A survival guide to hamstring injuries

Many strength or athletic development coaches aren’t lucky enough to have a physiotherapist working alongside them. That means when an athlete gets injured, someone else has to step up to help. Whether qualified or not, a little knowledge can go a long ways in assisting athletes through sensitive injuries. As both a physiotherapist and a coach, below I hope I can share some things coaches can look for and how they might look to tailor training when it comes to hamstring strains. injuries

A few rules of thumb for hamstring strains

There are some nice rules of thumb we physiotherapists have with regards to prognosis and progression in hamstring strain rehabilitation. In general, if you look out for these signs alone you will be in a much better position to gauge the progression rate of the hamstring strain injuries you see. I have excluded any signs and symptoms that are inconclusively associated with return to play duration.

AreaKey indicators
Mechanism of injurySlow-stretching type injuries (e.g. like those sustained in ballet practice) are associated with longer return to play times when compared to fast-sprinting or position change types seen in sports such as rugby and American Football.
Immediate symptomsPlayers who are able to continue playing after acute onset of pain for more than five minutes tend to have shorter return to play times than those who feel they must stop playing within five minutes of the onset of acute pain.

Those experiencing pain during everyday tasks for more than 3 days will usually have a prolonged recovery time.
The eye testBruising at or near the site of injury is an indication of longer return to play times.
Range of motionPain on trunk flexion and and with active knee extension in sitting are linked with longer time to return to play.
StrengthHand held dynamometer measurement in prone with the knee at 15° flexion has been shown to be related to return to play duration – with the lower relative strength measure indicating longer return to play times.
Location of painPalpation pain is an important feature for diagnostic considerations but less important as a prognostic indicator. Neither the location nor the length of palpation pain is consistently related to recovery time.
Follow up assessmentSeveral assessments combined between initial assessment and 7-day follow up consistently show to be important in guiding us regarding longer or shorter return to play times. The change in strength from initial examination to day 7, the maximum pain reported by the athlete at the time of injury, the presence of pain on performing a single-leg bridge at day 7 and the delay in starting physio/rehab all play their part in informing us about the return to play prognosis.

Our rehab process: the view from 30,000 feet

At our clinic in Dublin, Thomas Divilly and I use a bespoke return to play decision making tool based on this evidence and other practice-based evidence. The first table gives very broad guidelines on what should be covered in each of three levels of rehab. We all have our own preferred means of developing the qualities listed so I won’t go into much detail on exactly what exercises we use. 

Level 1Level 2Level 3
Hamstring range of motionKinetic chain deficits Fast stretch shortening cycle activities
Hamstring local strength Absorption and rate of force developmentSprinting
Pelvic control Sports conditioning Return to training 

While each level has a stated focus, our general approach is that the real focus is all levels is to not get lost so much in the details that we lose sight of the big picture: the athlete has to be prepared for the sport. Therefore in all levels we are working on certain qualities of the return to play picture like shapes, coordination or mobility related to the sport. The only restriction being how much load the injured site itself can tolerate in each level. In other words we must address the site specific limitations while we continue to train for athletic performance in general.

We need some form of decision making process to decide when we progress between levels and these measures below give us a large degree of confidence that the injured tissue is ready to be exposed to higher loads or faster loads. Please note that some of these tests require a hand held dynamometer to measure which not everyone will have access to. Manual muscle testing, while not objective, can give us a sense of the disparity between injured and uninjured side. Manual muscle testing is prone to error and should not be used solely as a decision making tool. 

Level 1:

  • Symmetrical range of motion or <10% difference
  • Inner range hamstring strength asymmetry <10% 
  • Pelvic/trunk control (Physical competence assessment single leg squat)

Level 2:

  • Mid Range hamstring eccentric test asymmetry <10%
  • Single leg strength – single leg squat  (5x 20 1rps 90deg on 1:1)

Level 3:

  • Outer range hand held dynamometer eccentric <10 asymmetry or 30 degree Forcedecks isometric 
  • Askling Test
  • Return to sprinting 
  • Timeline consideration for healing rates 

Progression and adaptability is key

In general during Level 1 it is important to maintain any non-irritable training for the athlete. During this phase, using common sense, we can continue to strength train and cross-train within reason if there is good trust and communication between practitioner and athlete. In place of irritable or potentially irritable exercises we can thread rehab concepts into general strength sessions. For example, in Level 1 we may add some isometric hamstring hip control exercises into a session in place of something like a single leg deadlift. 

Level 2 sees us in a potentially risky period of rehab where it is easy to do too much and set the athlete back. That’s where the progression criteria become very important. During this phase the athlete will be mostly pain free during the majority of their training but remain at risk of reinjury if exposed to too high a force or too rapid a loading. In this phase we tend to add some intensive conditioning on a bike to satisfy some game-related conditioning demands. In this phase we are preparing for higher and more rapid loads so it gives us some time to coach the athlete in the biomechanics of running and landing so that we might buffer the effect of higher and faster forces on the body. 

Level 3 becomes our “test the water” phase. We carefully reintroduce running and change of direction once the progression criteria are met. Here we shouldn’t forget our general progression principles and must be patient not to ramp their sprinting/change of direction loading too quickly with too much volume. 

Final thoughts

Injuries can be intimidating to many coaches. Much of strength and conditioning is measurable, while muscular injuries are often hidden from view. But if you know what to look for you start to get a better picture of what is going on and how to help athletes.

While seemingly very straight forward these tools can give a greater degree of confidence that you are doing the right stuff at the right time in the right amount with your hamstring injured athletes.