Physiotherapy for Hamstring Strains

Hamstring strains are up there with some of the most frustrating injuries. They are painful at the time, they take time and consistency to rehab, and the biggest thing they are known for is being recurrent. Even despite the millions invested in research we have yet to make much of a dent in knowing why they are so notorious. Currently, we do know a few things, long and strong hamstrings are good, injury prevention programs work, sprinting and Nordics are the best exercises for your hamstrings, and you need to watch your training load. All of these things can help reduce your risk profile of sustaining a hamstring injury. But let’s say you’ve already had one – what is the best pathway for getting back to your peak performance?

 

Active approaches to managing hamstring injuries are the best option rather than passive treatment styles such as relying on hands-on treatment or adjunct therapies such as ultrasound, TENS, or dry needling. They may have their place but not often do I utilise electrotherapies such as TENS or ultrasound, though dry needling can have some very nice effects. In essence, we need to work together as a team to achieve the optimal result, you can achieve more in an exercise program with my hands-on treatment, and you can achieve more on the park if you complete the exercise program.

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What we will discuss:

 

The first thing I will always want to know when someone comes in reporting that they’ve suffered a hamstring strain is “how did it happen?”. Hamstring strains are often split into 2 distinct groups – one who suffers an injury whilst sprinting (soccer, AFL etc), and another who suffers an injury in a stretched position (think dancers, gymnasts etc). Determining this gives us a good starting point of information on what muscles have likely been affected and begins to hint at a potential time to return to sport. 

 

Secondly, I usually like to know what you were feeling in the lead-up to the injury – did your hamstring start to feel tight, fatigued, or heavy, potentially you suffered a cramp just prior to feeling that distinct pulling or pop sensation in the back of your thigh. What this can allow us to do is piece together the puzzle of why you suffered a hamstring strain. Without being able to put these puzzle pieces together we can’t truly develop a complete injury prevention program.

 

In the interest of differential diagnosis, discussing any other potential symptoms such as lower back pain or any pins and needles, numbness, or altered sensation is a necessary discussion. The close proximity of the sciatic nerve means we really do have to rule it out clinically. It is surprisingly common how often I see clients for a 2nd opinion on a hamstring strain that actually has sciatic nerve symptoms. 

 

Last but not least is injury history. I need to know if you’ve suffered a hamstring strain before, and if so how many times and how recently did the last one occur. After that, we’ll discuss what you did in terms of rehabilitation and strengthening work. This gives me an idea of the previous baseline level of your hamstrings. I find a lot of clients often find that once they are back to training they feel they are back to sport and stop progressing from there, unfortunately, you are probably 75% of the way through the journey. Getting back to competitive gameplay requires greater levels of strength, endurance, and mobility of the hamstrings than training. There’s also the matter of developing an ongoing injury prevention program that not only all athletes should be completing, but is vital for those who have suffered a hamstring injury.

What we will assess:

 
Hamstring strains require an in-depth and comprehensive physical assessment to rule out other potential diagnoses and formulate an accurate return to sport timeline. Muscle injuries require three key diagnostic points, pain on contraction of the muscle, pain on stretch, and pain on palpation.
 

Specific muscular tests can be performed to assess both pain production as well as to assess for a client’s confidence to produce muscular force and output. Some clients with low-grade hamstring injuries may be able to confidently perform a maximum contraction in the “mid-range” position where the assessment is typically performed and cleared, but I try to work athletes through range. What this means is I take them into further ranges of hip flexion and knee extension to put further stress upon the hamstrings and pick up some outliers who may not have otherwise been picked up by typical testing procedures. 

 

Muscle length tests typically consist of two assessments, one test performed in mid-range where I extend the knee and assess hamstring flexibility, some clients again may not report symptoms, so for these clients, I will reassess with the same movement but instead, I will take them to a position of maximal hip flexion to add further stress to the hamstring muscle complex. 

 

Palpation is the third key marker, direct palpation of the muscle belly should produce a painful response, as physios what we can do is map this area and determine how large the area of sensitivity is and we can track and monitor this to ensure the area is reducing over time with hands-on treatment and an exercise and rehabilitation program.

 
Other diagnostic tests that will often be used revolve around ruling out sciatic nerve involvement. A passive straight leg raise and a slump test are two of the best assessments for assessing any potential involvement. It’s important to remember that biasing different parts of the neural system could result in the production of symptoms – for example, dorsiflexion of the ankle bias may result in the production of symptoms in some, whereas others may require a hip rotation and adduction bias to reproduce symptoms. A thorough assessment of the lower back including assessment of range of motion and palpation of the lumbar spinal levels to assess for stiffness or tenderness on palpation. 
 
