Back Pain Doctor
Acute Hamstring Strain
Written by Dr Joshua Hatch, Musculoskeletal GP, RACGP Fellow, Diploma in Musculoskeletal Medicine (FSEM UK).
A strain, not “tightness”
An acute hamstring strain usually has a recognisable moment: a sharp pain or pull during high-speed running, acceleration, kicking or a forced stretch. The injury can sit in the muscle, at the muscle–tendon junction, or closer to the tendon attachment. That location matters because a routine muscle strain and a tendon avulsion do not follow the same pathway.
Pain that developed gradually around the sit-bone, especially with sitting, is more consistent with proximal hamstring tendinopathy and is covered separately.
What needs checking early
The first assessment looks at how the injury happened, where the tenderness sits, walking and hip movement, pain with resisted knee flexion, strength, bruising and whether the sciatic nerve is involved. Marked weakness, extensive bruising, a palpable gap, pain very high near the sit-bone, or an injury caused by the leg being forced into a large stretch lowers the threshold for imaging.
Most hamstring strains do not need a scan. Imaging earns its place when it could reveal a high-grade tear or tendon avulsion, change the rehabilitation restrictions, or trigger an early orthopaedic opinion. A normal-looking return-to-play date cannot be read from an MRI: clinical function and progressive exposure to the demands of the sport still matter.
Rehabilitation has to reach sprint speed
Settling pain is only the first stage. Rehabilitation progressively rebuilds hamstring strength through range, hip-extension capacity, trunk and pelvic control, running volume, acceleration and deceleration, and then high-speed exposure. Eccentric hamstring work is usually introduced and progressed as symptoms allow rather than withheld until the end.
For field sport, a player who can jog but has not sprinted, cut, kicked or trained at near-match intensity has not completed rehabilitation. Return is based on demonstrated capacity and confidence, not simply on tenderness disappearing or a fixed number of weeks passing.
The 2022 hamstring strain clinical practice guideline supports progressive strengthening, running and sport-specific rehabilitation. It also emphasises reinjury risk, which is why the final stages should not be skipped to meet a calendar date.
Where medical assessment fits
Most rehabilitation is appropriately delivered with a physiotherapist. The medical role is to establish the diagnosis, decide whether imaging or surgical review is needed, manage pain without delaying loading, and help resolve cases that are not following the expected course. No referral is required to book, and a Medicare rebate applies to the consultation.
Common symptoms
- Sudden sharp or pulling pain in the back of the thigh
- Pain during sprinting, accelerating, kicking or bending forward
- Local tenderness, weakness, bruising or swelling
- Pain when lengthening the hamstring or pushing against resistance
Commonly seen in
Evidence for twelve treatment options in acute hamstring strain
This is not a fixed ladder or a package of treatments. Every option is assessed independently against this diagnosis, including treatments with limited direct research that may still be reasonable for a clearly defined tissue target. The evidence level, likely benefit, risks, cost and alternatives are weighed at consultation.
Foundation — diagnosis, education and rehabilitation
The part of care with the broadest relevance. For many people it is enough on its own; other options are judged against it, not automatically added after it.
Diagnosis, education and progressive rehabilitation Working out what is driving the pain, explaining what your imaging does and does not mean, and building a graded loading plan you can actually follow. Core care
What it involves
Assessment to identify the likely pain source, an explanation of what the diagnosis means, adjustment of the loads that aggravate it, and a progressive strength and conditioning plan — with weight management where that is clinically relevant.
What the evidence shows
Move it, within reason, rather than rest it. Pooling 22 studies, functional treatment beat immobilisation on return to sport, return to work, swelling, range of motion and patient satisfaction (Kerkhoffs, Arch Orthop Trauma Surg 2001). An overview of 46 systematic reviews found strong evidence for early mobilisation and moderate evidence for exercise (Doherty, Br J Sports Med 2016), and the international guideline prefers supervised exercise over passive modalities, reserving surgery for those who do not respond (Vuurberg, Br J Sports Med 2018). Exercise-based rehabilitation roughly halves the odds of doing it again within twelve months (Wagemans, PLoS One 2022). One honest caveat: in 503 patients with simple grade 1 to 2 ankle sprains, adding supervised physiotherapy to good advice produced no clinically important benefit (Brison, BMJ 2016).
Pairing reviewed 2026-09-02.
Where it fits for you
For a straightforward sprain or strain, clear advice and a graded return are usually enough, and you do not need to buy a course of anything. Supervised rehabilitation earns its place where the injury is more severe, where it keeps recurring, or where the demands you are returning to are high.
Muscle and symptom-modifying options
Useful only when the examination identifies the tissue they target or when short-term pain control creates a useful rehabilitation window.
