(Also known as Corked Thigh, Hamstring Bruise, Corky, Hamstring Haematoma, Charley Horse, Dead Leg)
What is a hamstring contusion?
A hamstring contusion is a condition characterized by a bruise or ‘corky’ to the back of the thigh, usually as a result of a direct impact. The group of muscles at the back of the thigh is commonly called the hamstrings (figure 1).
The hamstrings comprise of 3 muscles:
- biceps femoris
These muscles originate from the pelvis and insert into the top of the lower leg bones (figure 1).
Figure 1 – The Hamstrings
The hamstring muscles are responsible for bending the knee, straightening the hip and controlling knee and hip movements during activity. They are particularly active during running, jumping and kicking. The hamstrings also have a rich blood supply. Following a direct impact to the back of the thigh, damage to the muscle fibres, connective tissue and small blood vessels of the hamstrings may occur. This results in a ‘bruise’ and is known as a hamstring contusion.
Hamstring contusions range from minor contusions, resulting in minimal pain and allowing ongoing activity, to severe contusions, resulting in significant pain and loss of function.
Causes of a hamstring contusion
Hamstring contusions occur following a direct impact to the hamstring muscle from an object or person. This most commonly occurs due to a collision with another player during contact sports, such as football or rugby, or from an impact from a ball in sports such as hockey or cricket.
Signs and symptoms of a hamstring contusion
Patients with this condition usually feel a sudden pain in the muscle at the time of injury. In minor cases, pain may be minimal (or sometimes may go unnoticed) allowing continued activity. In more severe cases, patients may experience severe pain, muscle spasm, weakness and an inability to continue activity. Patients with a severe hamstring contusion may also be unable to walk without a limp.
Patients with a bruised hamstring usually experience pain during activities such as bending forwards, going up stairs, walking uphill, running, jumping, lunging or kicking. It is also common for patients to experience pain or stiffness after these activities with rest, especially upon waking in the morning. Swelling, tenderness and bruising may also be present in the hamstring muscle, along with an inability to stretch the injured leg as far as usual.
In severe cases a visible increase in size of the thigh may be detected due to bleeding and swelling. In these instances patients may be unable to sleep due to pain. Occasionally the swelling and bruising may track down to the knee joint or lower leg.
Diagnosis of a hamstring contusion
A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose a hamstring contusion. Further investigations such as an MRI scan or ultrasound may be required, in rare cases, to confirm diagnosis.
Treatment for a hamstring contusion
Most patients with a hamstring contusion heal well with appropriate physiotherapy. The success rate of treatment is largely dictated by patient compliance. One of the key components of treatment is that the patient rests sufficiently from any activity that increases their pain until they are symptom free (the use of crutches may be required). Activities which place large amounts of stress through the hamstrings should be minimized, these include: running, kicking, jumping and lunging. Rest from aggravating activities ensures the body can begin the healing process in the absence of further tissue damage. Once the patient can perform these activities pain free, a gradual return to these activities is indicated provided there is no increase in symptoms.
Ignoring symptoms, or adopting a ‘no pain, no gain’ attitude is likely to lead to the problem becoming chronic and can lead to further complications (such as Myositis Ossificans). Immediate, appropriate treatment in patients with this condition is essential to ensure a speedy recovery.
Diligently adhering to the R.I.C.E. Regime in the initial phase of injury (first 72 hours) will greatly assist in improving recovery time in patients with a hamstring contusion. This involves rest from aggravating activities, regular icing (i.e. 20 minutes every 2 hours), the use of a compression bandage, and keeping the injured leg elevated above the level of the heart. The use of crutches when walking may also be necessary to protect the muscle from further damage and to hasten the healing process. Care should be taken not to exercise or stretch into pain as this may lead to further bleeding. The use of heat, massage and the consumption of alcohol in the initial stages (for at least the first 72 hours) should also be avoided. Certain medications, such as aspirin, can also increase the degree of bleeding (its use, or cessation of use, should be discussed with a doctor).
