What's Up Doc? How can I tell if I ruptured my hamstring or just severely strained it?
A: The hamstring muscle is actually three muscles in the back of the thigh, the biceps femoris (two associated muscles, so some people consider the hamstring to be composed of four muscles total), the semitendinosus and the semimembranosus. These originate in the curved bone at the bottom of the pelvis (the ischial tuberosity) or the femoral shaft (the big long bone in the upper leg), and then insert in the head (top) of the fibula (for both parts of the biceps) or the medial (the part towards the center of the body) tibia (for the semitendinosus and semimembranosus). These muscles control the flexion (bending) of the knee and the extension (straightening) of the hip. The severity of hamstring injuries can be:  Minor (grade 1), usually called a strain, and due to a slight disruption of the muscles cells (think of this as over-stretching), causing swelling and typically minor pain;  Moderate (grade II), which is characterized by partial tear(s) of the muscle fibers, causing more severe pain, swelling, and typically partially compromising the strength and function of the affected muscles; or  Severe (grade III), where there is a more complete tear of at least some of the muscle units often with the patient hearing a pop, and causes pain, swelling, usually a hematoma (a collection of blood in the underlying tissues), and loss of function of the affected muscle(s). Hamstring injuries are very common, especially in athletes (both recreational and elite athletes) where they account for 10 to 25 percent of all sports-related injuries (the higher end of this range occurs in sports where changing direction during high-speed running is a big part of the sport, such as soccer; one study showed almost half of elite soccer players suffer some level of hamstring injury each season). Most of these injuries are strains (grade 1 injuries), although as many as 5 percent or more are severe enough to make the athlete miss three or more weeks of sport, and 30 percent of athletes develop recurrent hamstring issues. The severity of symptoms and the physical findings (testing for strength, looking for anatomical disruption including swelling, etc.) will typically raise suspicion of the grade of injury. In select cases, particularly when higher grade injury is suspected, imaging (usually with ultrasound and/or MRI) may be indicated. There are certain things that can be done to decrease (but not eliminate) the possibility of a hamstring injury, including:  Adequately warm-up  Ensure adequate flexibility,  Avoid over-training and muscle fatigue,  Ensure adequate and symmetric muscle strength,  Ensure adequate strength of other associated muscle groups,  Other factors. However, certain factors may be out of the athletes control, such as:  Age: hamstring injuries are more common as athletes age,  Prior hamstring injuries,  Other injuries (such as ankle injuries) that can cause increased strain on the hamstrings,  Other factors. RICE (rest including minimizing motion for several days, ice/even cryotherapy, compression with ace wraps or by other means and elevation) and over-the-counter pain medication as needed with acetaminophen, ibuprofen or other non-steroidal anti-inflammation drugs (NSAIDs), is the standard initial treatment for hamstring injuries. The next step of treatment usually includes physical therapy with appropriate stretching and exercise recommendations. More severe injuries should be referred to an orthopedic surgeon, and some cases (for example complete ruptures, and possibly certain other injuries) will require surgery. Platelet-rich plasma injections have been tried, but so far the data does not support benefit from this treatment. A key question in hamstring injuries is often "When can the athlete return to the sport?" This important question must be answered on a case-by-case basis, and with close consultation with their treating clinician(s). Recovery from a hamstring injury depends on the severity of the injury, and may range from days to weeks to months. Recurrent injuries are common, and premature return to the sport may increase the risk of the athlete having a recurrent injury, especially in the short-term. Jeff Hersh, Ph.D., M.D., can be reached at DrHersh@juno.com