnoses & Workup: Hamstring Injury |
 Treatment & Medication: Hamstring Injury |
| Follow-up: Hamstring Injury |
| References |
| « Previous Page | Next Page » |
References
Davis KW. Imaging of the hamstrings. Semin Musculoskelet Radiol. Mar 2008;12(1):28-41. [Medline].
Reid DC. Soft tissue injuries of the thigh. Sports Injury Assessment and Rehabilitation. Philadelphia, Pa: Churchill Livingstone; 1992:551-71.
Sarimo J, Lempainen L, Mattila K, Orava S. Complete proximal hamstring avulsions: a series of 41 patients with operative treatment. Am J Sports Med. Jun 2008;36(6):1110-5. [Medline].
Sallay PI, Friedman RL, Coogan PG, Garrett WE. Hamstring muscle injuries among water skiers. Functional outcome and prevention. Am J Sports Med. Mar-Apr 1996;24(2):130-6. [Medline].
Askling CM, Tengvar M, Saartok T, Thorstensson A. Proximal hamstring strains of stretching type in different sports: injury situations, clinical and magnetic resonance imaging characteristics, and return to sport. Am J Sports Med. Apr 30 2008;epub ahead of print. [Medline].
Croisier JL, Ganteaume S, Binet J, Genty M, Ferret JM. Strength imbalances and prevention of hamstring injury in professional soccer players: a prospective study. Am J Sports Med. Apr 30 2008;epub ahead of print. [Medline].
Clark RA. Hamstring injuries: risk assessment and injury prevention. Ann Acad Med Singapore. Apr 2008;37(4):341-6. [Medline]. [Full Text].
Clanton TO, Coupe KJ. Hamstring strains in athletes: diagnosis and treatment. J Am Acad Orthop Surg. Jul-Aug 1998;6(4):237-48. [Medline].
Hoskins W, Pollard H. The management of hamstring injury-- part 1: issues in diagnosis. Man Ther. May 2005;10(2):96-107. [Medline].
Levine WN, Bergfeld JA, Tessendorf W, Moorman CT 3rd. Intramuscular corticosteroid injection for hamstring injuries. A 13-year experience in the National Football League. Am J Sports Med. May-Jun 2000;28(3):297-300. [Medline].
Kujala UM, Orava S, Järvinen M. Hamstring injuries. Current trends in treatment and prevention. Sports Med. Jun 1997;23(6):397-404. [Medline].
Unger CL, Unger DA. Preventing and rehabilitating hamstring injuries. Athl Ther Today. May 1997;44-9.
Worrell TW. Factors associated with hamstring injuries. An approach to treatment and preventative measures. Sports Med. May 1994;17(5):338-45. [Medline].
Further Reading
Keywords
hamstring strain, hamstring pull, lower extremity injury, lower-extremity injury
