Hamstring Strain Rehab - Part 2
Phase 1 (0-2 weeks)
In this phase, we will introduce low intensity exercises in a limited and painfree range of motion. Excess hamstring stretching at this phase should be avoided as it can restrict muscle regeneration and cause scar formation. We can get all the length we need from eccentric strengthening in the later phases of rehab.
Pain should be used as a guide to determine the ROM limit. You may need to shorten your stride with walking or even use crutches in some instances.
One common mistake I see is players waiting far too long to begin rehab. We do not want complete rest and rehab can begin 1-2 days after the injury to minimize atrophy. We are going to stay in a protected range of motion and avoid lengthening exercises initially.
Cycling, rowing, or other forms of aerobic exercise can begin at this phase as long as they’re not painful.
Progression to Phase 2 (If these criteria are met immediately after injury, then you may begin at phase 2)
Normal walking
Low-speed jogging without pain
Pain free isometric hamstring contraction
For some athletes this may only take a few days, for others it may be a few weeks. Once these 3 criteria are met you can move to phase 2.
Phase 2 (2-6 weeks)
In this phase, we will gradually return to full ROM and begin eccentric strengthening, trunk stabilization, and return to running.
There is typically weakness in the muscle at longer lengths following this injury. A recent study by Paton et al. (2023) found that loading the hamstrings at longer lengths can increase fascicle (muscle fiber) length, change the length-tension relationship in the muscle, and reduce injury risk. As we covered in Part 1, it is important to include a variety of both hip and knee-dominant exercises to target different parts of the muscles.
These exercises alone tend to restore full range of motion to the hamstrings without the need for hamstring stretching. (This is not a one size fits all approach, so if the range of motion is severely limited and impacting movement, more specific hamstring stretching may be appropriate in a small number of cases.)
You can begin kicking as well in this phase as long as it’s painfree.
Return to Running
The hamstring muscles show different levels of activation when running. For example, when sprinting:
The semitendinosus has the highest lengthening velocity
The semimembranosus has the greatest force production
The biceps femoris undergoes the largest strain
A study from Askling et al. (2014) suggests that the biceps femoris long head can reach over 100% of its resting length (which may be why this muscle is most frequently injured with sprinting). This further reinforces the importance of strengthening in a lengthened position to prevent re-injury.
Hickey (2022) describes a 3 stage return to running program following hamstring strain. We will complete the first stage in this phase.
For the first stage:
Start with a slow jog for 20 meters
Then increase speed to about 50% of maximum velocity for 60 meters
Finish with a slow jog again.
If you have a field, slow jog to the 18, then run at 50% to the opposite 18, then slow jog to the end line. Build up to 5 repetitions.
Progression to phase 3
Perform bridge walkouts/sliders 3x10
Perform SL RDL 3x10 w/out pain
Jogging forwards and backwards at 50% speed painfree
Phase 3 (6-12 weeks)
For the third phase, we want to get as strong as possible in lengthened positions and return to full speed running prior to returning to sport.
By now you should have a good baseline of several eccentric hip and knee-dominant hamstring exercises. In this phase, we will start to introduce more load and increase the speed of the exercises to prepare the hamstrings.
Nordic hamstring curls are essential for both rehab and injury prevention in soccer players due to the high loads placed on the biceps femoris in a lengthened position.
If these are too challenging to begin with, check out this video which will show you how to build up to full Nordic curls.
Return to Running
For the second stage:
Start with a moderate jog for 30 meters
Increase speed to 80% of maximum velocity for 50 meters
Finish with a moderate jog again
For the third and final stage:
Begin with a moderate jog for 40 meters
Build up speed to 85% for 50 meters
Finish with a moderate jog.
Increase the running speed by 5% increments each session until you can sprint at 100% without pain. We do still want to manage running volume here, so I would perform between 4-8 repetitions per session with adequate rest in between reps.
Return to sport
We still want to be cautious at this point due to the high likelihood of re-injury with this condition. Most relapses will occur within the first 2 months of the initial injury, so it’s important to not rush back into games and potentially set yourself back even further.
There are two main criteria I’m looking for the athlete to meet before they return to training.
Hamstring Endurance Test
Perform 4x8 Nordic Hamstring Curls without pain
Painfree Repeated Sprinting
5x50 meters
Once those are met, training sessions can begin, and players should shoot for 5 training sessions (1-2 weeks) before returning to play. Nordic hamstring curls should be continued at least 1x/week after you have returned to sport to reduce the risk of future injury.
References
Ekstrand J, Bengtsson H, Waldén M, Davison M, Khan KM, Hägglund M. Hamstring injury rates have increased during recent seasons and now constitute 24% of all injuries in men's professional football: the UEFA Elite Club Injury Study from 2001/02 to 2021/22. Br J Sports Med. 2022 Dec 6;57(5):292–8.
