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  • Pulled hamstring

  • 848.9 Unspecified site of sprain and strain

  • T14.9 Dislocation, sprain, and strain of unspecified body region


  • Stretch injury to biceps femoris or semimembranosus resulting in disruption of muscular or musculotendinous units
    • Grade I: mild
    • Grade II: moderate
    • Grader III: severe to complete tear or rupture

Essentials of Diagnosis

  • Diagnosis made with patient history and clinical findings or with imaging
  • Pain with resistance
  • Location of Lesion May Influence Prognosis

General Considerations

  • Mechanisms of injury1
    • Deceleration during swing phase while running
      • Typically occurs during high-speed running
      • Involves intramuscular tendon or aponeurosis of biceps femoris (long head), semitendinosus (secondary injury)
    • Excessive stretch while dancing or kicking
      • Typically during extreme hip flexion with full knee extension
      • Injury at proximal tendon of semimembranosus


  • Previous hamstring injury is a strong predictor of recurrence
  • Athletes in high-speed-demand sports (e.g., football, track, rugby, soccer)
  • Athletes in sports/competition involving kicking or extreme hip flexion and knee extension (e.g., dancing, water-skiing)

Signs and Symptoms

  • Acute-onset pain at proximal hamstring during high-speed running, often with audible pop, typically early or late in athletic event
  • Pain at ischial tuberosity with sitting
  • Decreased range of motion (ROM) in knee and hip
  • Decreased strength with knee flexion and hip extension
  • Tenderness to palpation (possible palpable lesion) at proximal tendon or musculotendinous junction
  • Tenderness may occur along muscle belly proximal to ischial tuberosity

Functional Implications

  • Inability to run or sprint
  • Inability to sit without limitation from pain
  • Inability to flex hip with knee fully extended

Possible Contributing Causes

  • Previous history of hamstring injury
  • Explosion activity without proper warm-up
  • Muscle imbalance between quadriceps and hamstring

Differential Diagnosis

  • Adverse neural tension
  • Adductor muscle strain
  • Avulsion fractures at ischial tuberosity
  • Lumbar radiculopathy
  • Sacroiliac dysfunction
  • Sciatica


  • MRI for soft tissue

  • MRI can reveal area of fluid accumulation and location of lesion


Medical Procedures

  • Surgery to repair grade-III strain or avulsion

  • To hospital for imaging (MRI)
  • Surgery (if grade-III strain)

  • Inability to run or sprint
  • Inability to sit without limitation from pain
  • Inability to flex hip with knee fully extended

  • Take caution initially not to overstretch and eccentrically load injured muscle
  • Early and continued incorporation of core stability and eccentric hamstring loading progressing to full length
  • Rehabilitation for grade-I and grade-II strains
    • Phase 1, 1 to 5 days post-injury ...

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