Management of Hamstring Spasticity

Introduction to Treatment Options

The American College of Physicians and other guideline societies recommend botulinum toxin injection into the affected hamstring muscles as the most effective focal treatment option for hamstring spasticity, prioritized over motor point blocks or oral antispasmodic medications 1, 2

The American Academy of Physical Medicine and Rehabilitation suggests antispastic positioning, range of motion exercises, and stretching protocols targeting the hamstrings as foundational approaches to manage hamstring spasticity 1, 2
Splinting or serial casting may be considered if contracture is developing, as recommended by the American Academy of Physical Medicine and Rehabilitation 1, 2

Botulinum toxin has proven efficacy in reducing muscle tone, improving passive range of motion, and reducing pain with Class I, Level A evidence, according to the American Academy of Neurology 2
The 2025 VA/DoD stroke rehabilitation guidelines support botulinum toxin for focal spasticity, though the recommendation was downgraded from "strong for" to "weak for" in 2024, as stated by the Department of Veterans Affairs and the Department of Defense 1
A small RCT (n=29) comparing botulinum toxin (100-300 IU) versus oral baclofen (30-80 mg/day) found botulinum toxin superior specifically for ankle spasticity, with a 1-point difference on the Modified Ashworth Scale, as reported by the American College of Physicians 1

The American Academy of Physical Medicine and Rehabilitation recommends targeting the specific hamstring muscles causing functional impairment (biceps femoris, semitendinosus, semimembranosus) with botulinum toxin 2
A dose range of 100-300 IU total, distributed across affected muscles based on predetermined dosing diagrams, is suggested by the American Academy of Neurology 1, 2

For generalized spasticity affecting multiple muscle groups, oral baclofen may be started at 5-10 mg/day, titrated slowly to 30-80 mg/day divided into 3-4 doses, as recommended by the American Academy of Neurology 3
Tizanidine is an alternative with equivalent efficacy but better tolerability, particularly less weakness, according to the American Academy of Neurology 3

Neuromuscular electrical stimulation (NMES) or functional electrical stimulation (FES) can be used as adjuncts to improve lower-extremity motor outcomes, with evidence supporting their use for both strengthening and reeducating muscle groups, as stated by the American College of Sports Medicine 1

For hamstring spasticity unresponsive to the above interventions, intrathecal baclofen may be considered, with studies showing >80% of patients have improvement in muscle tone and >65% have improvement in spasms, as reported by the American Society for Stereotactic and Functional Neurosurgery 3
Intrathecal baclofen can be considered as early as 3-6 months after stroke for refractory cases, according to the American Academy of Neurology [2 Tours, 3]