Hamstring strains in athletes are common injuries and pose complicated rehabilitation challenges, especially in high impact or fast paced sports.
A 4-year study of injury rates for the Memphis State University football team showed that hamstring strains were the third most common orthopaedic problem after knee and ankle injuries. Hamstring injuries often result in significant recovery time, along with a lengthy period of increased susceptibility for recurrent injury; if not handled correctly, what may seem like a simple injury with a relatively short recovery time may turn into a chronic issue that can plague careers
Risk of Reoccurrence
The highest risk for injury recurrence appears to be within the first 2 weeks of return to sports.  A study that analysed 858 hamstring strains in Australian Footballers showed that the rate of recurrence was 12.6% during the first week of return to sports and 8.1% during the second week. The cumulative risk of re-injury for the entire 22- week season was 30.6%.
Despite this high risk, there is a lack of research in how to effectively rehab hammies; this can lead to confusion, or incorrect implementation of results from poorly designed studies. We have attempted to scour the journals to put together what info there is, and come up with a robust conclusion in how to rehab your injuries.
One little disclaimer though, always check with a doctor or physio before undertaking any rehab operation. Whilst we have been able to bring together years of research to create this article- everyone has different conditions and needs; so implement the tips and hints at your own risk.
Returning to sport at the same level of performance achieved before the injury, with a minimal risk of injury recurrence is the primary objective of a rehabilitation program.
Several factors likely contribute to the high rate of re-injury :
(1) Continued weakness in the injured muscle,
(2) Scar tissue reducing how much the muscle/tendon can extend
(3) The athlete subconsciously changing the way they move in the wake of the accident
Eccentric training is repetitively doing eccentric muscle contractions. For example slowly moving the weight back to the start position during a dumbbell curl would be a great eccentric exercise. Usually people will perform the positive motion of curling the dumbbell, then let it drop by using bicep contraction to slowly drop the weight, by doing so you are able to control the speed of descent.
An eccentric contraction is one of the three distinct phases in the movement of muscles and tendons, the other two are an isometric contraction (no movement), and a concentric contraction (contracting).
Eccentric training is particularly good for rehabilitating certain muscles and tendons, especially hamstrings!
Straight After the Injury
Ice, Ice, Baby
It may sound basic, but there is a lot of evidence to suggest that simple ice treatment may be highly effective for hamstring injuries. Teddy W. Worrell, writer of one of the most sourced hamstring review articles is quoted as saying:
I believe that ice provides the most efficient clinical method to limit inflammation.
Sourced below, KL Knight suggests adding crushed or cubed ice directly to the skin overlying the hamstring muscle group for 20 to 45 minutes, 2 to 4 times a day. Loss of tissue cooling occurs if a towel (wet or dry) is placed between ice bag and skin, however you should be careful if you are using frozen gel packs because skin damage can occur if you put them in direct contact with the skin.
The number of days that ice to an injury is applied is a subjective decision that is different in each case, however daily ice application should continue until symptoms begin to soften; usually 7-14 days.
Beginning To Move
After approximately 20 to 45 minutes of ice application, start to move your leg around really gently. You can sit on a chair or bed and just gently flex, there is good evidence that early motion exercises, can prevent or decrease the physical scar tissue and damage done [citation 3 below]. Keep on with Active Range of Motion exercises for 20 minutes as long as the pain isn’t too acute. If that is the case then it is better to cut the session short.
Signs of Recovery
We have heard this called the direct recovery or subacute phase of the rehab process; regardless of the name, it is a few days (2-4) after the injury occurred and the swelling has started to go down. At this phase you should be able to achieve full extension without pain; if you are still unable to do then then it is worth checking in with your doctor or physio once again, as there may be more underlying issues.
Getting Your Move On
Once you can perform isometrics at 100% effort you are able to start strengthening the injury. The prone position for hamstring strengthening replicates tension that occurs during running. Moreover proximal hip stabilisation and knee extension may mimic the ground contact phase of running. You can use light ankle weights at this phase, as long as it is not uncomfortable.
Generally, if exercises increase symptoms the capacity of the connective tissue has been exceeded and further inflammation occurs. Therefore, either the intensity, duration and frequency or all 3 need to be decreased. Because individual people’s ability to communicate and tolerate pain varies drastically, the rate of progression will vary.
Ensure you take things slowly and do not adopt a one-size-fits-all approach to getting started with exercise again. A period of light stretching, followed by more rigorous extension is essential to rehabbing your hamstring. Always take the advice of professionals around you, and don’t overdo it if you feel discomfort; it is better taking a week longer for a recovery than reinjuring yourself!
1. Orchard JW, Best TM. The management of muscle strain injuries: an early return versus the risk of recurrence. Clin J Sport Med. 2002;12:3-5.
2. Knight KL. Cryotherapy theory technique and physiology. Chattex Corp .. Chattanooga. 1985
3. Kisner, C., and L. A. Colby. "Therapeutic exercise: foundations and techniques, p 369." (1990).
4. Mann 1982: Stanton & Purdam 1989: Worrell et at. 1989
5. Mann RA. Sprague P. A kinetic analysis of the ground leg during sprinting. Research Quarterly for Exercise and Sport 51 : 33-1-348. 1980