Hamstring Injuries, Strains, and Return to Play: What You Need to Know

Hamstring injuries are among the most common soft tissue injuries in athletes, especially in sports requiring sprinting, cutting, or sudden acceleration. Whether you're dealing with a mild strain or a complete avulsion, the right rehab strategy is essential for a safe and lasting return to sport.. njuries Are So Common

Understanding Hamstring Injuries

The hamstring group includes three muscles: the biceps femoris, semimembranosus, and semitendinosus. These muscles cross both the hip and knee, making them vulnerable during high-speed activities.

Common types of injuries:

• Grade I (Mild Strain): Microtears, mild pain, minimal loss of strength.

• Grade II (Moderate Strain): Partial tear, swelling, bruising, and strength loss.

• Grade III (Severe Strain/Avulsion): Full-thickness tear or tendon pulled off bone, often requiring surgical repair.

  
  

There Is No One-Size-Fits-All Treatment

Every hamstring injury is different. What works for one athlete may not work for another. There is no one-size-fits-all treatment for hamstring injuries—rehab must be personalized based on the client’s needs, activity demands, and return-to-play goals. A weekend runner will require a very different plan than a collegiate sprinter or a recreational hiker recovering from surgery.

Personalized care ensures better outcomes, fewer setbacks, and a smoother return to function.

Risk Factors

• Poor eccentric hamstring strength

• Prior hamstring injury

• Limited lumbopelvic stability

• Inadequate warm-up or fatigue

• Sprinting mechanics

Rehab and Return to Sport Principles

Early Phase (Pain Control & Activation)

Goal: Reduce pain, restore muscle activation, and reintroduce load safelyWhen: Acute → sub-acute phase (Grade 1–2 strains, early post-injury)

1. Hamstring Isometric Heel Dig

• How: Lying on your back, knees bent, dig heels into the floor or bench.

• Hold: 20–30 seconds

• Sets/Reps: 4–6 holds

• Why: Reduces pain and restores neural drive without excessive strain.

  
  

2. Bridge Hold (Both Legs)

• How: Lift hips while squeezing glutes, keep ribs down.

• Hold: 20–30 seconds

• Sets: 3–4

• Why: Activates hamstrings and glutes with low stress.

  
  

3. Wall Sit (Hamstring & Quad Isometric)

• How: Stand with your back against a wall. Slide down until your hips and knees are bent to about 60–90 degrees, as if sitting in a chair. Keep your feet hip-width apart and slightly in front of your knees. Gently press your heels into the floor to engage the hamstrings while keeping your back flat against the wall.

• Hold: 20–45 seconds

• Sets: 3–5

• Why: Provides safe, pain-free isometric loading of the hamstrings and quadriceps, helps reduce pain, and improves early strength without excessive muscle lengthening. This makes it an ideal early-phase exercise after a hamstring strain.

Intermediate Phase (Strength & Control)

Goal: Build strength through range, improve pelvic control, and prepare for runningWhen: Pain minimal, able to walk and jog without symptoms

4. Single-Leg Bridge

• How: One foot on floor, opposite leg straight; lift hips evenly.

• Reps: 8–12 per side

• Sets: 3

• Why: Increases unilateral load and pelvic stability.

  
  

5. Hamstring Slider Curls

• How: Heels on sliders/towels, bridge up and slowly slide heels away and back.

• Tempo: 3–4 seconds out

• Reps: 6–10

• Sets: 3

• Why: Introduces eccentric loading — key for hamstring rehab.

  
  

6. Romanian Deadlift (RDL) – Light Load

• How: Slight knee bend, hinge at hips keeping spine neutral.

• Reps: 8–10

• Sets: 3

• Why: Strengthens hamstrings in a lengthened position.

  
  

Advanced Phase (Eccentric Load & Sport Prep)

Goal: Restore high-speed strength, deceleration, and resilienceWhen: Near-full strength, running without pain, good symmetry

7. Nordic Hamstring Curl (Assisted → Full)

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• How: Knees on pad, partner holds ankles, slowly lower body forward.

• Reps: 4–8

• Sets: 2–3

• Why: Gold-standard eccentric exercise for hamstring injury prevention.

  

  

8. Single-Leg RDL (Moderate Load)

• How: One leg stance, hinge while maintaining balance and hip control.

