Pulled your hamstring? Whether it happened sprinting, lifting, or slowly over time, proper rehab is the key to avoiding setbacks and returning stronger. At Vertex PT Specialists, we treat hamstring injuries every week at our clinics in Columbia, Cayce, and Irmo—from first-time strains to chronic tendon pain that hasn’t responded to rest.
In this post, we’ll walk you through the exact rehab progression we use in the clinic, with video demonstrations, pain guidelines, and return-to-sport benchmarks.
What Are the Hamstrings?
The hamstrings are a group of three muscles on the back of your thigh:
- Semimembranosus
- Semitendinosus
- Biceps femoris
They help extend the hip and flex the knee. Hamstring injuries typically happen due to eccentric overload (lengthening under tension), especially during sprinting, deceleration, or high-speed lifting.
Common symptoms:
- Sudden pain or “pulling” sensation in the back of the thigh
- Tightness, swelling, or bruising
- Pain with stretching or walking
- Stiff-legged gait
The 6-Phase Rehab Progression We Use at Vertex PT
Step 1: Calm Down the Pain
Goal: Reduce discomfort to improve movement and re-engage the muscle.
Interventions may include:
- Dry needling
- Body tempering
- Soft tissue mobilization
- Foam rolling
- Isometric exercises
Isometric holds are one of the best ways to decrease pain and keep the muscle engaged. Here are two you can try:
Isometric long lever bridge
Isometric elevated bridge
Step 2: Bridging Progressions
Once pain improves, we progress to bridging to reintroduce movement without over-lengthening the hamstrings. These build foundational strength across the hip joint without stressing the knee.
Key tip: Move your heels away from your glutes to shift the load to the hamstrings.
Long Lever Bridge to Single Leg Progression
Elevated Bridge to Single Leg Progression
Step 3: Controlled Lengthening & Mobility Work
At this stage, we add exercises that lengthen the hamstrings across both the hip and knee—but in a safe, graded way. Start light, and use reps to build tolerance.
Banded Primer
Hamstring Slider
Step 4: Loaded Eccentrics
This is where real progress happens. Eccentric loading helps rebuild strength and reduce reinjury risk. We teach and load proper hinge mechanics, progressing from bodyweight to heavy compound lifts.
Progressions include:
- Hinge with Dowel (drill technique)
- Goat Bag Hinge
- RDL
- Deadlift
- Single-Leg RDL
Goat Bag Hinge
RDL
Deadlift
SL RDL
Step 5: Plyometrics
Once eccentric loading is tolerated, we increase the speed and reactivity of the hamstring. This is essential for return to sprinting, cutting, or lifting explosively.
Examples:
- Banded Kettlebell Swing
- Russian Kettlebell Swing
- Hamstring Slam
- Hamstring Med Ball Kick
Banded KB swing
Russian KB swing
Hamstring slam
Hamstring Med Ball Kick
Step 6: Sport-Specific Activities
Depending on your goals, we reintroduce:
- Sprinting mechanics
- Agility and change of direction
- Jumping and cutting drills
- Advanced deceleration work
Key Tips for a Full Recovery
Pain Should Be Tolerable—Not Zero
A little discomfort is okay. We aim for pain 3–4/10 or less, and use that to guide loading. If pain increases with each rep or set, modify or regress the movement.
Don’t Rest Completely—Use Relative Rest
Rest doesn’t mean stop training. We encourage patients to stay active with:
- Upper body training
- Cycling
- Squats/lunges within tolerable range
- Daily activity and walking
Avoiding deconditioning is critical to a strong return.
Progress Isn’t Always Linear
You might fly through phases 1–4 in one session, but need to back off the next day. That’s normal. Hold onto the drills that work for you and continue using them for warm-ups and recovery, even after you’re “cleared.”
Every hamstring recovers on its own timeline.
Hamstring Physical Therapy in Columbia, Irmo, and Cayce SC
We treat hamstring strains, chronic tendinopathies, and high-level athletic injuries at all three of our Midlands locations. Every session is 1-on-1 with a Doctor of Physical Therapy—no techs, no fluff.
Ready to Start Real Hamstring Rehab?
Don’t settle for passive care and cookie-cutter plans. Get personalized physical therapy with real results.
Contact Us to schedule an appointment today.
Blood Flow Restriction (BFR) Training has been one of the most important recent additions to the worlds of orthopedics and sports rehab.