Wet needling and trigger point injection (trigger point injection) A fine needle into a tender band of muscle, with a small volume of dilute glucose solution injected through it. Plausible — no studies
What it involves
The needle is placed into the tender muscle band and a small volume of 5% glucose with 0.02-0.08% lignocaine is injected. Often done in the same visit as your assessment, and usable where the tender area sits deeper. Dry needling — the same technique with nothing injected — is not offered here.
What the evidence shows
No trial of trigger point injection in this condition specifically, and none at all using 5% dextrose — the myofascial needling trials used local anaesthetic or saline.
Pairing reviewed 2026-08-30.
Where it fits for you
Considered only where examination finds a tender muscle contributing to the pain, as an adjunct to the loading programme.
Ultrasound-guided injections Guidance means we can see the needle reach the target. What goes into the needle depends on the diagnosis. Only if relevant
What it involves
The injection is performed under ultrasound so the needle can be watched into the target structure. What is injected is decided by the diagnosis — and corticosteroid is used sparingly, for the reasons set out below.
What the evidence shows
Ultrasound improves needle-placement accuracy, but guidance is not a treatment in itself: benefit depends on a valid injectable target and what is injected. Condition reviewed: acute hamstring strain.
Evidence source: Oo et al., ultrasound-guided injection systematic review (2024)
Pairing reviewed 2026-08-30.
Where it fits for you
For acute hamstring strain, an ultrasound-guided injection is considered only when there is a specific diagnostic question or a separate joint, bursa, sheath or nerve target. The injectate and purpose are stated before treatment.
V-ACTOR vibration therapy (vibration therapy) Low-frequency vibration applied over tender muscle. Not a shockwave, despite sharing the machine. Plausible — no studies
What it involves
A vibration handpiece is moved over the tender muscle and fascia for a few minutes. It runs from the same STORZ MASTERPULS icon console as radial shockwave but is a separate handpiece delivering a different, gentler form of energy. No needles, no anaesthetic, no downtime.
What the evidence shows
No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.
Pairing reviewed 2026-08-30.
Where it fits for you
A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.
Energy-based treatment options
Radial pressure wave, focused shockwave and EMTT have different targets and different evidence. They are assessed separately rather than treated as one category.
Radial or focused shockwave? Read the overviewRadial shockwave (radial pressure wave) Broad treatment across tender muscle and fascia, close to the surface. One small sham-controlled trial
What it involves
A handpiece is moved over the tender tissue while ballistic pressure pulses are delivered, using a transmitter head chosen for the tissue — including heads shaped for fascia and for the muscle either side of the spine. The pulse is strongest at the skin and weakens with depth, so this is mainly a myofascial treatment, though it can reach deeper in some areas. No anaesthetic, no downtime, usually a course of sessions about a week apart.
What the evidence shows
This is the one acute muscle injury in which radial shockwave has been tested against a dummy treatment, and it came out ahead. Thirty-six semi-professional athletes with an ultrasound-confirmed grade 3b hamstring tear were randomised, with both the patients and the assessors blinded, to real or sham radial shockwave on top of the same eight-week rehabilitation programme. The treated group returned to sport sooner, 25.4 days against 28.3, and only the treated group avoided a strength deficit in the injured leg afterwards (Crupnik, Br Med Bull 2025). That is just under three days, in athletes whose job is to train; the trial is small and from one centre, the right dose and timing are not established, and there is no comparable trial in any other muscle.
Pairing reviewed 2026-09-25.
Where it fits for you
Reasonable to discuss as an addition to the rehabilitation programme, never instead of it — the programme is what determines whether the hamstring holds. Three days matters to someone with a season to get back to and probably does not to everyone else, and the trial was done in athletes, so that is who the result belongs to.
Focused shockwave (ESWT) A true shock wave converging at depth — for tendon, joint, ligament and bone. Only if relevant
What it involves
A focused system generates an acoustic shock wave that converges at a focal point set at a defined depth, concentrating the energy where the target is. This is the form we use for tendon, joint, ligament and bone. Typically four to six sessions about a week apart, no anaesthetic and no formal downtime.
What the evidence shows
The shockwave evidence is in chronic, load-related problems. There is no established role in an acute injury.
Pairing reviewed 2026-08-30.
Where it fits for you
Not part of early management. May become relevant if the problem becomes chronic.
EMTT (magnetotransduction therapy) High-energy magnetic pulses applied over the area. Painless, no contact. Plausible — no studies
What it involves
You sit with the applicator positioned over the area for a short session. Painless, no gel or contact required, and usually delivered as a course — commonly alongside shockwave.
What the evidence shows
There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that we can point to. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative — a randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).
Pairing reviewed 2026-08-30.
Where it fits for you
Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why we describe it this way.
Biologic and joint injection options
Each injection is assessed independently for the named diagnosis. Cost, uncertainty, likely benefit, risks and alternatives are part of the decision.
