Even a minor muscle tear can put an athlete out of action for several weeks, and a repeat injury for considerably longer. At the same time, it is precisely for muscle injuries that preventive programmes with a good evidence base exist. The editorial team has gathered the essentials on prevention, first aid, diagnosis and the situations when urgent medical help is needed.
Prevention: exercises with proven effectiveness
The best-studied means of preventing hamstring injuries is the Nordic hamstring exercise. The athlete kneels, a partner fixes their shins, and they slowly lean forward, braking the movement with the hamstring. This loads the muscles precisely in the eccentric mode, in which they are injured most often.
A randomised trial among amateur footballers showed that including this exercise in training substantially reduced the frequency of hamstring injuries (van der Horst et al., 2015). A meta-analysis that combined data from more than eight thousand athletes concluded that programmes with this exercise reduce the frequency of such injuries by roughly half (van Dyk et al., 2019).
Broader warm-up programmes, such as FIFA 11+, combine running exercises, strength work, jumps and balance exercises. A cluster randomised trial among young female footballers showed a reduction in injury frequency in teams that regularly performed such a warm-up (Soligard et al., 2008).
Other components of prevention are a gradual build-up of speed work, regular contact with maximal speeds in training, control of fatigue and competition density, and full rehabilitation after previous injuries.
- eccentric exercises (the Nordic exercise; for the calves — slow lowering);
- a structured warm-up before every workout;
- gradual inclusion of sprints and maximal weights;
- control of fatigue, sleep and the competition schedule;
- completed rehabilitation after a previous injury.
The first days after injury
A muscle tear is usually felt as a sharp pain or a "blow" during movement, after which continuing activity is painful or impossible. The first step should be to stop the load: an attempt to "run it off" or "push through" can significantly increase the extent of the damage.
The modern approach to first aid for soft-tissue injuries is described by the acronym PEACE & LOVE, proposed by B. Dubois and J.-F. Esculier (Dubois & Esculier, 2020). In the first days they recommend protection of the injured area, an elevated position, compression and informing the patient, as well as refraining from anti-inflammatory agents, which can theoretically hinder healing.
After the acute period, the emphasis shifts to gradual load that does not cause sharp pain, moderate aerobic activity and a positive attitude towards recovery. Prolonged complete immobilisation is not needed for most muscle injuries and is even harmful.
The use of cold to relieve pain is permissible, although its effect on the speed of healing remains a subject of debate. Massage and warming in the first days after injury are usually not recommended because of the risk of increased bleeding.
Diagnosis: examination, ultrasound, MRI
Diagnosis begins with questioning: the mechanism of injury, the nature of the pain, whether a "pop" was heard, whether it was possible to continue the movement. The doctor assesses the location of the pain, the presence of a defect or haematoma, the strength of the muscle, pain on stretching and on contraction against resistance.
Ultrasound examination allows one to assess the size of the damage and the haematoma, especially a few days after the injury. It is accessible and convenient for monitoring over time.
MRI gives a more detailed picture and helps determine whether the intramuscular tendon is involved. The British Athletics classification uses MRI data to grade the degree of injury and separately marks tendon involvement, which is important for the prognosis (Pollock et al., 2014).
If a complete tear or tendon avulsion is suspected — for example, of the pectoralis major, the distal biceps or the proximal part of the hamstring — imaging is needed as soon as possible, because the decision on surgical treatment depends on it.
| Situation | Method | Goal |
|---|---|---|
| Mild injury, function preserved | Clinical examination | Assessment of the degree, recovery plan |
| Moderate injury, haematoma | Ultrasound | Size of the damage, monitoring of the haematoma |
| Professional sport, doubtful prognosis | MRI | Classification, tendon involvement |
| Suspicion of a complete avulsion | MRI or ultrasound urgently | Decision about surgery |
Rehabilitation and return to sport
Rehabilitation should be active and phased. First the pain-free range of motion and basic strength are restored, then eccentric work, running with increasing speed and sport-specific movements are gradually added.
A randomised trial among Swedish footballers compared two programmes of hamstring-injury rehabilitation: a programme with an emphasis on exercises in a lengthened position of the muscle provided a faster return to sport than the traditional one (Askling et al., 2013).
The decision on returning to full load is made not only by the time that has passed but by functional criteria: absence of pain, symmetrical strength, the ability to perform sprints and specific movements at full speed, and the athlete's own confidence.
A hasty return is the main cause of relapses. Even after returning it is worth continuing preventive exercises, since a previous injury remains the strongest risk factor for a repeat one.
When to see a doctor
You should see a doctor for any injury after which you cannot walk normally, observe significant bruising or swelling, or if the pain does not decrease over several days.
Urgent help is needed if a defect in the muscle is visible or palpable, the muscle has "bunched up" into a lump, or pronounced weakness of a particular movement has appeared. This may indicate a complete tear or tendon avulsion, in which delaying surgery worsens the outcome.
Urgent examination is required for increasing tense swelling of a limb with severe pain, numbness or pallor — signs of possible compartment syndrome. Also dangerous are severe muscle pain and weakness with darkening of the urine after excessive load, which may indicate rhabdomyolysis.
Inform the doctor about all medications and drugs: statins, anticoagulants, anabolic steroids, recent corticosteroid injections. They affect the risks, the extent of the haematoma and treatment tactics.
Editorial conclusions
Prevention of muscle tears has a good evidence base: the Nordic exercise and structured warm-up programmes substantially reduce injury frequency.
In the first days after injury the main thing is to stop the load, protect the area and gradually return to movement, avoiding warming and massage.
The diagnosis is refined with ultrasound or MRI; a suspicion of a complete tear, compartment syndrome or rhabdomyolysis requires urgent help.
We also recommend reading our materials on the causes of muscle tears, on the prevention of tendinitis and on supplements discussed in the context of recovery after injury.
References
- van der Horst N, Smits DW, Petersen J, et al. The preventive effect of the Nordic hamstring exercise on hamstring injuries in amateur soccer players: a randomized controlled trial. Am J Sports Med. 2015;43(6):907–915.
- van Dyk N, Behan FP, Whiteley R. Including the Nordic hamstring exercise in injury prevention programmes halves the rate of hamstring injuries: a systematic review and meta-analysis of 8459 athletes. Br J Sports Med. 2019;53(21):1362–1370.
- Soligard T, Myklebust G, Steffen K, et al. Comprehensive warm-up programme to prevent injuries in young female footballers: cluster randomised controlled trial. BMJ. 2008;337:a2469.
- Dubois B, Esculier JF. Soft-tissue injuries simply need PEACE and LOVE. Br J Sports Med. 2020;54(2):72–73.
- Pollock N, James SL, Lee JC, et al. British athletics muscle injury classification: a new grading system. Br J Sports Med. 2014;48(18):1347–1351.
- Askling CM, Tengvar M, Thorstensson A. Acute hamstring injuries in Swedish elite football: a prospective randomised controlled clinical trial comparing two rehabilitation protocols. Br J Sports Med. 2013;47(15):953–959.
Andriy Melnyk
A strength-sports coach and author of programs for beginner and intermediate levels. Writes about training planning.
