Hamstring Strain Rehab

Tony Comella

March 19, 2023

Fourteen days after sustaining a mild hamstring strain, I was back to playing basketball. The purpose of this blog is to share with you my experience and rehab plan so that maybe one day, it can help you with your injury.

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Hamstring Strain Rehab Overview

The goal for my hamstring rehab was to follow 5 main principles:

1. Start early.

There are multiple studies showing that starting within one week is not only safe but can also have similar return to sport times and reinjury rates compared to a delayed start.

2. Return to high-speed running.

My injury, like most hamstring strains, occurred during sprinting, therefore, as Hickey et al in 2022 state “returning to high-speed running is arguably the most important aspect of rehabilitation given that it is fundamental to performance in many sports….”

I followed their 3-stage progressive protocol which gradually introduced increases in running intensity. I will expand on this more in a bit.

3. Emphasize hamstring strength.

In order to address common deficits seen after a hamstring strain and adequately prepare for the demands of sprinting, hamstring-specific exercises are equally as important.

These exercises focused on (1) eccentric knee flexor strength and (2) hip extensor strength at moderate to long muscle lengths. There are multiple options for both, but I chose to incorporate a hamstring slider and roman chair progression.

4. Allow pain during rehab.

Hickey et al in 2020 had one group of athletes with acute hamstring strains perform and progress exercises completely pain-free, while another group was allowed to perform and progress exercises up to a 4/10 pain. There were 3 major takeaways from this study:

Both groups had similar return to sport timelines.
Both groups had the same number of injuries 6 months later.
The pain threshold group had greater recovery of certain strength attributes and better maintenance of hamstring muscle structure than the pain-free group.

For my rehab, I followed their guidelines: I performed and progressed exercises with a 4 out of 10 pain or less.

**5. Return to basketball after meeting certain criteria.**

I used three different studies to help set 5 criteria:

No pain when pressing on the muscle.
No pain during strength exercises.
Similar eccentric knee flexor strength as the uninjured side.
Hamstring flexibility within 90% of the uninjured side and pain-free.
The ability to sprint at 100% effort without apprehension and without experiencing any pain during or after.

My Hamstring Strain Rehab

Here is a general overview of my rehab based on the previously mentioned principles.

Injury

My hamstring strain occurred while sprinting during a basketball game. I experienced immediate discomfort in the back of my right thigh, and could not walk without a limp for the first few hours. However, by the next day, I was walking normally with minimal pain.

Hamstring Exercises

On days 2, 4, 7, and 10, I performed 2 hamstring exercises.

These both followed a 3-level progression:

For the hamstring sliders, I started with double leg eccentric. Once I could perform 3 sets of 12 reps through my full range of motion with a 4/10 pain or less, I progressed to level 2: single leg eccentric. If I could perform 3 sets of 8 reps on each side following the same criteria, I progressed to a single leg slider for 3-4 sets of 4-8 reps on each side.

For the roman chair hip extension, level 1 was a double leg variation for 3 sets of 12 reps; level 2 was a single leg variation for 3 sets of 8 reps on each leg; and level 3 involved adding weight for 3-4 sets of 6-10 reps on each side.

Over the course of 2 weeks, I was able to progress through these levels without any major issues. Once I reached level 3, I continued to progress by increasing the number of repetitions.

Running Protocol

On days 4, 6, 9, and 11, I performed the running protocol.

Here is a general overview of how it works:

Once I could walk with less than 4 out of 10 pain, I could start the first stage.
Stage 1 begins with a slow jog for 20 meters, then increases speed up to about 50% of maximal velocity for 60 meters, then returns back to a slow jog for 20 meters. Once I could complete 3 repetitions at 50% of maximal speed within the pain threshold, I could progress to the next stage.
Stage 2 builds up to a moderate speed for 30 meters, then increases speed up to 80% of maximal velocity for 50 meters, before slowing back down again. Once I could complete 3 repetitions at 80% of maximal speed without pain, I could progress to the final stage.
Stage 3 involved slowly building up to maximal sprinting speed in 5% increments, over a distance of roughly 40 meters.