How It Works
By partially restricting arterial (“fresh”) blood flow to a working muscle, we can restrict the amount of oxygen available to that muscle. Exercise in an anaerobic environment (“lacking oxygen”) forces the muscle to produce higher amounts of lactic acid. We can “trick” the muscle into thinking it is working hard, giving you that deep high-intensity workout burn, while only doing very easy exercise. That build-up of lactic acid causes not only causes increased muscle fiber recruitment, but also causes the body to increase production of Growth Hormone (GH), and subsequently Insulin-Like Growth Factor 1 (IGF-1). These 2 hormones are extremely beneficial for rehab. Growth Hormone increases collagen synthesis throughout the body, which is a clear advantage when rehabbing an injured tendon or ligament. With larger, stronger tendons, it also doesn’t hurt to have larger, stronger muscles – IGF-1 has been known as a major driver of muscular hypertrophy.
They physiologic gains don’t stop there! Myostatin is a gene in the body that limits muscle growth. (Myo = Muscle, Statin = Stays the same). By downregulating the myostatin gene, BFRT can help the body grow more muscle, which is very important during rehab from some injuries and surgeries.
Why it is Relevant
There are 3 different types of muscle fibers in skeletal muscle:
- Type I, which are aerobic, slow twitch and low-force producing. Think “endurance” fibers that are small, but long-lasting.
- Type II X, which are anaerobic, fast-twitch and high-force producing. Think “explosive fibers” that are large, strong, and get tired quickly.
- Type II A, which are somewhere in between. They are fast-twitch, but medium-force producing and partially aerobic (though exhaust faster than Type I fibers).
Type I fibers are utilized for most of the low intensity things you do during daily life. You don’t need to access Type II fibers until you are doing high intensity sprints or heavy lifting. Using BFR allows us to access the Type II fibers during light activities, which directly leads to increased muscle strength and hypertrophy despite not being able to load the muscle adequately (due to pain, post-operative status, etc.). This will expedite the rehab from orthopedic surgeries, and will also help maintain muscle mass while dealing with various overuse injuries.
A study performed by Park et al. in 2010 showed that walking with blood flow restriction applied to the legs led to an 11% improvement in in VO2 Max over just 6 weeks. This experiment was done on Division II Basketball players, not un-trained individuals. This has major implications for endurance athletes rehabbing an over-use injury – keeping a high level of cardiovascular function during times of limited capacity is crucial for returning to peak performance.
Blood Flow Restriction cannot (and should not) replace heavy loading during rehab, but can act as an intermediary supplement with similar effects until heavy loading can be safely performed.
The last article post focused on building mental resilience. Now, let’s move on to physical resilience. Similar to our inability to internally withstand life’s stressors, physical injuries are basically the body’s inability to handle the external stress applied to it. Sometimes, injuries are sudden traumatic events like being in a car accident and will occur regardless of physical capacity. However, most physical ailments can be prevented if the person has the capacity to withstand the stress. For example, a stronger ankle will be more likely to avoid rolling when stepping awkwardly off the curb. An experienced runner will be able to withstand an acute increase in running mileage versus a novice runner. A mom who can lift and carry 150 pounds will be able to repeatedly pick up their 30 pound kid without excessively straining their physical system versus the mom who can only lift and carry 35 pounds. In order to reduce injury risk, your body must have more physical capacity to withstand the stresses applied to it. Makes sense, right?
So, how do we build physical resilience? The same way as mental resilience… by consistently stressing the physical system enough to challenge it without significantly overloading it. Avoiding physical strain and underloading the system does not challenge the body; therefore, the body does not have any stress to adapt to. Actually, avoiding physically demanding activities and living a more sedentary lifestyle will decrease physical resilience. However, when engaged in a physical training program, it is also important to not constantly overstrain/overtrain the system. Smart programming incorporates recovery periods to allow trained muscles, tendons, joints, bones, etc. to rest, rebuild, and adapt. This recovery is key to allowing the body to become stronger and, therefore, more physically resilient in the long term.