 
There are other potential causes of symptoms, however, a hamstring strain or sciatic nerve/lower back referral are two of the most common diagnoses for pain in the back of the thigh. 
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How we treat it:

 

Treating hamstring strains takes a targeted approach of individualised hands-on treatment and a targeted exercise program to develop the strength and capacity to tolerate the return to sport. Hands-on work is a little contentious in the physio world these days, but I certainly think it still has its place to assist in improving functional capacity and improving your freedom of movement. Often in the early stages, I don’t do a significant amount of work around the hamstring and the injury site, instead, I work a lot on the secondary sites that may either overload due to taking up the slack or tighten up to protect the hamstring. The common areas for these two things are the gluteals, hip flexors, quadriceps, and calves. We can realistically perform near on any soft tissue technique aimed at reducing muscle tone, so this could include massage, trigger point therapy, or dry needling most commonly. Some light soft tissue work around the hamstring can be done in the early stages but if I were to do any work located around that area I tend to opt for dry needling instead in the early stages before transitioning to more hands-on work as we reduce some of the sensitivity. 

 

When we are getting towards the later stages of rehabilitation I find that working the hamstring through range with hands-on techniques can be highly beneficial for improving range of motion and flexibility. Often this involves working on a combination of hip flexion and knee extension together as we work through any soft tissue restrictions utilising hands-on techniques such as massage or dry needling. 

 

In some cases where there may be some sciatic nerve involvement treatment of the lower back may be needed, direct work through the sciatic nerve pathway through the hamstrings, or directly through the gluteals as it travels down towards the hamstrings. Lower back treatment will often revolve around resolving any joint stiffness that may be causing any potential nerve restriction. Work around the sciatic nerve pathway is about reducing any restrictions or muscle tightness that limits the nerve’s ability to glide along. The gluteals are quite a common site for this to occur and are often the cause of sciatic nerve issues in a lot of presentations I see.

Exercise Programming

 

You can get all of the hands-on treatment in the world but it won’t mean you’ll be racing back to the starting team anytime soon if you don’t do your exercise program. Developing load tolerance of your hamstrings through the entire range of motion is necessary for a successful return to sport process. In the early stages of rehabilitation, we will likely be performing isometric loading of the hamstrings or light isotonic work as well as making sure we are keeping the rest of the body in check by working on the calves, quads, glutes, and core. If we neglect everything else, we simply make our return to sport process harder. 

 

As we work through the rehab program we will be wanting to work the hamstring muscles through a further range of motion as well as add in eccentric work. Eccentrics are essential for hamstring rehabilitation these days. You want your hamstrings to be long and strong, and eccentrics are the best way to achieve it. Nordics have been found to be one of the most effective exercises at reducing your risk profile of sustaining a hamstring injury due to their double effect of improving muscle fascicle length and improving strength. Research has been able to find that introducing early eccentric loading, even into tolerable levels of pain, results in a slightly faster return to sports times, and improved measurements at the time of returning to play. Eccentrics don’t appear to be the cure-all we are looking for with hamstrings, but they certainly appear to be a big part of the picture.

 

As with every other injury, keeping everything else surrounding the area strong and stable is necessary. As such we always like to keep the quadriceps, gluteals, calves, and core working well and improving. Just because you have a hamstring strain doesn’t mean you neglect everything else.

 

Last but not least, everyone’s favourite, sprinting. It’s actually one of the best exercises for hamstring strengthening out there showing it has the highest levels of hamstring activity out of typically programmed hamstring exercises. The even better point is it’s incredibly functional. Nearly every person who plays sport has to sprint, and often repeatedly, many times throughout a game. So it both improves hamstring strength, improves tolerance to one of the most common mechanisms for hamstring strains, and makes you a better performing athlete. If only I could find a way to make repeated sprint training enticing and enjoyable for clients.

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Return to Training and Sport

 
Ultimately returning to sports is what every athlete wants when they are rehabbing an injury. But returning to sport needs to be a process that is tailored to the individual athlete. Gone are the days when we just say “Yeah you can go back to training”. Our athletes deserve more time and attention given to a very deliberate process. 
 

Returning to training should be a graded process whereby athletes are gradually exposed to more complex environments and increasing physical demands. Often I find players are able to initiate solo drills relatively early on in their rehabilitation and able to return to light jogging. For example, at the soccer club I work with, athletes will often be performing passing drills and light jogging and potentially light agility work within the first week after injury dependent upon the grade of injury. 

 

From here I will look to progress upon two different streams – the first being individual ball work and skills progressing towards team-based drills, and the second being a fitness, running, and sprinting stream that they will perform individually. Both streams need to be working ideally to optimise the return to sport, if one isn’t completed the athlete will either fall back on their skills, or they will lag behind in their strength and running tolerance rehabilitation work. Often this process will be occurring simultaneously as you progress through your strength training outside of work at training. Athletes are typically able to begin light training when pain on isolated contraction is low, I typically use a 3/10 as a marker, as well as have good mobility and flexibility on a muscle length test. Each athlete needs to progress gradually whilst monitoring symptoms for increases either during or following the session that day or the following morning to assess for signs that you have progressed too quickly.

