In this blog, I am going speak about how you can rehab a hamstring tear. This includes everything from early stage, all the way to late stage. This is for education purposes only – please consult a clinician or physiotherapist to have your injury assessed first!

Hamstring strain injuries result in a sudden onset of pain in the back of the thigh, often causing an abrupt end to activity.

A muscle strain usually occurs during movements involving forceful and extensive hamstring lengthening, such as sprinting, slowing down from sprinting or kicking. This is because the hamstring muscle has been overstretched beyond its capacity or from a sudden load.

Since these muscles originate from your sitting bone and insert onto your lower leg, they have actions at both the hip and the knee. Along with your glute max and adductor magnus, they contribute to hip extension, and are the primary muscles responsible for knee flexion.

When you strain or pull your hamstring, it usually involves the long head of the biceps femoris, although it can also occur to one of the other two hamstring muscles – the semitendinosus or semimembranosus.

Rehabilitation Overview

Following an injury to the hamstring, the goal of rehab is to address specific deficits seen in strength and muscle structure, as well as preparing you for the demands of your life/sport ensuring that you have made a full recovery before returning.

Your timeline from injury to return to sport/work can take anywhere from 1 – 12 weeks or in some cases longer. This is widely variable from person to person, as it will depend on a number of factors, in particular the severity of your injury.

Immediately following the injury, you will likely rest for a few days as this allows time for acute symptoms to reduce before starting rehab.

When you should begin hamstring specific exercises is not exactly known, but most research shows that starting early – within the first week is great!

You should not avoid completing the rehab if you are experiencing pain. Pain when exercising is a normal response but ensure that your pain stays 4 or less out 10. You may ask what is 4/10 pain, well it is whatever is tolerable for you.

Throughout this program you should continue with general lower body strength i.e. squat with heels elevated, split squat, glute bridge, calf raises etc.. You should also maintain CV fitness through 20-30 minutes 3-4 times per week. Lastly, you should continue upper body training as normal but do modify exercises that aggravate the hamstring.

There are four stages to this rehabilitation program and each stage is important to follow:

Stage 1: re-gain ROM/restore initial strength

Stage 2: emphasis on strength

Stage 3: begin plyometrics and running

Stage 4: return back to sporting performance

Re-gain ROM/Restore Initial Strength

The first stage is focusing on restoring your range of movement and beginning isometric contractions. An isometric is great way to reduce pain and keep those muscle fibres activated. It is great to start moving it the best that you can within pain tolerance. Keep walking as much as you can and general day-to-day activities normal, with modifications where needed to avoid aggravating your hamstring. I advise you to start with exercise 1 and built it up gradually.

Movement Exercises:

1: hold back of the knee and extend the knee in supine (20-30 reps throughout the day, slow and controlled, pain ≤4/10)

2: prone knee bends (20-30 reps throughout the day, slow and controlled, pain ≤4/10)

3: standing knee bends (20-30 reps throughout the day, slow and controlled, pain ≤4/10)

4: heel slides (20-30 reps throughout the day, slow and controlled, pain ≤4/10)

Isometric exercises

 Non-gym options:

1: seated heel against other leg (2-4 sets, 2-5 reps, 50-75% of max force, hold for 5-10 seconds per rep, pain ≤4/10)

2: prone lying heel against other leg (2-4 sets, 2-5 reps, 50-75% of max force, hold for 5-10 seconds per rep, pain ≤4/10)

Gym options:

1: seated leg curl machine (2-4 sets, 2-5 reps, 50-75% of max force, hold for 5-10 seconds per rep, pain ≤4/10)

2: lying leg curl machine (2-4 sets, 2-5 reps, 50-75% of max force, hold for 5-10 seconds per rep, pain ≤4/10)

 

Once pain, swelling and bruising has reduced, move onto the next stage. You will be looking at around 10-14 days post injury.

 

Emphasis on Muscular Strength

The second component is increasing muscular strength of the hamstring. Each exercise category will have multiple levels of difficulty/variations of each exercise, which you will progress through based on how easy or hard it is and your pain level. For example, if an exercise has 3 levels of difficulty, you will first start with level 1. Once you can complete the prescribed number of sets and reps through the full range of motion with a tolerable level of pain, you can progress to level 2, and so on.

Knee flexion examples –

Hamstring slider:

1: two-legged slider (2-4 sets of 12-15 reps, pain ≤ 4/10, 3-4 times per wk)

2: single-leg eccentric slider (2-4 sets of 8-10 reps, pain ≤ 4/10, 3-4 times per wk)

3: single-leg slider (2-4 sets of 4-8 reps, pain ≤ 4/10, 3-4 times per wk)

Seated hamstring curl:

1: two-legged curl (2-4 sets of 12-15 reps, pain ≤ 4/10, 3-4 times per wk)

2: single-leg eccentric curl (2-4 sets of 8-10 reps, pain ≤ 4/10, 3-4 times per wk)

3: single-leg curl (2-4 sets of 8-12 reps, pain ≤ 4/10, 3-4 times per wk)

