Special Considerations for Hamstring Rehabilitation

When you think of high level strengthening in physiotherapy – hamstring injuries are likely the first condition to come to mind, and for good reason. Seeing people deadlift hundreds of pounds of weight is not uncommon whereas you’ll never see people do rotator cuff exercises with that same weight. Hamstring injuries are some of the most enjoyable to rehab as:

• Almost all of the ones I’ve treated are in people who are generally pretty healthy, active and fit.
• And they are one of those conditions, particularly when you’re getting an athlete back to sport, where the therapy bridges the gap between rehab and S&C.

That said – hamstring strains and tendinopathies are known for their high likelihood of recurrence (1) and there are some special considerations to their rehab other than “just load it.” The purpose of this article is to discuss those specific considerations. Note that this will focus more on hamstring strains but can largely apply to both strains and tendinopathies.

Before we ‘’sprint’’ into the main content of the article (see what I did there) if you’re interested in this topic, I highly encourage you to check out this masterclass by Dr. Matthew Bourne on Hamstring Strain Injury.

The four main considerations for hamstring rehab are:

1. Load
2. Speed
3. Muscle length and joint angle
4. Adherence

1) Load

In my opinion, one of the main reasons why hamstring strain re-occur is due to not properly loading the client to begin with. Basic bridges and isolated theraband leg curls are all fine and good for gen pop clients, or those who are really deconditioned but if you’re working with someone who is returning to sport or a physically demanding job you will need to push clients harder.

My rule of thumb is that if a person can do their prescribed reps easily (usually 10-15 except for the case of Nordics which are obviously lower) with no more than a small increase in pain that goes away right afterwards – then it’s time to take it up a notch.

Side note: it’s crucial to educate clients as to the rationale for these exercises. Quite often I try to make home exercises as convenient and easy to do as possible – however, there aren’t many hamstring exercises that can be done that will load someone enough to help them withstand the demands of their activity. On Day 1 I have the discussion with clients that with hamstring injuries (especially for people with high activity demands) there are a much smaller number of exercises that are clinically effective.

I cover a few higher level home exercises (among others) in this video:

2) Speed

The most common injury mechanism that people associate with hamstring strains is sprinting at full speed.

A commonly missed part of rehabilitating the hamstring is preparing the athlete for the speed demands of his or her activity. This applies to both strengthening AND sprinting.

With regards to strengthening – eccentric strengthening is popular and for good reason given its effects on flexibility (2), hypertrophy and injury prevention.

What gets forgotten about is the speed of the concentric. This is something to consider with other areas as well as it’s not uncommon for people to “go through the motions” during rehab exercises which, admittedly, can get a bit boring and repetitive after a while. In these cases I cue people to go up as explosively as possible and slowly on the way down to get the best of both worlds. Quite often I’ll keep these exercises in the 3-5 set and 3-5 rep ranges.

This is best often applied to exercises such as romanian or stiff-leg deadlifts, conventional (not as much sumo) deadlifts, rack/block pulls, and kettlebell swings.

With regards to speed the two main tips I have are:

1. Don’t rush back into full sprinting right away: I usually like to have people start with Charlie Francis’ influenced tempo runs at a perceived 60-70% of maximal speed (or 6-7/10 RPE). Then build up speed by about 10 percent at a time once they can do 10 or more “sprints” painfree. Once getting back into near full speed (85% plus), rest really needs to increase – I like the rule of 30s or more rest per 10m of sprinting.
2. Progress sprinting (and volume) slowly: I generally like the acute:chronic workload ratio guidance that Tim Gabbett recommends (3) or the 10-20% per week rule – but every client tolerates volume increases differently.

3) Muscle length and joint angle

Some research recently in rugby players (4) has shown that injuries don’t just occur during sprints but during tackles and other positions where the leg is in an extended position and the leg being turned away from the body.

As such, I tend to focus on exercises that put the hamstrings in a more lengthened position.

Examples of each category are:

• Hip extension – lengthened position: stiff legged deadlift, long lever bridge with legs straight – all can be done double or single leg
• Knee flexion: unilateral leg curl, 2-up-1-down leg curl, nordics (can be assisted with a ball or reverse band)
• Combined hip extension and knee flexion: bridge and leg curl with a stability ball, valslides, furniture sliders, or foam roller; glute ham raise

Combined hip extension and knee flexion: bridge and leg curl with a stability ball, valslides, furniture sliders, or foam roller; glute ham raise

1. Powerblocks or Bowflex dumbbells – these are a bit bulky, and at first seem expensive, but are far less costly and space consuming than having a whole bunch of individually paired dumbbells.
2. Strength training bands and Resistance tubing – these are portable and relatively inexpensive for home exercise programs.

4) Adherence

One of the tricky things with exercise in general is adherence. This becomes an even bigger problem with hamstring specific rehab as those injuries, particularly for athletes, require a harder and heavier form of loading. It can become even more problematic as clients lose the desire to continue them as they recover.

Hamstring exercises in general can be known for having a lower rate of adherence – particularly the dreaded and revered Nordic in recent research (5).

Some strategies I use to help for adherence are

• Really emphasizing and hammering the point of doing the exercises to not only rehabilitate the issue but to minimize (you can never prevent) recurrence.
• Understanding the minimums: I’d rather have clients do more than the bare minimum – but I’d also rather see a client do something rather than nothing. We know that:
  • For injury risk reduction 1-2 sets of 2-4 Nordic reps 1-2 times per week is the minimum (5)
  • And for general strength improvement (as a disclaimer this is in healthy people) 4 sets per body part per week is the minimum (6)

So if you work with that in mind, it can be much easier to help facilitate effective rehab and adherence both short and long term.

Wrapping up

I hope this piece has given you some things to think about and some ways to up your game when doing hamstring rehab with your clients. If you found this useful, you will love this masterclass by Dr. Matthew Bourne on Hamstring Strain Injury.

As always – thanks for reading!