 

So what does an athlete need to be able to do to return to sport? In my mind, there are a few boxes to tick here. The first and most important is that you have completed at least one full training session, but ideally you should have completed a full week of normal training load of full training with your team. Second is running and sprint loads, have you been able to firstly tick the box of being able to perform repeated sprints, but can you perform as many as other players on the pitch, if you can’t perform at training, you almost certainly won’t be performing at your best on game day. Last but not least is clinical measures, as we’ve mentioned above, long and strong hamstrings are best. Range of motion assessed via a hamstring length test such as a 90/90, an MHFAKE, an ASLR test, or even a combo of the 3 is often the best battery to look at. 

 

The strength I assess in a few different ways, the first is an elevated foot single-leg bridge. The athlete places their foot on my shoulder and places the other leg in the air and has to perform as many reps as possible before fatigue and then we compare to the other side. Next, I will utilise a handheld dynamometer to perform a maximum strength test in two different positions, one with the hamstring in a mid-range position (90deg bend at the hip and 90deg bend at the knee while laying on their back) and one in a lengthened position (neutral hip flat on the bed and 15deg bend at the knee laying on their stomach). We are looking for a maximum contraction where I will look for the athlete to match the force I am putting down before I break it and overcome their force. Until we beat the athlete, we are unable to truly determine what their maximum force production is. What we are looking for with these tests is mostly maximum force production and comparing side to side, but we can also look at hesitancy, whether they cramp more on one side, or does one side take longer to work up to a maximum contraction.

Injury Prevention Program

 
Hamstring strains need some TLC after they have sustained an injury. They are notorious for their risk of reinjury, so what can we do to help you minimise your risk of re-injury? We’ve tailored a hamstring-specific injury prevention program for those of you who have suffered a hamstring strain. I’ve compiled an evidence-based prevention program that I stand by. It is designed as a program that you can utilise as part of your warm-up, with designated areas for running and agility work, as well as strengthening and flexibility components. 
 

Alas, we can’t prevent every single injury, it’s just not realistic, injury prevention programs are all about minimising your risk of injury, whilst simultaneously improving your performance as an athlete.

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Treatment Packages

3 Week Program

Our 3-week program was designed for clients who have suffered an acute injury and want to get out of pain ASAP. Low-grade acute hamstring injuries could respond really well to an intensive 3-week treatment block and can provide significant pain relief and assist in restoring functional capacity. Return to training and play can occur within this time period. Realistically this package is best suited for athletes who are able to walk comfortably within a few days after their injury as the best measure for people to decide on if a 3 or 6-week package may be best suited to them.

 

Our 3-week program is inclusive of the following:

  • 3xweekly 45min physiotherapy consults 
  • $40 equipment allowance for bands, trigger point balls, foam rollers etc.
 
Total cost: $940

Package price: $770

6 Week Program

Our 6-week program is designed for clients who have sustained a higher grade injury, we are looking more at the grade 2 hamstring strain end of the spectrum here. These clients will often have difficulty walking for a few days post-injury and will often have issues going up and down stairs and potentially have some bruising at the injury site. Our 6-week treatment block works to reduce your symptoms and improve your functional capacity, but also specifically dive in and address causative factors such as muscle weaknesses or imbalances, areas of increased stiffness and tightness that may have predisposed you to sustain a hamstring injury.

 

Our 6-week program is inclusive of the following:

  • 2xweekly 45min physiotherapy consults 
  • $80 equipment allowance for bands, trigger point balls, foam rollers etc.
 
Total cost: $1280

Package price: $1050

12 Week Program

Our 12-week program is designed for clients who have sustained a higher-grade injury, we are looking more at the high-grade 2 hamstring strain spectrum. These clients will often have significant difficulty walking for a few days post-injury and will often have issues going up and down stairs and have some bruising at the injury site. Our 12-week treatment block works to reduce your symptoms and improve your functional capacity, but also specifically dive in and address causative factors such as muscle weaknesses or imbalances, areas of increased stiffness and tightness that may have predisposed you to sustain a hamstring injury.

 

Our 12-week program is inclusive of the following:

  • 2xweekly 45min physiotherapy consults 
  • $150 equipment allowance for bands, trigger point balls, foam rollers etc.
 
Total cost: $2550

Package price: $2050

A graph displaying the risk of re-injury following a hamstring strain correlating hamstring length and nordic strength displaying that strong and long is the lowest risk of reinjury

Top 5 Mistakes Clients Make Rehabbing a Hamstring Injury

Hamstring strains cost the sporting community millions of dollars in lost player games year on year, hundreds of researchers worldwide are looking for answers to help reduce the re-injury rates of hamstring injuries. It can be extraordinarily frustrating for players who suffer from repeated hamstring strains search high and low for answers and come up with nothing. I’m not proclaiming to have solved the mystery of hamstring re-injury rates but I think there are a number of key factors that are missed in rehabilitation by clients who I have seen. Here are my top 5 common mistakes I see from clients who have sustained hamstring injuries.

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