Manual “hands-on” therapy from the physiotherapist such as massage, trigger point releases, joint mobilisation, dry needling, stretches and electrotherapy can also assist with improving range of movement and function following a hamstring contusion. This can generally commence once the physiotherapist has indicated it is safe to do so.
A graduated, pain free flexibility and strength program guided by a physiotherapist is essential to ensure an optimal outcome, recondition the hamstring muscle and reduce the likelihood of injury aggravation following a hamstring contusion. The treating physiotherapist can advise which exercises are most appropriate for the patient and when they can be commenced.
For those patients who wish to return to running or sport, a graduated return to running program may be required in the final stages of rehabilitation to recondition the hamstrings for running in a safe and effective manner. This should include the implementation of progressive acceleration and deceleration running drills before returning to training and eventually sport, with close monitoring of the athlete’s response and recovery between each session (see Return to Sport).
Prognosis of a hamstring contusion
With appropriate management, patients with a minor hamstring bruise can usually recover in one to three weeks. With larger contusions, recovery may take four to eight weeks or longer, depending on the severity of injury. In rare cases, patients can sometimes develop myositis ossificans (i.e. bony growth, or calcification, inside the contusion). This condition is more common in severe contusions (especially those that are managed inappropriately) and may prolong recovery by weeks to months.
Physiotherapy for a hamstring contusion
Physiotherapy for patients with this condition is vital to hasten the healing process and ensure an optimal outcome. Treatment may comprise:
- soft tissue massage (after the initial 72 hour period)
- electrotherapy (e.g. ultrasound)
- dry needling
- joint mobilization
- anti-inflammatory advice
- the use of crutches
- applying a compression bandage
- the use of protective padding to the hamstrings to prevent re-injury
- ice or heat treatment
- exercises to improve strength and flexibility (particularly of the hamstrings)
- activity modification advice
- establishment of an appropriate return to activity or sport plan
Other intervention for a hamstring contusion
Despite appropriate physiotherapy management, some patients with a bruised hamstring do not improve adequately. When this occurs, the treating physiotherapist or doctor can advise on the best course of management. This may include investigations such as an Xray (to assess for myositis ossificans), ultrasound, CT scan or MRI, pharmaceutical intervention, or referral to appropriate medical authorities who can advise on any intervention that may be appropriate to improve the condition.
Exercises for a hamstring contusion
The following exercises are commonly prescribed to patients with this condition. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed 3 times daily and only provided they do not cause or increase symptoms.
Your physiotherapist can advise when it is appropriate to begin the initial exercises and eventually progress to the intermediate, advanced and other exercises. As a general rule, addition of exercises or progression to more advanced exercises should take place provided there is no increase in symptoms.
Static Hamstring Contraction
Begin this exercise in sitting with your knee bent to about 45 degrees (figure 2). Press your heel into the floor tightening the back of your thigh (hamstrings). Hold for 5 seconds and repeat 10 times as hard as possible pain free.
Figure 2 – Static Hamstring Contraction (right leg)
Knee Bend to Straighten
Lying on your back, slowly bend and straighten your knee as far as possible without increasing your pain and provided you feel no more than a mild to moderate stretch (figure 3). Repeat 10 – 20 times.
Figure 3 – Knee Bend to Straighten (right leg)
Begin this exercise lying on your back in the position demonstrated (figure 4). Slowly lift your bottom pushing through your feet, until your knees, hips and shoulders are in a straight line. Tighten the back of your thigh (hamstrings) as you do this. Hold for 2 seconds then slowly lower your bottom back down. Perform 10 – 30 repetitions provided the exercise is pain free.
Figure 4 – Bridging
Resistance Band Hamstring Curl
Begin this exercise lying on your stomach with a resistance band tied around your ankle as demonstrated (figure 5). Slowly bend your knee tightening the back of your thigh (hamstrings). Perform 10 – 30 repetitions provided the exercise is pain free. Once you can comfortably perform 30 repetitions of this exercise consistently without pain, you can progress the exercise by increasing the resistance of the band. Begin with only a few repetitions with the heavier band initially and then build up to 30 repetitions gradually over a number of days provided there is no increase in pain.
Figure 5 – Resistance Band Hamstring Curl (right leg).