Platelet-rich plasma (PRP) Your own blood, concentrated and injected under ultrasound guidance. Not offered; trials disagree
What it involves
Blood is taken from your arm, spun to concentrate the platelets, and injected into the target under ultrasound guidance in the same appointment.
What the evidence shows
Trialled in a torn hamstring, with results that disagree, and not offered here. The two newest pooled analyses favour it. Across nine randomised trials and 474 people with an acute muscle injury, return to sport was about a week sooner with PRP, in the hamstring trials and in the double-blind trials taken on their own as well as overall, on evidence the authors grade as limited, with five of the nine trials at high risk of bias (Bensa, Sports Med Open 2026). Across six hamstring trials and 277 people it was 21 days against 30, with results that varied widely between trials and certainty rated low to moderate (Nakagawa, Br J Sports Med 2026). The positive trials compared PRP plus rehabilitation with rehabilitation alone and were not blinded: 26 days against 34 in 60 athletes with a moderate tear (Desouza, Eur J Orthop Surg Traumatol 2025) and 27 against 43 in 28 (A Hamid, Am J Sports Med 2014). The best-designed trials found less. In a multicentre double-blind trial of 80 athletes, PRP was no better than a placebo injection for return to play or for re-injury at two months or one year (Reurink, N Engl J Med 2014; Br J Sports Med 2015). In 90 professional athletes it was 5.7 days faster than an injection of platelet-poor plasma but not significantly faster than no injection, and the authors concluded it added nothing to intensive rehabilitation (Hamilton, Br J Sports Med 2015). Re-injury was no less common in the pooled trials, 15% against 16%. An earlier pooled analysis found no benefit once only the double-blind trials were counted (Grassi, Sports Med 2018), a Danish evidence statement rated the effect on return to play as trivial (Ishøi, Br J Sports Med 2020), and a German-Austrian-Swiss consensus found no clear evidence that any injection into an injured muscle helps (Hotfiel, J Exp Orthop 2018).
Pairing reviewed 2026-10-10.
Where it fits for you
Not offered for a hamstring strain. These tears are monitored and rehabilitated. A torn muscle has already bled into the injury, so an injection of concentrated platelets is unlikely to add to what is there. The best-designed trials agree: against a placebo injection, or against no injection at all, PRP added nothing to a proper rehabilitation program, and it did not reduce re-injury. Progressive loading and a staged return to running and sport are what determine the outcome.
Prolotherapy (dextrose) A course of dextrose injections into and around the structure and its attachments. Only if relevant
What it involves
Hypertonic dextrose is injected at the tender ligament and tendon attachments, and into the joint where relevant, usually as a series of treatments a few weeks apart.
What the evidence shows
No human trial has tested prolotherapy in acute hamstring strain. Reviews of orthobiologics for muscle injury name prolotherapy but report that high-level clinical evidence is lacking (Droz, Clin Sports Med 2024; Stephens, Phys Med Rehabil Clin N Am 2023). The animal work conflicts — dextrose improved repair in a mouse muscle-injury model (Tsai, Int J Med Sci 2018), while a rat model reported excess connective tissue and necrosis and advised against it (Kunduracioglu, Neurosciences 2006).
Pairing reviewed 2026-09-05.
Where it fits for you
Not used for the acute tear. Graded loading is what rebuilds the muscle and lowers the re-injury risk. Injection is considered only much later, and only for a persistent tendon attachment problem such as chronic proximal hamstring tendinopathy.
Viscosupplementation (hyaluronic acid) A gel-like injection into an arthritic joint. Widely used, and genuinely contested. Not used here
What it involves
One or a short series of hyaluronic acid injections into the joint under ultrasound guidance.
What the evidence shows
Untested in people. A search pairing hyaluronic acid with muscle injury, muscle strain, muscle tear, calf strain, hamstring injury, tennis leg and contusion terms returned 39 records. Twenty-five were animal, hydrogel, scaffold or spinal cord studies, and none of the other 14 was a trial of hyaluronic acid for a muscle injury. The nearest were a single case of a torn adductor muscle given hyaluronic acid together with platelet-rich plasma (Giannini, J Sports Med Phys Fitness 2023) and a review of injections in professional footballers, which gives hyaluronic acid a role only for cartilage injury (Jader, Int Orthop 2024). No study has injected it for a hamstring strain.
Pairing reviewed 2026-10-05.
Where it fits for you
Not offered for an acute muscle injury. Graded loading and a staged return to sport is what changes the outcome.
Nerve-targeted options
Relevant when examination identifies a superficial neuropathic pattern or a compressed peripheral nerve—not simply because pain is present.
