Hamstring Rehab Progression

Lets start with the basics- the term “hamstrings” refers to a group of three muscles that run along the back of the thigh- the semimembranosus, semitendinosus, and biceps femoris. As a group, these muscles generally act to extend the hip (bring the thigh backwards in relation to the trunk) and flex the knee (bring the lower leg back and up toward the glutes). Hamstring injuries commonly occur more slowly with overuse, or suddenly with forceful eccentric contraction. (The term “eccentric” contraction means that the muscle is lengthening under load). Common complaints after a hamstring injury can include pain, tightness, increased discomfort with motions that lengthen the hamstring, and walking with a “stiff legged gait”.

In the following few paragraphs, I will walk you through the general progression that I like to use when helping people return to functional and athletic activities after a hamstring injury.

Step 1- Calm down discomfort
This can be done in many ways including:

-Dry Needling
-Body tempering
-Isometric exercises
-Foam rolling
-Soft tissue mobilization

These interventions are useful for decreasing discomfort, and allow for improved activity tolerance for a period of time immediately afterwards. In other words, once pain has decreased, people are typically able to work through a greater range of motion and activate the hamstrings more. Dry needling and body tempering require help from someone that knows what they are doing, like a licensed professional, but soft tissue mobilization, isometric exercises, and foam rolling can easily be done on your own. One thing that I like about using isometric exercises is that they allow you to continue working the hamstrings while also decreasing pain. A couple of the isometric exercises I like to use are listed below. The key with these types of exercises is to hold the desired position for a prolonged period of time, up to 45 seconds if possible.

Isometric long lever bridge

Isometric elevated bridge

Step 2- Bridging

Once pain and discomfort has decreased noticeably, I like to then start working through some modified bridges. Bridging is a good way to start to move the hamstrings a little more while minimizing the lengthening that occurs through the muscles. This is because the knee can be held in a static position while the hamstring muscles are lengthened/shortened across the hip joint. (Only getting stretched at one of the two joints that this muscle group crosses). This is a good way to reintroduce smaller amounts of mobility, especially during a period of time when lengthening the hamstrings might still be irritating. Bridging is usually done to target the glutes, but this exercise can be modified to make the hamstrings pitch in more. To target the hamstrings during this exercise, move your heels out away from the glutes. This takes some of the work off the glutes and shifts it down to the hamstrings.

Long lever bridge to single leg progression

Elevated bridge to single leg progression

Step 3- Lengthening/ mobility work

Once we know that bridges are tolerated well, it’s a good time to try light exercises that will require lengthening of the hamstrings across both the hip and knee joints. These exercises can be easily modified to keep the movement within what feels tolerable. Ideally, you will start to notice decreased discomfort with successive repetitions as the nervous system allows the muscles to lengthen more. A couple of my favorite exercises to accomplish this are listed below.

Banded primer

Hamstring slider

Step 4- Loaded eccentrics.

Once lengthening the hamstring across both the hip and knee is tolerated well, I will then move into eccentric loading of the hamstrings. Here is where you really start to get a lot of bang for your buck, as you start to rebuild the strength and resilience that will help you return to your prior level of function and decrease the risk of future injury. For this, I like to use different hinge movement variations, starting out by drilling proper technique within tolerable/available range of motion, and then progressively loading this movement. Some hinge progressions are shown below

Hinge with dowel
(focusing on proper technique, and maintaining contact at the tailbone, back of the head, and the portion of the spine between the shoulder blades)

Goat Bag Hinge

RDL

Deadlift

SL RDL

Step 5- Plyometrics
Once we know that the hamstrings are strong and tolerate loaded functional movements well, it is time to speed up the movements/rehab exercises performed and introduce more athletic activities. Some of my favorite exercises for this phase of rehab are listed below

Banded KB swing

Russian KB swing

Hamstring slam

Hamstring medball kick

Step 6- Athletic activities
Once plyometric movements are tolerated well, it is now time to start re-introducing more sport specific activities. Activities that fall into this category depend on the person, but include things like sprinting, cutting, and jumping

Important things to keep in mind through the rehab process-

Keep discomfort within tolerance-

Allow discomfort to help guide you throughout this process. Typically, performing exercises that feel tolerable, even if they feel somewhat uncomfortable, will help you

make sure that you are pushing your limits. I typically tell people that “tolerable” discomfort is usually rated as about 3-4/10 pain or below. Pushing your limits in this way will help you do enough to create the adaptations necessary for recovery without flaring up your discomfort. If an activity causes your discomfort to rise above this level, or to a level that you would consider “intolerable” then you should back off. Additionally, I tell people that if their discomfort starts feeling worse with each set/rep, then that specific activity may be too much, and I would recommend modifying the activity if possible. If this is not possible, then they should simply move on to the next exercise they had planned.

Along these same lines, it is important to keep in mind that just because you may be experiencing pain or discomfort, it does not mean that you are causing further tissue damage. This is another reason why I recommend operating within “tolerable discomfort”. For more info on this topic, I recommend reading Dr. Brandon Vaughn’s blog post on our site – “The Pain is in Your Head!” and watching the animated video at the bottom of the post, which can be found here: https://vertexpt.com/2019/09/09/the-pain-is-in-your-head/

RELATIVE rest

The key word here is relative. Rest does not mean sit on the couch until your hamstring feels better. A passive approach to recovery will only cause you to become weaker and more deconditioned, increasing the odds that you suffer another injury. Throughout the rehab process, it is important for people to continue to perform activities that do not increase their discomfort. It is important to prevent a hamstring injury from causing you to become deconditioned or weak in other areas. Because of this, it is crucial that you continue doing things within your normal fitness program or daily life that are tolerated well such as upper body exercises, squats and lunges within a comfortable depth, biking, walking, household responsibilities, yard work etc.

Rate & maintenance of progress

Sometimes within a short period of time, people are able to work from the initial phases of this rehab progression to the later stages very quickly. I commonly see people that are able to work all the way from step 1 to 4 in one PT session. However, this does not mean that 2-3 hours later they will able to get off the couch and pick up where they left off. For a period of time, it will likely be necessary to use pain relieving interventions or lower level activities in order to warm up before more challenging ones. However, as your tolerance to higher-level activity improves, you will likely find that you don’t need to spend as much time on lower level exercises and things aimed toward decreasing pain. Furthermore, it may be a good idea to hold onto the exercises and pain relief strategies that work well for you, and continue to use them as a warm up or recovery tool. Different people will respond differently to various interventions, and take different amounts of time to fully recover. This is due to a number of different factors. Because of this, it is important to stay patient, figure out what works best for you, and continue pushing the limits of what feels tolerable until you are back to 100%.

Questions? Thoughts? Feel free to email me at casey.powers@vertexpt.com

Casey Powers PT, DPT