Place your foot on a step or chair. Keep your knee and back straight, lean forward at your hips until you feel a stretch in the back of your thigh / knee (figure 6). Hold for 15 seconds and repeat 4 times at a mild to moderate stretch pain-free.
Figure 6 – Hamstring Stretch (left leg)
Hamstring Curls on Swiss Ball
Begin this exercise lying on your back with a Swiss ball under your legs as demonstrated (figure 7). Keeping your back straight, slowly bend your knees tightening the back of your thighs (hamstrings). Then return to the starting position. Perform 10 – 30 repetitions provided the exercise is pain free. Once you can comfortably perform 30 repetitions of this exercise consistently without pain, you can progress the exercise by performing it on each leg individually. Begin with only a few repetitions using one leg initially and then build up to 30 repetitions gradually over a number of days provided there is no increase in pain (figure 8).
Figure 7 – Hamstring Curls on Swiss Ball
Figure 8 – Hamstring Curls on Swiss Ball Single Leg (right)
Hamstring Stretch (Knee Bent)
Place your foot on a bench or chair. Keep your back straight and your knee bent slightly. Lean forward at your hips until you feel a stretch in the back of your thigh (figure 9). Hold for 15 seconds and repeat 4 times at a mild to moderate stretch pain free.
Figure 9 – Hamstring Stretch (Knee Bent)
Place the foam roller under your hamstring (back of your thigh) as demonstrated (figure 10). Using your arms, slowly move your body forward and backwards allowing the foam roller to massage the back of your thighs. Breathe normally keeping your legs relaxed. Repeat this process for 15 – 90 seconds provided it is comfortable and does not cause pain. This exercise can be progressed by crossing your legs and massaging one thigh at a time or placing the leg that is not being massaged in contact with the ground (via the foot) with the knee bent.
Figure 10 – Hamstring Release
Hamstring Self Massage
Place the spikey massage ball under your hamstrings (back of your thigh) as demonstrated (figure 11). Using your arms and opposite leg, slowly move your thigh forwards, backwards and side to side allowing the spikey ball to massage the back of your thigh. Breathe normally keeping your legs relaxed. Repeat this process for 15 – 90 seconds provided it is comfortable and does not cause pain. You can also apply sustained pressure to a particular tight spot for periods of 15 – 60 seconds or until the soft tissue relaxes.
Figure 11 – Hamstring Self Massage
The following is a general rehabilitation protocol for a hamstring contusion. This needs to be tailored to each individual and should be discussed with your treating physiotherapist prior to commencing. Progression through this program can vary from several days to many weeks depending on injury severity and quality of treatment:
- See your physiotherapist as soon as possible to confirm diagnosis, establish the likely prognosis, identify any contributing factors to injury and begin appropriate treatment.
- Follow the R.I.C.E. Regime for the first 48 – 72 hours. This should primarily comprise:
- Rest from any activity that increases pain (if walking is painful or causing a limp, crutches are usually required)
- Ice the sore area for 20 minutes and repeat every 2 hours (using an ice pack wrapped in a damp tea towel).
- Compress the thigh using a compression bandage to minimise swelling (remove this at night and ensure it is not too tight i.e. it should be comfortable and there should be increase in pain and no colour change, swelling, pins and needles or numbness of the leg or foot).
- Elevate the affected leg to a level above the heart (provided there is no increase in symptoms).
- Anti-inflammatory medication may be beneficial (discuss this with your doctor and/or pharmacist)
- Avoid H.A.R.M. for the first 48 – 72 hours or when inflammatory signs are present (night-time pain, morning ache / stiffness or pain at rest) including:
- Heat (avoid using heat on the injured area, this includes the use of heat packs, hot baths or spas)
- Alcohol consumption
- Rigorous Exercise of the affected body part
- Settle symptoms – Aim to settle symptoms as quickly as possible by avoiding aggravating activities (and in some cases, using crutches). Any activity that increases pain during the activity, or after the activity with rest should be avoided, particularly running, kicking, jumping and lunging.
