28 AUG THE ULTIMATE GUIDE

TO HAMSTRING STRAIN
REHABILITATION
Posted at 18:00h in Exercises, Lower Body, Physical Therapy, Running by zlongdpt 

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A hamstring strain can be one of those stubborn injuries that far too often become recurring
injuries or a more chronic strain. Their high rate of recurrence is often due to a lack of careful
rehabilitation and training following the injury. If you are experiencing chronic hamstring
strains, there is a speci c and well-understood way to begin to exercise the injured body part
and progress back to full athletic participation.

ACUTE PHASE
CONSIDERATIONS: DID YOU
JUST INJURE YOUR
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HAMSTRING OR IS IT
HAMSTRING, OR IS IT
CURRENTLY PAINFUL? 
The rst step in rehabilitating insulted muscle tissue is to nd ways to use this muscle
without causing further injury. Isometric exercise is de ned as a muscular contraction where
the muscle length is not changing. In other words, the muscle is being exed, but it is not
creating any movement. An example of an isometric exercise is showing off your arm
muscles or exing your abs as hard as you can. Isometrics have been shown to help with
pain and are an effective initial way to start exercising after injury. The bridge position is a
good place to start with isometric hamstring exercise.

ISOMETRICS FOR ANALGESIA:

DIRECT LOAD PROGRESSIONS
FOR A HAMSTRING STRAIN 
Isometrics have numerous applications in strength training as well as rehab. They are an
effective way to warm-up and prime muscles for movement as well as decrease sensitivity
and pain after injury. Isometric contractions allow the athlete to recruit a maximal amount of
muscle bers and can help to optimize the nervous system for e cient muscular
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contraction. This process is often called “activating” muscles and is done before strenuous
lifting. In addition to activation, isometric strength training develops strength that is
extremely speci c to the range of motion trained. This can be helpful in training weak points.
l h ld h b f ( ) d dl f
For example, isometric holds in the bottom of a squat (pause squats), or isometric deadlift
holds just above or below your sticking point can help bust plateaus.

In addition to the physiological bene ts of pain relief, the increased neuromuscular

recruitment e ciency, and the practical strength training application of isometrics, they can
be extremely helpful in teaching exercise progression and introducing new movement. For
example, in the bridge progression chart below, you must complete an isometric hold of each
new challenging position before you do it for reps.

During rehab, there might be a session where you do the dynamic movement of one position,
and the isometric holds from the next most challenging position. This is how you can slowly
advance the di culty of rehab. Isometrics allow us to “feel out” new ranges of motion.
They’re helpful for teaching lifting for this same reason as for rehab. They are a useful
method of self-limiting progression to ensure we do not push ourselves too much and take a
step back as well. Isometrics builds the initial strength and comfort in each new range of
motion.

BRIDGE PROGRESSION CHART

Phase 0: 2 feet on the box and at ground → begin to experiment with single leg holds
1st Phase: single leg bridge marching and holds on the box and at ground
2nd Phase: begin to increase bridging distance. Bridge walk-outs start here. Moving the
feet further away makes the bridge more hamstring intensive.
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3rd Phase: bridging on a swiss ball, sliders, slide board, or sorinex roller, 2 feet
4th Phase: able to do all single-leg slider bridges with no pain

Hamstring Rehab: Bridge Progressions

 Hamstring Rehab: Bridge Progressions

Start all new positions with isometric holds, then progress to reps and movement. Build from
2 sets x 5-8 reps to 3 x 10-12 before entering each new phase. Use pain and form as your
guide for progression.

MODIFYING BRIDGES FOR PAIN

Hamstring Rehab: Bridging Modi cations

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If the phase 0 bridge is painful with your hamstring strain, there are a few ways to modify the
exercise and experiment with nding pain free movement. The range of motion can be
altered to reduce the strength of the contraction. Introducing extra isometric resistance in
other planes of movement can help to recruit varied musculature and signi cantly alter pain
sensation. Additionally, there are pelvic and core positioning cues and considerations that
can be used to nd pain free movement. A posteriorly tilted pelvis and exed spine
positioning can effectively shorten the length of the hamstrings and increase contraction
strength. This is one cue that can help to decrease sensitivity during the initial phase and
also train the core to prepare for proper positioning under load later on.