There are many ways to gauge how hard you are pushing yourself. And nowadays, there are a plethora of gadgets to monitor all sorts of data like heart rate, heart rate variability, recovery, sleep, and more. Having a gadget is nice but not necessary as research shows perceived exertion to be pretty reliable as well. For example, the Borg Scale of Perceived Exertion is a 6-20 scale where 6 is how you feel resting and 20 is extreme max effort. The numbers correlate with heart rate (6 with 60 beats per minute, 20 with 200 beats per minute). So, if you are doing aerobic/cardio training, you can wear a monitor or simply use this scale to see how hard you are pushing yourself. A useful tool for weight training is Reps In Reserve (RIR) where you perform enough repetitions to tax the system without going to complete exhaustion or muscle failure. For most people, I recommend performing sets where you complete as many reps as you can but quit when you feel you only have 1-3 reps left “in the tank”. This is the point where you struggle with the weight but not going to complete failure. This is applicable for muscle endurance, strength, and hypertrophy training. The last tool is another scale applicable to any training (cardio, strengthening, mixed) and is a simple 0-10 Rate of Perceived Exertion (RPE). If you find yourself always below a 7 out of 10, then you are unlikely applying enough stress to your system to build resilience. If you are always pushing yourself at 9 or 10, you may be applying too much strain. Though challenging, the goal is to find a good balance of tough workouts but allowing yourself to recover. I recommend an average of 7-8 RPE over the course of a week where some workouts may be a little lighter and some more strenuous.
Alright, the topic of resilience is clearly important to me and I could go on and on about this. However, we’ll leave it at that for now. To wrap this up, I’ll leave you with another quote. This one is from Mark Rippetoe, a well-known strength and conditioning coach. I feel this quote applies to both mental/emotional strength and actual physical strength:
“Strong people are harder to kill than weak people, and more useful in general.”
If you were to sit and watch a mass of runners going by at the local 5k race, you will see all sorts of varying running forms, techniques, and movement strategies. Noticeable differences include varying head positions, arm swings, elbow angles, spinal postures, hip movements, knee drives, stride lengths, and step cadences. A largely debated topic is landing mechanics, specifically if it’s a running sin or not to heel strike (land heel first). My goal with this article is to discuss the differences in foot landing positions as well as give my opinion as a runner and physical therapist on the subject.
The heel strike landing pattern (also referred to as rearfoot strike (RFS)) became a more widely-accepted and adopted technique with the creation of the cushioned running shoe. Prior to shoe companies adding extra cushion under the heel, it was near impossible for someone to consistently heel strike for miles and miles without crushing their calcaneus (heel bone) into oblivion. Therefore, most (if not all) runners “back in the day” were midfoot or forefoot strikers, allowing the soft tissue structures of the feet and legs to absorb more of the load. Many advocate a midfoot or forefoot landing pattern now since it is more “natural” when not influenced by the modern advancement of the cushioned running shoe.
So what’s the big deal between strike patterns? Great question!
Heel striking is exactly as it sounds and occurs when the runner lands heel first (usually on the outer heel) with their ankle flexed and toes up. Most runners nowadays are heel strikers. The benefits of heel striking include the naturalness of it for most runners (especially novice) and the decreased soft tissue strain when compared to the other landing types. However, heel striking increases the amount of force experienced by the leg bones, hips, and knees because the foot and ankle is unable to absorb some of the load like with midfoot and forefoot runners. Though the max peak force experienced is similar between the different landing patterns, heel strikers typically experience more overall forces due to 1) an increased initial peak force with landing (see image below), and 2) increased contact time with the ground required to go from landing to push off. The increased force exposure and absorption may increase a heel strike runner’s risk for general joint pains and boney stress injuries compared to forefoot and midfoot runners.
Midfoot striking occurs when a runner lands flat footed with relatively equal distribution of weight throughout the foot while forefoot runners land more on the ball of their foot. These landing patterns are commonly described as more natural styles of running because running barefoot would likely require adopting one of these landing patterns to help distribute the landing forces. Unlike with heel striking, the foot and ankle are able to absorb much of the force, reducing the forces experienced in the leg bones and joints proximal to the ankle. Additionally, these landing patterns usually result in a quicker step cadence, resulting in an overall decreased contact time with the ground. Though there may be reduced stress to the leg bones and joint structures, there is oftentimes increased strain to the soft tissues, especially those in the foot and lower leg. This is why runners transitioning from heel striking to midfoot/forefoot landing are advised to transition slowly. These runners do not experience the same initial contact peak force as heel strikers do; however, the max experienced force is relatively the same.
Source: https://www.researchgate.net/publication/319104024_Common_Running_Overuse_Injuries_and_Prevention
So, is one landing pattern better than the others? Well, it depends on who you ask. Below is this runner’s and physical therapist’s opinion.