- Once symptoms settle, aim for pain free rehabilitation – i.e. gradually increase strength, flexibility and activity, provided there is no increase in symptoms during activity or upon rest following activity (e.g. upon waking the next morning). This should take place gradually over days to weeks.
- If using crutches, walk normally, but take enough weight off the injured leg so walking is pain free and limp free. Sometimes smaller steps may be required for a period of time. Gradually increase weight through the injured side as tolerated provided there is no increase in pain or limp until eventually you are only using one crutch (using the crutch in the opposite hand to the injured leg i.e. right hand for a left hamstring contusion) and eventually no crutches.
- Begin “Initial Exercises” 72 hours following injury provided there is no increase in symptoms.
- Heat treatment can usually commence 72 hours following injury provided there is no inflammation (i.e. night-time pain, morning ache/stiffness or pain at rest). Apply a heat pack to the injured area at a comfortable warmth for 20 – 30 minutes before exercises. If inflammation is still present (i.e. night-time pain, morning ache/stiffness or pain at rest), continue to use ice instead of heat.
- Increase walking distance, and eventually speed, gradually, and provided there is no increase in pain or limp (this should take place over days to weeks).
- Do not increase activity levels too rapidly especially in the first 2 – 6 weeks beginning from when symptoms have settled. During this period, injury recurrences are common. Be particularly careful when returning to running, kicking, jumping and lunging activities. Moderate the intensity, duration and frequency of exercise or activity to prevent injury recurrence.
- Progress to the “Intermediate Exercises” once the “Initial Exercises” can be performed pain free and to the same extent on the injured side as the non-injured side. Ensure all new exercises do not increase symptoms. The ‘Intermediate Exercises’ should replace the ‘Initial Exercises’. Generally you should begin with one “Intermediate Exercise’ and then add the remaining ‘Intermediate Exercises’ after a few days provided there is no increase in symptoms.
- Hydrotherapy, swimming or cycling may be included in your rehab to maintain fitness levels and assist in restoring range of movement and muscle strength during rehabilitation. All new exercises should generally begin gently and for a short duration and then gradually increased over a number of days provided symptoms do not increase. Ensure all new exercise do not increase symptoms.
- Progress to the “Advanced Exercises” once the “Intermediate Exercises” can be performed pain free and to the same extent on the injured side as the non-injured side. Ensure all new exercises do not increase symptoms. The ‘Advanced Exercises’ should replace the ‘Intermediate Exercises’. Generally you should begin with one “Advanced Exercise’ and then add the remaining ‘Advanced Exercises’ after a few days provided there is no increase in symptoms.
- The “Other Exercises” may be added once the “Advanced Exercises” can be performed pain free for a few days consecutively. Ensure all new exercises do not increase symptoms.
- A gradual Return to Running Program can be implemented for individuals who aim to return to running following injury provided there is no increase in symptoms.
- A gradual return to sport and activity can occur as directed by your physiotherapist and provided there is no increase in symptoms (see Return to Sport).
- Ensure your physiotherapist has identified any contributing factors to your injury and appropriate intervention has taken place to address these issues to minimize the likelihood of injury recurrence.
Physiotherapy products for a hamstring contusion
Some of the most commonly recommended products by physiotherapists to hasten healing and speed recovery in patients with this condition include:
Physiotherapy products that may be beneficial after the initial 72 hour period following injury and under guidance by the treating physiotherapist include:
- Heat Packs
- Resistance Band (for strengthening exercises)
- Swiss Balls (for strengthening exercises)
- Spikey Massage Balls (for self massage)
- Foam Rollers (for self massage)
To purchase physiotherapy products for a bruised hamstring click on one of the above links or visit the PhysioAdvisor Shop.
Find a physiotherapist in your local area who can treat this condition.
- Hamstring Stretches.
- Hamstring Strengthening Exercises.
- Core Stability Exercises.
- Balance Exercises.
- View detailed information on How to use Crutches.
- Learn about initial injury management and the R.I.C.E. Regime.
- Read about when to use Ice or Heat.
- Read our comprehensive Return to Running Program.
- View detailed information on Returning to Sport.
- View our Thigh Diagnosis Guide.
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