Hamstring strain injuries are one of the most common lower body injuries to occur during sport, accounting for an average of 6-7 injuries per AFL or Soccer club per season. Studies in AFL have also shown that 20% of these athletes that have injured that hamstring will do it again within that season. The biggest issue with hamstring strain injuries is the time taken to return to sport. Higher level athletes with only a minor strain will still lose at least 3 weeks of game-time at best, however, these injuries can take anywhere up to 12 weeks to be able to return to sport.
The hamstring is a group of 3 different muscles that are involved in bending the knee and straightening or extending the hip. Hamstring strains can range between a mild muscle cramp to a complete rupture of the muscle. The majority of hamstring injuries tend to involve the larger muscle, the biceps femoris, and tend to occur lower down in the muscle, just above the knee, where the muscle and tendon join. Muscle strains are graded based on their severity.
- A Grade I or mild muscle strain involves tearing of only a few muscle fibres with minimal swelling and discomfort and minimal loss of strength and range of movement.
- A Grade II or moderate strain will present as a more noticeable loss of strength as the result of greater damage to the muscle.
- A Grade III or severe strain is a tear that extends across a large portion of the muscle and results in a near total lack of muscle function.
- A complete rupture usually involves an avulsion fracture where either the muscle alone or the muscle and part of the bone is torn away from where the muscle attaches on the ischial tuberosity in the pelvis.
Generally, a diagnosis can be made based on client history and a physical examination looking at function, range of movement and strength and generally does not require any further scans or imaging.
The majority of hamstring injuries tend to occur during the season and towards the end of the first or second half of the game, and most commonly occur during running or sprinting, however, may also occur during stretching, sliding, turning, kicking, jumping or twisting.
The initial management for a hamstring injury strain is similar to that of other injuries, and involves the RICE principle: rest, ice, compression and elevation. It is then important to start a lower body and core strengthening and mobility program as soon as possible. The exercises given vary depending on the severity of the injury. The goal of rehabilitation is to restore strength and function in the shortest possible time.
Phase 1 (Acute – Days 1-7)
The goal of the first phase of treatment is to control bleeding and reduce pain and swelling. This may involve rest, ice, compression, elevation and a possible short-period of non-steroidal anti-inflammatory drugs 2-4 days after the injury. It is important to start an early range of movement program to prevent or decrease scar tissue including basic movements without resistance where you simply bend your knees for mobility. It is important that the exercises are pain free to prevent further injury to the muscle group.
Phase 2 (Sub-Acute – Day 3 – Week 3)
Once the signs of inflammation such as heat, redness, pain and swelling have started to settle, we can start some gentle strengthening exercises to prevent muscle atrophy and to help with the healing process. These again should be pain-free and may be isometric or concentric exercises.
Other activities can be resumed in this phase to maintain cardiovascular fitness. Instead of running, this could involve swimming or stationary bike riding, as well as a full body and core strength program.
Phase 3 (Remodelling – Weeks 1-6)
The goals of this phase are to restore range of movement, by increasing the frequency and intensity of static stretching. It may be normal to feel a slight stretching or pulling sensation with stretching but must not be painful. Once the individual is managing other concentric strengthening well, then eccentric strengthening can start to occur.
Phase 4 (Functional – Months 2-6)
In this phase, we are trying to return the athlete back to sport without the risk of reinjury. Signs that the athlete is ready to progress include full range of movement, normal hamstring strength (value to be within 10% of the non-injured leg). Running activities are graduated from pain-free jogging to lower intensity running and then sprinting. Once this is achieved, then return to sport-specific activities and training can occur. The athlete must be able to train at 100% intensity with no discomfort during or after activity to be able to return back to sport.
Phase 5 (Prevention – Ongoing)
Once the athlete is back at sport, the goal is to avoid reinjury. The athlete should be set up with an ongoing mobility and strengthening program to prevent another injury.
There are a number of risk factors for hamstring injuries which can be divided into modifiable and non-modifiable.
