The accurate diagnosis of the injury and the degree of its severity is the crucial factor to be decided initially as this indicates how the injury is to be expected to improve and how long it will be until the patient has functionally recovered. The mainstay of treatment is physiotherapy and the physio has to decide the how to progress the treatment according to the level of tissue injury and the time which has elapsed since the event. There is no effective scientific evidence for managing this kind of injury and the physiotherapist will design the rehabilitation programme individually to suit the particular and variable requirements.

There are three initial phases which hamstring injuries can be classified into: the acute phase, the sub-acute phase and the remodelling phase. There is a different treatment plan and strategy for each phase and the time elapsed since injury. The acute stage can last up to the end of the week since injury and the main aims are to reduce the levels of inflammation, pain and swelling secondary to the tissue damage. Treatment normally follows the PRICE system: protection; rest; ice; compression; elevation. Protection is aimed at eliminating any significantly harmful stresses to the damaged tissues, with the treatment options of using crutches to limit the amount of weight on the leg or bracing the knee in flexion.

Rest is the second requirement to protect the damaged muscle tissue by eliminating force through the area although athletes find this difficult to adhere to. Ice is a primary treatment for acute injuries and reduces pain when applied for approximately 20 minutes, with a check after 10 to ensure skin health. Cold inhibits inflammatory changes in the local area by reducing metabolism and so the amount of circulation coming to the area. Compression may be more useful than cold, which is typically used by physios, and controls local swelling, with elasticated bandages applied to the limb an effective strategy.

For acute injuries elevation of the affected parts is usually advised with the part lifted above heart level to give the best effect in providing build up of tissue fluid. The position of the injury to the hamstrings makes elevation impractical and it may be unnecessary. A reduction in the levels of pain and inflammation allows the physiotherapist to start passive movements to the limb and to prescribe active assisted movements. Physios avoid stretching at this point as this may aggravate the symptoms and damage the area. Minor hamstring injuries typically recover in a few days but should still be managed appropriately. So monitoring during hamstring injuring recovery time is critical for overall healing.

Soft tissue injuries take at least six weeks to heal, even minor ones, so once feeling much better athletes should be encouraged to ease slowly into doing more stressful activities and should pay attention to strengthening muscles, stretching and balance to reduce the likelihood of the injury recurring. In the sub acute phase, which lasts until about three weeks after injury, the pain and inflammation of the acute injury should be reducing and so the physiotherapist can progress the treatment on to active range of motion exercises and then to muscle strengthening.

To facilitate hamstring rehabilitation without a high degree of weight bearing on the limb it can be appropriate to use pool therapy and patients can continue with their aerobic training to maintain their cardiovascular ability and arm training. The injured area will be exercised with sub maximal training effort. The phase of remodelling takes the injury towards the six week time after the injury and the physio will test to see if the patient can cope with a full strength contraction without any pain. If successful the rehab can be progressed via through range exercises (isotonic) with light weights and high repetitions.

The patient starts this process in prone with light ankle weights, progressing to heavier and heavier resistance provided the pain in the injured area is not provoked. The progression of weights should be conservative as too rapid an increase may lead to relapse and a more long term problem. Once the patient has achieved good strengthening with the muscle shortening (concentric contraction) they should be progresses to strengthening with the muscle lengthening (eccentric contraction).

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapists, physiotherapy, Physiotherapy Leeds, back pain, orthopaedic conditions, neck pain and injury management. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.