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Exercise Rehabilitation for Hamstring Injuries: A Resource List (2015)

By Luke McManus | 27th September 2015 | Clinical Development

This is part 3 in this month’s theme: Hamstring Injuries in Sport (2015).

The previous two articles looked at mechanisms of hamstring injuries, risk factors, as well as some of the latest evidence-based assessments we can do in the clinic.

The aim of this article is to build a growing resource list summarising the latest research findings, as well as clinical recommendations for exercise prescription.

  • What exercises are best suited for athletes at different phases of tissue healing?
  • What exercises might be able to help reduce injury recurrence?

These are questions that we think about often.

Using a biopsychosocial approach, and taking the time to assess the athlete, will help to highlight what factors are contributing to any individual’s hamstring injury.

When it comes to exercise prescription, this thorough assessment is a big help in arriving at a more accurate diagnosis (classification and grade). 

From an anatomical perspective, it is important to identify the location of the hamstring strain (proximal to distal) and any suspicion of central tendon involvement. These factors are known to affect tissue healing time frames and the rate of exercise progression.

An athletes diagnosis, taking into account the athlete’s thoughts, goals, ambitions, and sports-specific requirements will also help guide what exercises are useful.

If anyone isn’t following the British Journal of Sports Medicine (BJSM), I think you should get onto it. They have some great resources, including their podcast, as well as journal abstracts, and open-access papers.

Recommended Listening for Hamstring Injuries

1. BJSM - Hamstring Injuries: A 10-min evidence update on optimal treatment

 Summary:

A recent systematic review and meta-analysis by Haiko Pas discussed:

  • Askling Protocol of eccentric lengthening exercises. See below for a video of these exercises
  • Integrating trunk stabilising exercises into exercise rehabilitation is associated with lower statistical injury recurrence. What are these trunk stabilising exercises? (see below)
  • Plasma-rich plasma (PRP) injections do not influence hamstring rehabilitation. They do not improve time to return to sport, nor do they reduce injury risk

 

2. BJSM - Eccentric hamstring exercises – they work in practice but not in theory?

Summary:

Dr David Opar (lecturer at the Australian Catholic University in Melbourne) provides a clear, honest and sensible look at the current literature:

  • There is no single ‘silver bullet’ in terms of a single exercise to definitively rehabilitate hamstring injuries.
  • It’s a good idea to look at the strengths and limitations of any exercise approach and try to perhaps integrate approaches as appropriate, to try to reduce these limitations
  • A deficit in eccentric hamstring strength, through the range, is a considerable risk factor to acute injury as well as injury recurrence
  • Nordic eccentric hamstring lengthening exercises have a growing body of evidence in helping to address these deficits in eccentric strength, and can potentially mitigate other non-modifiable risk factors, such as age and history of a previous hamstring injury
  • Sports-specific functional retraining is very important. High speed running as part of the exercise rehab is important, in getting the athlete back to competition
  • With high-speed running, as with all higher load tasks, the injury risk while performing this rehab is high, especially if progressing inappropriately
  • Keep an open mind with exercise rehabilitation. Manage each athlete with their own individual sports-specific demands in mind

 

3. Physio Edge - Hamstring Strength, Flexibility and Injuries with Kieran O’Sullivan

Summary:

  • A considerable risk factor for hamstring injury: excessive/inappropriate increase in training load
  • Progression from isometric, to concentric, and eventually eccentric hamstring strengthening is important. This is to improve the musculotendinous unit’s ability to undertake load
  • Principles of R.I.C.E. (rest, ice, compression, elevation) in acute management have limited evidence in improving recovery times in hamstring injuries
  • Exercises moving through a greater range of available muscle length may help improve tissue load adaptation
  • There should be a continuation of rehab after the athlete returns to sport. This ‘maintenance’ is aimed at monitoring and planning appropriate tissue loading for the athlete's requirements

What exercise does the literature support?

The following are videos and links to the three most commonly discussed exercise approaches to hamstring rehabilitation. This is obviously not comprehensive, but are most commonly referred to in the literature.

Exercise dosage is not discussed, as I feel this should be guided by your assessment of the athlete, as well as being determined by the physical characteristics you are training (strength, endurance, power?).

1. Askling eccentric lengthening protocol

The Extender:

Video courtesy of Aspetar.

The Diver:

Video courtesy of Aspetar.

The Slider:

Video courtesy of Aspetar.

2. Eccentric Nordic Hamstring Exercise

Video courtesy of Aspetar.

The full Aspetar protocol can be viewed as a YouTube playlist here.

3. Trunk stabilisation exercises

The kinds of trunk stabilisation exercises that are referred to in the literature are probably best represented in the following FIFA 11+ protocol, which is available at the following link:

http://f-marc.com/11plus/home/

This is actually a well-researched compilation of lower limb and trunk exercises, which are mostly functional, for the prevention of lower limb injuries in general (not just hamstring).

Ideas for exercise progression

It's pretty difficult (and not evidence-based) to give a recipe based exercise progression that is suitable for all athletes.

As mentioned above, there are many factors to consider, including:

  • The grade and classification of the hamstring injury
  • Previous history of a hamstring injury
  • Age
  • Sports-specific requirements

Rather than a time-based progression, it might be better to think more in terms of an athlete’s key performance indicators (KPIs).

In other words, when an athlete demonstrates that he/she can do a particular exercise correctly, with:

  1. no pain, and
  2. no change in muscle tone, then a progression can be looked at

Here are some general ideas for exercise progressions based on tissue healing and individual performance.

This is definitely not exhaustive and is not meant to be used all at once, and especially not as a recipe-based prescription.

Stage 1:

  • Isometric contractions
  • Bridging (double, single leg)
  • Prone hamstring double leg curl (low load, concentric)
  • The ‘Extender’ (see above)
  • Single leg balance exercises

Stage 2:

  • The ‘Diver’
  • Modified squats (fitball squats, low load goblet squats)
  • Single leg hamstring curls - with some eccentric focus
  • Fitball seated walking exercise
  • Fitball hamstring curls

Stage 3:

  • Nordic eccentric exercise (double leg)
  • The ‘Slider’
  • Single leg Romanian deadlift
  • Kettlebell swings (double arm)
  • Low back extensions (isometric and concentric)
  • Fitball hamstring curls (comparing double and single leg - concentric and eccentric)

As mentioned above, these are just some simple ideas, and the criteria for exercise progression is:

  1. no pain, and
  2. no change in muscle tone, during, as well as after the exercise

Entering from stage 2 into stage 3 will be guided by the athlete’s goals and sport-specific demands.

This can consider other task-specific strength and conditioning, as well as motor control strategies and training that you feel could help the athlete in their specific role.

What are your thoughts and experiences with prescribing exercise for hamstring injuries in sport?

References:

  1. Podcast: BJSM - Hamstring Injuries: A 10-min evidence update on optimal treatment
  2. Podcast: BJSM - Eccentric hamstring exercises – they work in practice but not in theory?
  3. Podcast: Physio Edge - Hamstring Strength, Flexibility and Injuries with Kieran O’Sullivan
  4. Aspetar Hamstring Protocol

A special thanks to Greg Mullings (Sports Physiotherapist, Fremantle Football Club), for his presentation on hamstring injuries in sport in Perth, November 2014.

Creative Commons Photo by Humphrey Muleba on Unsplash and has been edited.

Luke McManus

Luke is Musculoskeletal Physiotherapist from Perth, Australia. He created Physio Development to help physiotherapists identify their unique career pathway and to enjoy a long and successful career in physiotherapy.

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