The ‘non-modifiable’ factors that we can’t change include age and previous injury. Studies have shown that those aged over 25 years had nearly a 20% greater chance of injuring their hamstring compared to those less than 20 years.
The ‘modifiable’ factors, or things that we can change include muscle flexibility, muscle strength of the glutes and hamstrings, sufficient warm-up, fatigue levels and high-speed running loads.
Athletes who return back to sport before completing their rehabilitation are at risk of reinjuring or a more severe muscle strain or other injury.
A basic strengthening program targeted at the hamstring and glute muscles can prevent hamstring injury by up to 65%. One of the best exercises that has been consistently shown to decrease hamstring injury in the nordic hamstring curl. Interestingly, the most effective ways to get rid of constantly tight hamstrings is to perform eccentric loading exercises, such as the nordic hamstring curl.
- Start in a kneeling position with your ankles fixed or with someone holding your ankles down.
- Arms across your chest or arms straight by your side
- Keeping your body in a straight line, start to lower yourself down towards the ground, resisting the fall for as long as possible using your hamstring muscles.
The Nordic Hamstring curl should be started 3 times per week, with only 2 sets of 5 reps. Once this is completed easily, the number of repetitions and sets can be gradually progressed.
Hamstring Exercises for Beginners
Below are some examples of hamstring exercises for beginners that may typically be part of your first 1-2 weeks of rehab. Alternately, these are great exercises for starting to build hamstring strength if you have not done a lot of work in this area before.
The exercises in the initial stages are to help maintain movement through the joints and muscles around the area and start getting a little bit of range and strength back into the hamstring.
Two of the best hamstring exercises are the banded hamstring curl and a double leg glute bridge. Have a look below at the set-ups for these and see how they feel for you!
Single leg Banded Leg Curls
- Lay on your stomach with one end of a band fixed, and the other around your ankle.
- Make sure you keep the other foot on the mat as you bend your knee against the band.
- Your upper body and lower back should stay flat on the ground with only the right leg or the left leg moving at one time.
- Hold up at 90 degrees for a second and slowly return back down to the floor.
- Alternatively, this can also be performed at the gym on a pin-loaded machine.
- Start on your back with your feet flat and hip-width apart and your knees bent.
- Keeping your knees in a straight line, lift your hips up as high as you can, squeezing your glutes at the top.
- Hold position for 1-3 seconds, lower your body back down to the starting position and repeat.
- By digging down through your right and/or your left foot, you should feel your glutes and hamstring muscles start to work.
- If this is simple, you could try to progress by keeping your hands across your chest or by holding one leg up at 90 degrees
- When pain allows, start to add in some light weights and gradually progress them over time. The Romanian Deadlift can be a great addition to any hamstring workout.
- Start by standing up tall, with your feet shoulder-width apart, holding either 2 dumbbells or a barbell.
- With your knees slightly bent, push your hips back and lower the weights towards your feet. Keep the weights close to your legs at all times.
- Push your hips forwards to return to the starting position, squeezing your glutes at the top.
What to remember
- If you have injured your hamstring, it is always best to seek guidance on rehab as soon as possible to make sure you are given a program that is best suited for your level of injury and for your sport.
- Physiotherapy outcomes are about what you do! You could have the best program in the world written for you but if the work doesn’t get done, you don’t get better.
- Take de-loading seriously. Physiotherapists generally don’t enjoy telling someone they can’t play sport or participate in whatever thing it is that gives them joy! We are making this recommendation so you can get back to playing and feeling 100% as soon as possible. If you jump back in too quickly, the more likely the issue isn’t going to be resolved properly and its just going to raise its head again (keeping you out even longer)!
- If prescribed rehab and are receiving ongoing monitoring from a physiotherapist, see it through! When prescribed antibiotics, you finish the whole course even if your symptoms have subsided. Physical therapy is much the same, just because your pain is gone – doesn’t mean the issue is resolved and won’t come back!