Early Hamstring Rehab: Key Strategies for Physios

Hamstring injuries are among the most prevalent and stubborn musculoskeletal injuries in sporting populations. Recurrence is one of the biggest challenges facing physios rehabilitating patients with hamstring injuries; it’s important to get rehab right to reduce the risk and set your patients up for success.

However, not all injuries are the same, and therefore they require a tissue and mechanism-specific approach. This blog outlines some of the expert insights from physio Scott Hulm’s Practical where he shares how he navigates the management of hamstring strain rehab for his patients.

If you’d like to see exactly how expert physio Scott Hulm manages hamstring injuries, watch his full Practical HERE. With Practicals, you can be a fly on the wall and see exactly how top experts assess and treat specific conditions – so you can become a better clinician, faster. Learn more HERE.

First, consider the patient factors

Scott reinforces that to properly rehabilitate a hamstring strain injury and build an effective management plan, you must understand the mechanism of injury and desired return-to-play function. This is where your detailed subjective assessment will come in handy. Was the injury a result of high-speed sprinting or overstretch? Is there tendon involvement, or a complex aponeurotic injury?

By working backward from the athlete’s end goal, whether that’s elite-level sprinting, football or recreational activity, tailoring the rehab approach using tissue-specific principles is key. This means careful selection of exercises, modulation of range of motion, and criteria-led progression based on objective strength and mobility benchmarks.

Early-stage rehab

Early management is integral to set the stage for everything that follows. This phase can often be underutilised, it’s important that physios know how to find the balance between tissue protection and loading. It’s not about resting, it’s about restoring. Here’s a few tips on hitting that right balance:

1. Pain-guided functional thresholds

Scott introduces simple criteria for gauging severity and guiding early loading:

• Time to pain-free walking.
• Ability to cycle at ~150 watts for 20–30 minutes without symptoms.
• Early assessment of hip flexion and knee extension mobility compared to the unaffected limb.

These markers, combined with potential imaging insights where available, help classify injury type and severity, so you can tailor your exercise prescription accordingly.

2. Mobility restoration

Scott advocates for manual therapy to address:

• Neural tension (assessed via straight leg raise, slump test).
• Muscular restrictions surrounding the injury site (e.g., iliopsoas, adductor longus, gluteals).
• Contralateral mobility impairments that may influence pelvic control and hip extension in running.

Combined with carefully loaded active mobility such as knee extenders within pain-limited ROM, these strategies can help the patient restore pain-free mobility in the early stages of rehab.

3. Introduction to load

As early as days 3–7 days post-injury (severity-dependent), Scott begins low-load activation and controlled mechanical stimulation of the healing tissue. He usually starts with hamstring sliders, then once they are able to complete those pain-free, his patients may progress to a more difficult exercise, such as a TRX eccentric knee extension – see Scott demonstrate this in the below video from his Practical:

As Scott explains, the focus here is to restore fascial length, promote early eccentric control, and prepare the athlete for more intense knee-dominant loading tasks later on. The transition from double-leg to single-leg, and eventually to weighted variations, is informed by pain tolerance and functional performance.

It’s also important to rehab hip extension strength in hamstring injuries. For this, Scott’s go-to exercise is the 45° hip extension exercise, starting with double-leg isometrics, and progressively adding ROM, single-leg and weighted variations. See him demonstrate in the below clip from his Practical:

Return to running

As strength, ROM, and tissue resilience are restored, the return-to-run phase begins. But it’s not just about sprinting, it’s about smart, gradual reconditioning and load management. Scott demonstrates an ankle dribble series he starts his athlete’s with, this is a safe and comfortable way for patients to rehearse running cadence and sequencing. This drill enables reintroduction to stiffness in vertical ground reaction forces, and promotes postural control and foot placement for early gait mechanics. See the below video from Scott’s Practical:

Wrapping up

As physios, it’s important to move beyond generic hamstring rehab protocols and apply strategies which reflect the patient’s injury, goals, and individual needs. It’s about balancing protection with early loading, and developing treatment plans which ensure the patient is progressing with the appropriate dosage, timing, and type of exercise to achieve their long-term functional and performance goals.

Want to see exactly how a top hamstring strain injury expert manages his patients? Watch Scott Hulm’s full Practical HERE.