• Reps: 6–8 per side

• Sets: 3

• Why: Mimics sport-specific unilateral demands.

9. Sprint Progression Drills

• Examples:

  • A-skips

  • Sub-max accelerations (60–80%)

• Volume: Short distances, high quality

• Why: Prepares hamstrings for high-speed running demands.

  
  

Programming Guidelines

• Early phase: Daily or every other day

• Intermediate: 3–4x/week

• Advanced: 2–3x/week with adequate recovery

• Progress only if pain ≤ 2/10 and no next-day soreness increase.

  
  

Key Takeaway for Patients

Hamstring rehab isn’t just about stretching — it’s about progressively loading the muscle, especially with eccentric strength, to reduce re-injury risk and support a safe return to sport.

NOTE: Your physical therapist may add more than what was listed here.

Special Consideration: Hamstring Avulsion

In complete proximal avulsions (typically from the ischial tuberosity), surgical reattachment is often indicated. Post-op rehab should be surgeon-guided and involves:

• Protected weight bearing

• Delayed active knee flexion

• Progressive glute and core activation

• Return to sport often occurs between 4–6 months depending on sport demands

Prevention Tips

• Regular eccentric hamstring work (e.g., Nordic curls, Romanian deadlifts)

• Core and pelvic control exercises

• Proper warm-up protocols

• Monitor sprint loads and allow adequate recovery

Conclusion

Hamstring injuries don’t have to be career-limiting. With individualized rehab, progressive loading, and evidence-informed return-to-play testing, athletes can return to full performance—and reduce the risk of re-injury.

If you're recovering from a hamstring injury or want to prevent one, our team at Praxis Physical Therapy is here to provide care that’s tailored to your body, your sport, and your goals.

References

1. Mendiguchia J, Brughelli M. A return-to-sport algorithm for acute hamstring injuries. Phys Ther Sport.2011;12(1):2-14. doi:10.1016/j.ptsp.2010.07.003

2. Schache AG, Dorn TW, Blanch PD, Brown NA, Pandy MG. Mechanics of the human hamstring muscles during sprinting. Med Sci Sports Exerc. 2012;44(4):647-658. doi:10.1249/MSS.0b013e318236a3d2

3. Bourne MN, Timmins RG, Opar DA, et al. An evidence-based framework for strengthening exercises to prevent hamstring injury. Sports Med. 2018;48(2):251-267. doi:10.1007/s40279-017-0796-x

4. van Dyk N, Behan FP, Whiteley R. Including the Nordic hamstring exercise in injury prevention programmes halves the rate of hamstring injuries: a systematic review and meta-analysis. Br J Sports Med. 2019;53(21):1362-1370. doi:10.1136/bjsports-2018-100045

5. Shield AJ, Bourne MN. Hamstring injury prevention practices in elite sport: evidence for eccentric strength vs flexibility. Strength Cond J. 2021;43(1):21-29. doi:10.1519/SSC.0000000000000617

6. Timmins RG, Bourne MN, Shield AJ, et al. Short biceps femoris fascicles and eccentric knee flexor weakness increase the risk of hamstring injury. Br J Sports Med. 2016;50(24):1524-1535. doi:10.1136/bjsports-2015-095362

7. Buckthorpe M, Wright S, Bruce-Low S, et al. Recommendations for hamstring injury prevention in elite football: translating research into practice. Br J Sports Med. 2019;53(7):449-456. doi:10.1136/bjsports-2018-099616

8. Mendiguchia J, Alentorn-Geli E, Brughelli M. Hamstring strain injuries: are we heading in the right direction? Br J Sports Med. 2012;46(2):81-85. doi:10.1136/bjsports-2011-090536

9. Tol JL, Hamilton B, Eirale C, Muxart P, Jacobsen P, Whiteley R. At return to play following hamstring injury the majority of professional football players have residual isokinetic deficits. Br J Sports Med. 2014;48(18):1364-1369. doi:10.1136/bjsports-2013-093016

10. Green B, Bourne MN, van Dyk N, Pizzari T. Recalibrating the risk of hamstring strain injury (HSI): a 2023 systematic review. Sports Med. 2023;53(4):675-695. doi:10.1007/s40279-022-01802-3