Hamstring Injury Protocol

Hamstring injuries are very common in athletes and can lead to prolonged time away from sport. Athletes typically describe a sudden onset of sharp, stabbing or twinge-like posterior thigh pain, occasionally an audible ‘pop’ is also report.

Injuries to the hamstrings complex usually occurs in sports that involve sprinting, kicking, or high-speed skilled movements, such as football, rugby, and track. They are also common in sports that involve extensive muscle lengthening-type manoeuvres, such as dancing. Injuries that happen to the hamstrings as a result of a slow stretch type mechanism, initially appear less severe than the sprinting type injury, but usually take longer to rehabilitate and return to sport.

Acute hamstring strain injuries can be classified by severity, pain, weakness and loss of range of motion. Grade 1 injuries are mild with no loss of strength or function, minimal loss of muscle-unit structural integrity, and low-grade inflammation. Grade 2 injuries include partial or incomplete tears and present with moderate loss of strength, muscular swelling and a haematoma. Grade 3 injuries are severe, involve complete tears or rupture and result in significant loss of function. Your Physiotherapist will perform a clinical assessment and give your hamstring injury a grade.

It is difficult to put a timeframe on recovery, however present research has reported several factors that are likely to lead to a prolonged recovery: grade of hamstring injury, proximity of injury to ischial tuberosity (gluteal fold), if the injury involves the proximal free tendon, and increased length and cross-sectional area of the injury.

Approximately one-third of hamstring injuries will recur, with the highest risk for injury recurrence being within the first 2 weeks of return to sport. This high recurrence rate is suggestive of an inadequate rehabilitation program, a premature return to sport, or a combination of both. It is worth noting that should the hamstring injury recur, the second injury is usually more severe than the first, typically requiring a longer time away from sport than the original one. Therefore, it is extremely important to follow the advice of your Physiotherapist.

Progression of hamstring rehabilitation is influenced by multiple factors.  Progression is usually function/goal driven and not time based. This protocol is designed to give you a guide around what functional goals are needed to help achieve a successful return to activity. 

Below is a guideline of the multiple steps involved in navigating a successful hamstring injury rehabilitation with the goals of each outlined below:

  • Phase 1: Acute
  • Phase 2: Control and capacity
  • Phase 3: Strength accumulation
  • Phase 4: Sport preparation
  • Phase 5: Return to play and maintain performance

Acute - Phase 1:

Initial management of a hamstring injury is focused on preventing further injury and creating the optimal environment for healing.

It is common during this initial phase for athletes to shorten their stride during ambulation and they may use crutches for more moderate to severe injuries.

This phase can be quite short, lasting less than week in more minor injuries.

Control and Capacity – Phase 2:

This phase of recovery is focused on early loading of the hamstring complex, targeting both strength and flexibility.

Starting on jogging/running as quickly as possible in rehabilitation is high on the list of priorities for most. It’s rare that we don’t start some form of running within a few days of injury, although it should be noted that with more severe hamstring injuries this running may initially be very slow and is probably more accurately termed a slow shuffle.

From the first day of rehab, it is important that the Physiotherapist considers maintaining load through other key body areas that are required for the athlete, lest you run the risk of deconditioning, for example the adductors of a kicking sport athlete, or the calves of a runner.

Strength Accumulation - Phase 3:

During this phase your Physiotherapist will progress your hamstring strengthening exercises into a prolonged position, and gradually add weight. Askling (2014), showed that loading the hamstrings during extensive lengthening leads to a shorter rehabilitation period, than regular hamstring strengthening exercises. They also showed that these exercises – The Glider, The Diver and The Extender – reduced the rate of reinjury upon return to sport.

Research has also shown that athletes who performed progressive agility alongside trunk stabilisation demonstrated faster return to play and reduced re-injury rates compared to those who solely focused on the hamstring complex. Therefore, your Physiotherapist will incorporate weighted exercises that target the rest of the muscles in the limb.

Sport Preparation Phase – Phase 4:

A progressive return to high-speed running and sprinting is likely the most important aspect of rehabilitation, given that it is fundamental to performance in many sports and is a common way athletes injure their hamstring. When high-speed running and sprinting have been achieved without discomfort, your Physiotherapist will individualise your agility program based on the sport you are returning to. This may include shuttles, direction changes, and sport-specific tasks, for example picking up a ball while running in AFL or running and making a clearing kick in rugby.

Return to Play and Maintain Performance – Phase 5:

Athletes are now well into running, hopping and changing directions in both a controlled unpredictable environment. This phase is about incorporating sport specific chaotic environments and unplanned reactions into rehab and integrating the athlete back into a sport/team environment.

Once you have been given the all clear from the medical team to return to sport it is important to keep fit and maintain your strength.

For more information on the Foundation Clinic Hamstring Protocol email [email protected], or phone 07 579 5601

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