Hip extension examples –

45 degrees hip extension machine:

1: two-legged (2-4 sets of 12-15 reps, pain ≤ 4/10, 3-4 times per wk)

2: single-leg (2-4 sets of 8-10 reps, pain ≤ 4/10, 3-4 times per wk)

3: double/single-leg with a weight (2-4 sets of 6-10 reps, pain ≤ 4/10, 3-4 times per wk)

RDL:

1: body weight single-leg diver (2-4 sets of 12-15 reps, pain ≤ 4/10, 3-4 times per wk)

2: weighted RDL (2-4 sets of 8-10 reps, pain ≤ 4/10, 3-4 times per wk)

3: single-leg weighted RDL (2-4 sets of 6-10 reps, pain ≤ 4/10, 3-4 times per wk)

Bridge with feet on bench/box:

1: two-legged (2-4 sets of 12-15 reps, pain ≤ 4/10, 3-4 times per wk)

2: single-leg eccentric (2-4 sets of 8-10 reps, pain ≤ 4/10, 3-4 times per wk)

3: single-leg (2-4 sets of 6-10 reps, pain ≤ 4/10, 3-4 times per wk)

Other exercises to include-

Squat with quadriceps emphasis:

1: heel elevated squat (2-4 sets of 12-15 reps, 3-4 times per wk)

2: split stance squat (2-4 sets of 10-15 reps, 3-4 times per wk)

3: bulgarian split squat (2-4 sets of 8-12 reps, 3-4 times per wk)

Hip thrust with glute emphasis (back on the bench/box):

1: two-legged bridge (2-4 sets of 15-20 reps, 3-4 times per wk)

2: two-legged bridge weighted (2-4 sets of 12-15 reps, 3-4 times per wk)

3: single-leg bridge (2-4 sets of 8-10 reps, 3-4 times per wk)

Heel raise with calf emphasis:

1: two-legged raise on a step (2-4 sets of 15-20 reps, 3-4 times per wk)

2: single-leg raise on a step (2-4 sets of 12-15 reps, 3-4 times per wk)

3: weighted single-leg raise on a step (2-4 sets of 8-10 reps, 3-4 times per wk)

Other Considerations-

Cardio

Whether you are rehabbing an injury or training towards a specific goal, including aerobic fitness in your plan is a must. It is always good to keep a good level of fitness even with an injury. This could even be an area that you prioritise whilst you cannot do your normal routine. There is always a form of cardio that you can do, from swimming to cycling, to rowing or hand bike, you can always do something!

Upper body training

It is absolutely fine to train upper body with a hamstring strain. However, you may have to alter certain exercises so that they do not aggravate the hamstring. For example, a bent over row you could substitute for a seated chest supported row whilst your hamstring heals.

Mobility Movements

1: leg swings

2: knee extension standing

3: inch worm

Running Protocol

The third component of the rehab is a progressive running protocol. As stated in a 2022 paper, it is arguably the most important aspect of rehab since it’s fundamental to performance in many sports and is a common mechanism of injury. Many hamstring injuries occur as a result of sprinting or slowing down from sprinting.

Below outlines a 3-stage protocol with gradual increases in running intensity to begin once you can walk with a pain rating of 4 or less out of 10:

Stage 1:

Jog slowly for 20 meters (up to ~25% of max speed), then increase your speed up to 50% of your maximal velocity for 60 meters, and then return back to a slow jog (~25% max speed) for 20 meters. Once you can complete 3 repetitions at 50% of your maximal speed with minimal pain (≤4/10), progress to stage 2.

Stage 2:

Slowly ramp up to moderate-speed for 30 meters, then increase to high-speed running (up to 80% of your maximal velocity) for 50 meters, before slowing back down again. Once you can complete 3 repetitions at 80% without pain (0/10), progress to the final stage.

Stage 3:

You will perform shorter sprint distances at a higher intensity. Your goal is to gradually increase your running speed in 5% increments, until you are able to safely build up to 100% effort sprints without pain.

Returning back to sport

The fourth component is returning back into sporting performance. Generally, the research to support return to sport is scarce, likely because the process is complex and multi-factorial. But there is consensus on some criteria that must be met prior to returning to play.

The main criteria includes:

Possessing similar eccentric hamstring strength side-to-side is a criteria, but not essential for reducing risk of re-injury. However, because it is associated with sprinting acceleration mechanics, maximizing eccentric hamstring strength should still be a desirable rehab outcome for sports performance. An exercise like a Nordic curl is a great example of an eccentric loading hamstring exercise.

You should continue to perform these exercises even after you return to sport in order to avoid regression of the positive changes in the hamstring muscles structure. You will not need to complete them 3-4 times per week but recommend at least 1-2 times per week alongside your other commitments and routine.

You should complete a phase return rather than going straight back into training and games. Gradually allow yourself to get back into the sport. It is important to understand that when you return back to your sport, it might not be at 100% of your desired level. This will take time until you can gradually build back up to performing at pre-injury level or higher.

Thank you for reading this. Please contact us with any questions that you may have or give us your feedback with your thoughts.