Based on the recommendations from a couple of studies, I gave myself a limit of 9 total repetitions on a given day in order to manage my high-speed running volume.

Over the course of 2 weeks, here is how I progressed:

On day 4, I completed stage 1 and attempted stage 2. However, pain prevented me from ramping up to 80% of my maximal speed.

On day 6, I was able to complete stage 2 and start stage 3, where I successfully completed 3 sets at 85% and 3 sets at 90% max speed without pain.

Then, on day 9, I ran at 95% and 100% speed pain-free for 3 repetitions each.

Even though I had already completed the last stage, on day 11, I sprinted at 100% intensity again but decided to increase the volume to 6 repetitions.

Return to Sport

At this point, I had met all return to sport criteria, so on day 14, 2 weeks after my initial injury, I returned to playing basketball.

Additional Information for Hamstring Strain Rehab

Since that was a very brief overview of my recovery, I also want to provide 8 additional considerations for hamstring rehab:

1. Pain.

I chose to perform and progress exercises with 4 out of 10 pain or less, but you can do these exercises with less or no pain and likely still achieve similar outcomes.

2. Hamstring Exercises.

Sliders and the roman chair progressions are just some options. For knee flexion, you could also perform the nordic hamstring exercise or hamstring curls on a machine.

For hip extension, other options include an RDL, single-leg RDL, or long lever bridge.

Regardless of exercise choice, just remember that your focus should be on building eccentric knee flexor strength and hip extensor strength at moderate to long muscle lengths.

3. General Lower Body Strength.

In addition to the hamstring exercises, I also performed squats, split squats, and calf raises since they target other muscles that are important for running and sport. Depending on your goals, you may also want to include these or other similar movements.

4. Hamstring Flexibility.

In most cases, your range of motion will recover independently, especially because you are strengthening the hamstrings through your full range of motion. However, if you want to include additional exercises, you could do leg swings, inchworms, alternating knee extensions, or other movements. Whether you do these on their own or as part of your warm-up, I highly recommend you perform these within a tolerable range of motion.

5. Aerobic Conditioning.

In addition to the running protocol, I also included lower-intensity, long-distance runs and rode a stationary bike about once a week in order to help maintain my cardiovascular fitness.

6. Upper Body Training.

Even though you injured your hamstring, you should still consider training your upper body. Not only does it have physical benefits, but if you have a more severe injury and are limited in your training early, this can help you mentally.

7. Imaging.

An MRI has not been shown to have additional value over clinical examination when predicting the time to return to sport or hamstring re-injury. It might be used in some situations, however, for most people, rehab is going to be primarily dictated by symptoms and function, not imaging results.

8. Return To Sport.

I waited 2 days before starting rehab and I was able to progress back to my desired sport in only 2 weeks. Based on the severity of your injury, symptoms, goals, sport, etc., your timeline may be different. For example, if you have a severe strain with increased symptoms, it may take you longer to start exercising.

It is also important to understand that full return to sport should be viewed as a continuum. It may take you 2 weeks – or several months – to gradually build up the volume and intensity of your training until you are back at your preinjury level or higher.

Lastly, even after you return back to your sport, you should continue performing the hamstring exercises in order to help reduce your risk of re-injury. If needed, you can reduce your training volume while maintaining a high intensity and likely still maintain desired muscle adaptations.

Hamstring Strain Rehab Summary

To summarize, this is what my rehab program looked like following a mild hamstring strain:

I started hamstring strength exercises within 2 days and I was running by day 4. Over the next 10 days, I performed and progressed these exercises and increased my running speed while staying within a certain pain threshold. Only after I met certain criteria did I return back to playing basketball, which was 14 days after my initial injury.

At the time of this blog’s release, it has been about a month since I returned to sport. Even though I am almost back at 100% of my preinjury level, I still perform the exercises 2-3 days a week and will likely continue doing so indefinitely.