If you have ever tried changing your own landing pattern or tried teaching someone else, it is extremely challenging and frustrating for all parties involved. It can be awkward for the runner and can take months to master a new running technique while slowing ramping up mileage to avoid overuse injuries. Plus, many runners cannot accurately identify their own landing patterns (many think they are midfoot/forefoot runners but on video analysis are actually heel striking). Therefore, I do not believe changing the strike pattern is necessary for most runners as there are other components of the running that may be easier to modify with bigger results: foot placement and stride cadence.
A common issue associated with heel striking is overstriding, meaning the landing foot is hitting the ground ahead of the runner. It’s hard to do so when landing midfoot or forefoot. The further out front the foot lands, the harder the impact typically experienced through the leg. Additionally, the foot will spend more time in contact with the ground as it becomes the supporting post for the body transitioning over into the next step. In general, increased time with an external force can increase injury risk. Also, when the foot lands ahead of the body, it creates a temporary braking force. Newton’s Law of Physics states a force will create an equal and opposite force, so a foot landing out in front will create an impact force right back at the runner. If the goal is to keep moving forward, eliminating opposing backward forces would be good, right? If a runner can decrease their stride length so that the foot lands more under their body instead of outfront, it can significantly reduce the overall force absorbed, decrease contact time with the ground, and reduce/eliminate the backward impulse generated.
Source: https://groups.google.com/forum/#!topic/just-south/KdopHHtEU2o
Increasing stride cadence (step frequency) is another fairly easy modification a runner can make to reduce strain and improve running efficiency. Given a set overall speed/pace, the runner with a slower cadence must have a longer stride length than a runner with a quicker cadence. This longer stride increases ground contact time and forces the body has to absorb. Purposefully increasing stride frequency helps reduce stride length and improves foot landing placement, resulting in a more efficient motion (less braking forces) and decreased load. I recommend a cadence of 160-180 steps per minute. If your cadence is significantly lower than this, do not immediately increase your step frequency to match it. Start by increasing your current step frequency by 10% and gradually increase as you get more comfortable with a quicker yet shorter step. I heard from a buddy once that a runner should pretend to be a ninja trying to sneak up on someone (think quick and quiet feet!).
In summary, there are many variances to running form and technique with arguably the most disputed being foot strike pattern. To me, there are pros and cons of each. However, I feel adjusting foot landing placement and stride cadence are more beneficial (and easier) than adjusting foot strike. By focusing on landing more under the body and quickly transitioning into the next step, a runner will likely be more successful in reducing overload forces, improving efficiency, and reducing injury risk. If constantly dealing with overuse running injuries or feeling inefficient with running, try modify one or both of these instead of focusing on how your foot is landing!
Shameless Plug: Having pain with running and issues with modifying running mechanics, come see us at Vertex PT Specialists to have one of our trained therapists evaluate your running form, help address any physical impairments you may have, and get you back to running sooner!
It seemed like for a while the biggest fitness craze was core stability training with every fitness and rehab guru flooding the internet and social media with exercises using every combination of positions, movements, and equipment possible. I’m sure I saw someone doing quadruped bird dogs with ankle/wrist weights with a resistance band pulling them one way while maintaining balance on a BOSU ball that a buddy was unpredictably tapping to create perturbations on an unstable service. Yeah, exercises like that can be effective and meet the intent, but it doesn’t need to be that complicated. Additionally, oftentimes such exercises can be too challenging and complex for the “Average Joe”. In this article, we’ll dive into a simple way to progress trunk and core stability exercises. But first, let us quickly dive into a quick anatomy review and the why behind the importance of maintaining a strong trunk.
The trunk musculature can be divided into two categories based on their primary function: movers and stabilizers (note: each trunk muscle can have both a mover and stabilizer function but has a primary role of one over the other). The movers are the bigger muscles located more externally and primarily work to move the body in different directions. This includes the abdominals (flex the spine), paraspinals (extend the spine), and the obliques (side bend and rotate the spine). Stabilizers are deeper and function to maintain a spinal trunk position at rest and during movement. These include the transverse abdominis (TrA), quadratus lumborum (QL), and the lumbar multifidi (LM) muscles.