Lyftogt perineural therapy (perineural injection therapy) A series of small dilute dextrose injections just under the skin, over tender superficial nerves. Only if relevant
What it involves
Small injections of low-concentration dextrose, usually 5%, placed just beneath the skin along tender superficial nerves. Given as a series of short sessions.
What the evidence shows
No study has tested small dextrose injections under the skin for a torn hamstring. Searching the perineural injection, neural prolotherapy, subcutaneous dextrose, glucopuncture and neurofascial terms against hamstring, muscle strain, muscle tear and muscle injury returns no treatment study of any design, and widening to any dextrose or prolotherapy injection finds no human study of a hamstring strain either. A review of injection treatments for muscle injury, prolotherapy among them, concludes that high-level clinical evidence is lacking (Droz, Clin Sports Med 2024). The nearest dextrose report is in the tendon rather than the muscle, and it was a failure: a three-injection course of 12.5% dextrose gave no lasting relief in a 61-year-old with chronic semimembranosus tendinopathy (Senchyshak, Pain Med Case Rep 2026). The skin nerve that runs down the back of the thigh, the posterior femoral cutaneous nerve, can cause pain in the same area. It has been injected under ultrasound with local anaesthetic, with immediate partial relief and no adverse events reported, but in a technique paper that gives no patient numbers and no follow-up (Vita, J Ultrasound 2025).
Pairing reviewed 2026-10-06.
Where it fits for you
Not part of treating a hamstring tear. Graded loading is what rebuilds the muscle and lowers the re-injury risk. Considered only if tender, hypersensitive skin over the back of the thigh persists once the tear has otherwise healed.
Ultrasound-guided nerve hydrodissection Fluid placed around a nerve to free it from the surrounding tissue. Only if relevant
What it involves
Under ultrasound, fluid is placed in the plane around the nerve to separate it from the tissue that is tethering or compressing it.
What the evidence shows
Hydrodissection evidence is concentrated in ultrasound-confirmed peripheral nerve entrapment, especially carpal tunnel syndrome; no direct evidence was identified for this diagnosis itself. Condition reviewed: acute hamstring strain.
Evidence source: Buntragulpoontawee et al., hydrodissection injectate review (2021)
Pairing reviewed 2026-08-30.
Where it fits for you
For acute hamstring strain, hydrodissection may be considered only if ultrasound and examination identify a separate compressed or tethered peripheral nerve. It is not treatment of the primary diagnosis.
This is general information only and suitability is assessed individually. Treatments with limited or condition-dependent evidence may still be discussed, but only with clear explanation of the uncertainty, the expected benefit, risks, cost and alternatives. Red flags, progressive neurological symptoms or suspected serious pathology require a different pathway.
Every treatment above is described in full on the non-surgical treatments page, including what each one is used for and what the evidence supports. Ratings apply to the named diagnosis; an adjacent muscle, tendon, joint or nerve problem is assessed as a separate target. The method behind the ratings, and the treatments we do not offer, are set out on the evidence page.
Corticosteroid injection is reviewed separately for each diagnosis.
Cortisone reliably reduces pain in the short term, and that can be genuinely useful when pain is stopping you sleeping or moving enough to rehabilitate. Beyond that window the picture changes. A systematic review of 41 randomised trials and 2,672 participants found that corticosteroid injection reduced pain in the short term but that the effect reversed at intermediate and long term; in pooled analysis for lateral epicondylalgia the short-term effect was large (SMD 1.44, 95% CI 1.17 to 1.71) while no intervention was favoured at 26 weeks (-0.40, -0.67 to -0.14) and at 52 weeks (-0.31, -0.61 to -0.01) (Coombes, Lancet 2010). In a randomised trial in lateral epicondylalgia, 83 per cent of the corticosteroid group had completely recovered or much improved at one year against 96 per cent given a placebo injection, and recurrence ran at 54 per cent against 12 per cent; adding physiotherapy made no significant difference at one year (Coombes, JAMA 2013). In joints, repeated corticosteroid injections have been associated with cartilage loss. It does not repair anything.
So we do not build treatment plans around it. Where an injection is the right call, we review the specific diagnosis and target, discuss what is being injected and why, keep the number low, and pair it with the loading work that changes the longer-term course.
When we would still consider it
- Pain severe enough to block rehabilitation
- A clear inflammatory or bursal target on imaging
- A specific short-term goal — a trip, a procedure, a return to work
- Diagnostic use, where the response tells us where the pain is coming from
When a cortisone injection is worth doing, and when it is not
Other hip & pelvis conditions
Pain in the same area can come from more than one source, and the label matters less than what the examination and history point to. These are the other guides for this region.
Related articles
Shorter articles that answer the questions patients ask most often about this.
Frequently asked questions
Is this the same as hamstring tendinopathy?
Does every hamstring strain need an MRI?
When can I sprint again?
Why do hamstring strains recur?
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