Hickey JT, Opar DA, Weiss LJ, Heiderscheit BC. Hamstring Strain Injury Rehabilitation. J Athl Train. 2022 Feb 1;57(2):125-135.
Jokela A, Valle X, Kosola J, et al. Mechanisms of Hamstring Injury in Professional Soccer Players: Video Analysis and Magnetic Resonance Imaging Findings. Clin J Sport Med. 2023 May 1;33(3):217-224.
Gronwald T, Klein C, Hoenig T, et al.. Hamstring injury patterns in professional male football (soccer): a systematic video analysis of 52 cases. Br J Sports Med. 2021;56:165–171.
Larson JH, Fenn TW, Allahabadi S, Nho SJ. Hamstring Strains: Classification and Management. Sports Health. 2024 Jul-Aug;16(4):661-663.
Lempainen L, Banke IJ, Johansson K, et al.. Clinical principles in the management of hamstring injuries. Knee Surg Sports Traumatol Arthrosc. 2014;23:2449–2456.
Cross KM, Gurka KK, Saliba S, Conaway M, Hertel J. Comparison of hamstring strain injury rates between male and female intercollegiate soccer athletes. Am J Sports Med. 2013 Apr;41(4):742-8.
Heiderscheit BC, Sherry MA, Silder A, Chumanov ES, Thelen DG. Hamstring strain injuries: recommendations for diagnosis, rehabilitation, and injury prevention. J Orthop Sports Phys Ther. 2010 Feb;40(2):67-81.
Verrall G M, Slavotinek J P, Barnes P G, Fon G T, Spriggins A J.Clinical risk factors for hamstring muscle strain injury: a prospective study with correlation of injury by magnetic resonance imaging Br J Sports Med 20013506435–439.
Hägglund M, Waldén M, Ekstrand J. Previous injury as a risk factor for injury in elite football: a prospective study over two consecutive seasons. Br J Sports Med. 2006;40(09):767–772
Green B, Bourne MN, van Dyk N, et al.. Recalibrating the risk of hamstring strain injury (HSI): a 2020 systematic review and meta-analysis of risk factors for index and recurrent hamstring strain injury in sport. Br J Sports Med. 2020;54:1081–1088.
Bisciotti GN, Chamari K, Cena E, Carimati G, Bisciotti A, Bisciotti A, Quaglia A, Volpi P. Hamstring Injuries Prevention in Soccer: A Narrative Review of Current Literature. Joints. 2020 May 25;7(3):115-126.
Guruhan S, Kafa N, Ecemis ZB, Guzel NA. Muscle Activation Differences During Eccentric Hamstring Exercises. Sports Health. 2021 Mar;13(2):181-186.
Keerasomboon T, Mineta S, Hirose N. Influence of Altered Knee Angle and Muscular Contraction Type on Electromyographic Activity of Hamstring Muscles during 45° Hip Extension Exercise. J Sports Sci Med. 2020 Nov 19;19(4):630-636.
Hegyi A, Csala D, Péter A, Finni T, Cronin NJ. High-density electromyography activity in various hamstring exercises. Scand J Med Sci Sports. 2019 Jan;29(1):34-43.
Paton BM, Read P, van Dyk N, Wilson MG, Pollock N, Court N, Giakoumis M, Head P, Kayani B, Kelly S, Kerkhoffs GMMJ, Moore J, Moriarty P, Murphy S, Plastow R, Stirling B, Tulloch L, Wood D, Haddad F. London International Consensus and Delphi study on hamstring injuries part 3: rehabilitation, running and return to sport. Br J Sports Med. 2023 Mar;57(5):278-291.
Askling CM, Tengvar M, Tarassova O, et al. Acute hamstring injuries in Swedish elite sprinters and jumpers: a prospective randomised controlled clinical trial comparing two rehabilitation protocols. Br J Sports Med 2014;48:532–9.
Kellis E, Galanis N, Kapetanos G, et al. Architectural differences between the hamstring muscles. J Electromyogr Kinesiol 2012;22:520–6.
Bourne MN, Duhig SJ, Timmins RG, et al. Impact of the Nordic hamstring and hip extension exercises on hamstring architecture and morphology: implications for injury prevention. Br J Sports Med 2017;51:469–77.
Mendiguchia J, Garrues MA, Cronin JB, et al. Nonuniform changes in MRI measurements of the thigh muscles after two hamstring strengthening exercises. J Strength Cond Res 2013;27:574–81.
Macdonald B, McAleer S, Kelly S, et al. Hamstring rehabilitation in elite track and field athletes: applying the British athletics muscle injury classification in clinical practice. Br J Sports Med 2019;53:1464–73.
Guex K, Millet GP. Conceptual framework for strengthening exercises to prevent hamstring strains. Sports Med 2013;43:1207–15.
Bourne MN, Timmins RG, Opar DA, et al. An evidence-based framework for strengthening exercises to prevent hamstring injury. Sports Med 2018;48:251–67.