Hamstring Muscle Strain

Authors
Affiliations

Nate Yomogida, PT, DPT

Doctor of Physical Therapy

B.S. in Kinesiology

Chloë Kerstein, PT, DPT

Doctor of Physical Therapy

B.A. in Neuroscience

APTA current concepts

Stage Goals Intervention Criteria for advancement
Acute phase
  • Pain and edema management
  • Prevent development of tissue adhesions
  • Limit atrophy and strength deficits
  • Limit flexibility and ROM deficits
  • Normalize gait pattern
  • Relative rest and avoidance of aggravating activities
  • Ice, compression, local electrophysical agents as indicated
  • Soft tissue mobilization
  • Active ROM and submaximal strengthening
  • Gait training
  • Symmetrical passive and active hip and knee ROM
  • Normal gait pattern
  • No reactive pain or symptoms with prescribed therapeutic exercises
Intermediate phase
  • Increase strength and muscular endurance
  • Regain preinjury flexibility
  • Restore lumbopelvic stability
  • Improve lower extremity neuromuscular control
  • Progress lower extremity and lumbopelvic strengthening
  • End-range & eccentric strength exercises
  • Stretching & flexibility exercises
  • Low intensity cardiovascular endurance exercises
  • Single leg balance and neuromuscular control exercises
  • Symmetrical flexibility and muscle length
  • Symmetrical hamstring strength
  • Adequate neuromuscular control
  • Symmetrical jogging (if appropriate) pattern without reactive pain
Late phase
  • Return to all desired activities including sports or heavy manual labor
  • Restore general and muscular endurance necessary for sport or other activity demands
  • Identify and address modifiable factors for reinjury
  • Strength and flexibility exercise progression
  • Emphasize lengthened state, eccentric strength, and higher velocity movements
  • Progress balance and neuromuscular control exercises
  • Perturbation training and reactive tasks
  • Sport-specific or work simulation training
  • Plyometric and agility exercises as appropriate
  • Full and pain-free hamstring strength at all muscle lengths
  • Demonstrate tolerance to all sport or work specific tasks
  • No apprehension on H-test if patient anticipates returning to high level sport participation

Early phase

  • Reduce pain

  • Reduce edema

  • Protect further damage by minimizing load

  • Minimize atrophy

  • 3-4 Days of immobilization

  • Excessive mobilization can cause excessive scar formation

  • Use crutches

AD usage

  • Use if ambulation exacerbates pain
  • Foot flat > toe-touch or NWB

Limit Atrophy

  • Low-intensity & Pain-free ROM

  • Avoid isoalted hamstring exercises

  • Hip AROM

  • Knee AROM

  • Submaximal pain-free hamstring isometrics

  • Transverse Abdominis activation

  • Low-resistance stationary bicycling

  • Side-stepping

Progression Criteria

  • Normal gait pattern
  • Full hip A/PROM
  • Full knee A/PROM
  • Pain-free submaximal hamstring contraction

Intermediate phase

Goal: Progressive and restoration

  • Increase LE strength
  • Regain pre-injury muscular length
  • Improve lumbopelvic stability
  • Restore neuromuscular control

Stretching

Avoid Stretching

  • Significantly weak muscles
  • The muscle may be unable to protect itself

Eccentric strengthening

Criteria:

  • Good tolerance to rehabilitative exercises
  • >50% contralateral strength

Eccentric is important for rehabilitation and prevention

  • a 10-week eccentric hamstring strengthening program reduced 1st time injuries and recurrent injuries by ~85%1

Lumbopelvic stability should be included prior to sport-specific training

Sport-specific training

  • No proximal stability deficits

Late Stage

Criteria

  • Tolerance to all current therapeutic activities
  • Symmetrical hamstring flexibility
  • 5/5 manual muscle testing grade or 90% involved versus noninvolved side instrumented strength testing for hamstring muscle
  • No obvious balance deficits
  • No obvious neuromuscular control deficits
  • Ability to jog forward and backward at greater than 50% effort without symptoms

Gradually expose individual to sport/preinjury activities

Goals:

  • Muscle flexibility
  • Strength
  • Neuromuscular control
  • Endurance

Strength

  • Eccentric focus
    • increasing ROM
    • resistance
    • volume
  • Deadlifts
  • Single-leg Romanian Deadlifts
  • Nordic Hamstring Curls

Nordic hamstring curl

Van der horst found that nordic hamstring curls decreased rate of hamstring injuries in amateur soccer players1

References

1.
APTA. Current Concepts of Orthopaedic Physical Therapy. 5th ed.; 2024.

Citation

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