How a hamstring injury is treated depends on the location and severity of the tear. Patients with an injury to the myotendinous junction are treated differently than patients with hamstring avulsion type injuries.
Treatment of myotendinous junction tears
The course of treatment for myotendinous junction tears is usually non-operative (conservative), in which rehabilitation is followed by a properly-timed return to play.8,18,22,28,53 Conservative management is divided into three phases based on the phases of healing.22,28 Patients with a myotendinous junction injury typically have a faster recovery and a higher rate of return to prior level of function than those who experience an avulsion type injury. 24,51,52
Phase 1: Inflammatory phase
During the initial inflammatory phase of healing, the goal should be to control pain, decrease inflammation, and protect the tendon so scar tissue can develop.22,28 This stage may require crutches and taking weight off the injured leg in order to facilitate recovery, healing, and protection.
In addition, patients should:
- Avoid excessive stretching during this stage, because it may be detrimental to the recovery process.22,28
- Use ice, elevation, rest, and non-steroidal anti-inflammatory medications (NSAIDs) as needed for inflammation and pain control.
- Limit exercising to a protected and pain free range of motion.22
The length of this phase depends on the severity of injury, but typically lasts 3 to 7 days.22,28,54 A qualified clinician should make decisions about progression to the next phase based on the patient’s clinical examination and function.
Generally, a patient is considered ready to progress to the second phase of healing and treatment when he or she can tolerate a normal walking gait, an isometric contraction at 50% to 70% maximal, and a very low-speed jog without pain.22,28 An isometric contraction literally means without movement. An example of this would be a clinician holding the heel while a patient tries to bend (flex) the knee, but not allowing it to bend. While the muscle contracts, it does not shorten.
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Phase 2: Reparative phase
During the reparative phase of treatment, the patient should try to regain full range of motion, with continued caution to avoid overaggressive stretching.22,28 Over time, the patient can do more challenging exercises as tolerated, remembering always to do these in a pain-free manner.
This phase can last from 6 to 8 weeks, but depends on the patient and the severity of the initial injury.22,28,54 Progression to the third phase of healing and treatment requires full strength and range of motion, with the ability to tolerate a backward jog at 50% maximal speed.22 It is recommended that a qualified clinician evaluate the patient and guide the therapy appropriately.
Phase 3: Remodeling phase
During the third phase of treatment, it is important to customize the rehabilitation to the patient’s specific needs. Sport or activity-specific exercise and agility drills are recommended to promote tissue remodeling and help prepare the patient for return to his or her previous level of function.22,28 Drills that emphasize quick movements and change of direction, such as plyometric exercises, are ideal and will help prepare the patient for return to activities.22 As in the previous phases of healing, it is important to have a qualified clinician involved to guide the rehabilitation and recovery.
Treatment of proximal hamstring avulsions
A proximal hamstring avulsion refers to when the tendon has torn away from where it inserts into the pelvic bone, possibly pulling away a small bone fragment with the tendon. Advanced imaging is important in cases of proximal injuries in order to expedite surgical consultation and possibly improve outcomes and return to play.19,43
If surgery is not required, conservative treatment of proximal hamstring avulsions will follow the same phases 1 through 3 described above, though the exact protocol (e.g. stretches and exercises) may differ.
If a proximal hamstring avulsion has more than 2 mm of displacement, a surgical consultation for reattachment is recommended.39-41 Early surgical repair can yield superior results over both conservative treatment and delayed surgical repair of proximal hamstring avulsions.39-41
The recovery process following surgical repair can take from 6 to 12 months or longer, depending on the severity of the initial injury and required surgical intervention.38,39,42,43,52 It is important that patients follow the surgeon’s instructions during rehabilitation and recovery.