When looking at the trunk and reviewing its function, it helps to view the entire system as a three-dimensional cylinder around the spine and guts. The abs and anterior portion of the TrA comprise the front of the cylinder, the obliques with the lateral TrA fibers make up the outer walls, and the LM and paraspinals solidify the backside. Like a soda can, this cylinder also has a top (diaphragm) and a bottom (pelvic floor musculature). A healthy and properly functioning cylinder will be able to generate pressure against all walls within it, locking down and stabilizing the trunk during exertion (like the stiffness of a full unopened soda can). A poorly pressured cylinder will not be as strong and stiff (like the walls of an empty opened can). Now, the cylinder does not need to be fully pressurized all day, everyday but only when needed to complete the task. And the amount of pressure generated can and should be based on the demand. For example, generating 100% pressure and stiffness is needed for a max deadlift effort but not for picking up an empty laundry basket. Having an appropriately pressurized cylinder will reduce injury risk by maintaining proper mechanics and evenly distributing the force to the right load-bearing structures.
Now, how do we initiate a trunk strengthening program correctly with a good progression? There are certainly different strategies and approaches out there. For the most part, there isn’t a necessarily “right” or “wrong” way as long as the exercise and dosing is appropriate for the person. For example, it may not be a good idea to perform heavy deadlifts right away for a deconditioned individual with acute low back pain. I personally view trunk strengthening progression as a three phase process:
Phase 1: Isometric holds maintaining a static position for a designated period of time, starting with a shorter time then increasing duration to build endurance and confidence. Examples include front planks, side planks, and back bridges.
Phase 2: Build off the isometric holds from Phase 1 by incorporating an unweighted or minimally resisted dynamic limb movement. The purpose is to train the trunk to remain stable and strong while moving the arms and legs. Examples include bird dogs, dead bugs, and rolling planks.
Phase 3: This phase is where I introduce more dynamic movements and heavier loads to challenge the trunk strength and endurance. These are oftentimes referred to as more “functional” exercises as they replicate natural movements and carry over to tasks we commonly perform during the day. With these exercises, the trunk is usually not the primary focus or working muscle group but serves more of a supporting role (but extremely important, nonetheless!). Examples include kettlebell swings, deadlifts, and weighted carries.
Check out the videos below for examples of this outlined progression for the lateral and posterior trunk musculature.
As you can see, phasing a trunk strengthening program like above helps progressively build up the trunk strength and endurance appropriately. It doesn’t seem smart to overload a patient or client with heavy deadlifts if they aren’t able to hold a basic unweighted back bridge for more than ten seconds, right? Overloading a patient or client too soon without the proper baseline strength and endurance will increase injury risk, aggravate an existing injury, create frustration, and/or compromise trust with the provider/trainer. Let’s train and rehab smarter!
This isn’t rocket science but hopefully seeing a phased trunk strengthening progression is beneficial for you. The goal is to start small and progressively build strength and confidence while keeping it simple!
So, your knee is starting to give you a little trouble when you squat. Many times, people come to us having been told they need to stop squatting and rest it, or that “squatting is bad for your knees, you should never go that low.” And don’t get me started on the “knees shouldn’t go past your toes” myth… All of this couldn’t be further from the truth! If your healthcare provider is telling you otherwise, it’s time to find someone else. A big part of getting you back to 100% is volume management. This means your recent squat volume may have been a little too much for your tissues to handle and we need to take some time to calm them down and build them back up. But in the meantime, we can still find ways to get after it in the gym!
An experienced PT will not only assess your knee and design an appropriate loading program, but evaluate your squat mechanics, make future programming recommendations, and most importantly, find a way to keep you moving! Our goal with physical therapy is not about telling you what you CAN’T do, but helping you figure out what you CAN do. Rather than telling you to stop squatting, we work with each patient to figure out a squat variation that allows them to continue moving without increasing their symptoms. This could simply be moving them toward a more hip dominant squat to decrease the demand on the knees.
An easy rule of thumb is to move across the squat continuum to variations that utilize a more vertical shin. For example, if you’re having symptoms when you front squat, try a high bar back squat. When the load moves from the front rack to the upper back, the torso angle changes and the squat becomes more hip dominant vs ankle/knee dominant. Having an issue with high bar back squats? Try a low bar variation, or try box squats. This will let you really load the hips and keep your shins more vertical. From there we can keep adjusting by increasing the height of the box, decreasing range of motion to further remove the demand on the knees. There is a variation out there that will let you keep squatting, you just have to find it!
Over time, as the specific interventions for the knee continue to progress, we can gradually work back into the variation of the squat that was causing symptoms. Your rehab should be an active process, and there is no reason you can’t keep squatting!
Have questions? Send us a message at josh@vertexpt.com
