manual therapy for a hamstring strain usually include massage of the hamstrings

How do we treat hamstring strain with manual therapy?

Manual therapy treatment for a hamstring strain:

During the acute inflammatory stage of a hamstring strain while torn muscle tissue is still healing, manual therapy treatment is oriented toward decreasing inflammation and allowing the damaged tissue to heal. RICE (rest, ice, compression, and elevation) are recommended. Any soft tissue manipulation performed should be gentle and oriented from distal to proximal. If the client/patient is limping, proactive work should be done to the low back and contralateral lower extremity to help avoid dysfunction there as a result of the compensatory increased physical stress to these areas.

Even though the injured hamstring musculature cannot be stretched or strengthened during the acute phase, there is a benefit to stretching the client’s/patient’s non-injured hamstring group, and if possible strengthening it as well. Stretching and strengthening has been shown to have some neural cross-over effect for the other side of the body. Therefore, any work done to the non-injured side during the acute phase of the injury can help to some degree to prevent the development of excessive tightness and weakness of the injured musculature. This can help to speed up the rehabilitation process.

Cross fiber work to the biceps femoris and semitendinosus muscles of the hamstring group. Permission: Joseph E. Muscolino. The Muscle and Bone Palpation Manual, 2ed (2016), Elsevier.

Cross fiber work to the biceps femoris and semitendinosus muscles of the hamstring group. Permission: Joseph E. Muscolino. The Muscle and Bone Palpation Manual, with Trigger Points, Referral Patterns, and Stretching, 2ed. (2016) Elsevier.

Once the acute stage of a hamstring strain has resolved and there is tissue integrity and inflammation has decreased, the goal of manual therapy is to decrease hamstring hypertonicity and help promote healthy scar formation. This can be accomplished by using moist heat, soft tissue manipulation, and stretching. Both longitudinal and cross fibers strokes can be performed; usually cross fiber strokes are more effective as the tendon is approached. Deep stroking massage and/or sustained compression can be used on the trigger points. If tendinosus (fascial degeneration) is present, deeper work, especially cross fiber work at the tendon is indicated.

When stretching the hamstrings for a client with hamstring strain, the tension of the hamstrings will tend to posteriorly tilt the pelvis, thereby allowing the hamstrings to slacken and diminishing the effectiveness of the stretch. When this occurs, the contralateral (opposite-side) thigh can be seen to lift from the table. The therapist can stabilize the client’s/patient’s pelvis by using their hand or knee to press down on the client’s/patient’s opposite-side anterior distal thigh. After working on the myofascial tissues, it can be important to address the intrinsic tissues of the hip joint with joint mobilization.

If the client/patient has an antalgic gait, in other words is limping because of the pain, proactive treatment should also be administered to their low back and other lower extremity to prevent dysfunction and pain from developing because of the asymmetrical stress forces due to the antalgic gait.

Finally, in the chronic stage of hamstring strain, due to the inactivity during the healing process of the acute strain, it is likely that hip joint restrictions (adhesions) will have formed. Therefore, joint mobilization (arthrofascial stretching) is might be indicated.


Summary of Manual Therapy Treatment Protocol for Hamstring Strain
1. Acute stage: Ice and gentle distal-to-proximal effleurage
2. Chronic stage: Moist heat, soft tissue manipulation (especially cross fiber at the tendon region), and stretch
3. Stretch and possible strengthen the contralateral (non-injured) hamstring group.
4. Hip joint mobilization (arthrofascial stretching)
5. If the client/patient is limping, proactively work the low back and other lower extremity


Precautions/contraindications for treating a hamstring strain:

During the acute stage of a hamstring strain, nothing should be done that would increase swelling; therefore, any soft tissue manipulation should be gentle in force. If soft tissue manipulation is performed proximally near the ischial tuberosity or distally and laterally near the fibular head, caution must be observed because of the proximity of the sciatic nerve or its common fibular branch. When stretching the client’s/patient’s hamstrings, even though the knee joint should not be allowed to flex, be careful to avoid hyperextending it. Because of the region being worked, proper draping is essential for client/patient comfort and modesty and can be accomplished by tucking the drape under their other thigh.