ARE YOU STRETCHING YOUR

HAMSTRINGS TOO MUCH, TOO
SOON?
One very common misconception is that tight feeling muscles need to be stretched. Muscles
can feel tight for a variety of reasons, and it is not always necessary or even bene cial to
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stretch a muscle. Sometimes, it can even be detrimental to its recovery. During most muscle
injuries, the bers or microscopic cells are slightly torn. In extreme cases where bleeding is
excessive, this can be seen in the form of bruising, swelling, and highly sensitized painful
tissue. Insulted tissue responds much better to gentle exercise and movement than it does
vigorous stretching. If this has been your method of relieving pain or rehabbing a hamstring
strain, you are in for a rude awakening.

Stretching a muscle can create a temporary inhibitory effect on its bers, causing the tone of
the muscle to relax and thus allowing for more range of motion. Muscle length is a uid and
dynamic quality that changes based on the status of the nervous system and muscle bers
themselves. For example, if your hamstrings are extremely stiff after a killer deadlift workout,
their bers and cells are highly sensitive and do not want to be tugged on and stretched.
Therefore, your nervous system knows this and disallows intense stretching. Your muscles
did not physically shorten over night, and if worked back into range of motion properly, they
will return to a comfortable resting length once the soreness is resolved.

IS STRETCHING ALWAYS WRONG?

After a hamstring injury, there are some gentle stretching and mobility techniques for the
hamstrings and posterior chain that can be helpful. Some gentle mobility is OK, but this
should not be a rehab focus until basic movements like lunges, squats, and bridges are pain-
free and mobility is seen as a limiting factor. For many, a properly performed lunge or single
leg deadlift is a mobility movement by itself. Make single-leg strength training the priority, not
just stretching.

Here is a video of some gentle stretching techniques that can be used. Incorporating hip
rotation into stretches will ensure the entire hamstring group is stretched equally.
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Hamstring Stretching Alternatives

GOOD PAIN VS BAD. STRETCH
VS. PULL
Hamstring rehabilitation involves feedback and monitoring of pain and feeling in the
hamstring. The more in tune you are with your body, the better your recovery and
rehabilitation will go. It is important, to be honest with yourself and be disciplined here, as it
is human and athletic instinct to want to constantly push yourself. Testing limits is OK and
necessary. It just needs to be done correctly with the proper thinking and feedback
mechanisms.

The goal is to continually add progressions and challenges to the exercises while being able
to distinguish between good pain, working muscles, stretch vs. pull, and bad pain. Good pain
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during a hamstring rehab is a slight stretch or a very small pulling feeling that improves
throughout the exercise or set. Good pain is muscular soreness afterward. Bad pain is a
strong or painful pull, a tug, and any strength of contraction that would not be able to be
tolerated for a 5-10 second hold. If you are working with a patient, come up with some
mutually shared ways to communicate about stretch vs. pain vs. pull, good vs. bad pain, etc.

HAMSTRING STRAIN
EXERCISE PROGRESSIONS
FOR ATHLETES
UNILATERAL EXERCISES
Athletes require more advanced ways to increase the strength of their hamstrings and move
beyond the basic bridge and isometric progressions. Unilateral exercises can teach body
stiffness, core control, balance, and controlled eccentric lengthening along with reciprocal hip
movement. They can be bene cial for all athletes, including barbell lifters. Developing single-
leg strength is markedly different than lifting with both your feet on the ground, it will make
you stronger and more resilient. These exercises are sure to challenge even the healthiest of
hamstrings.

SINGLE-LEG DEADLIFT
The single-leg deadlift should be in everyone’s training program. It’s a key move for
combining hamstring mobility and strength into one movement. All of these exercises can be
progressed with speed as well as weight. Hamstrings are called up on to contract quickly and 
need to be rehabbed accordingly.
 Hamstring Rehab: Single Leg Deadlift Progressions

STANDING BAND PULLDOWN

The band pulldown recreates the cyclical motion of gait with the swing leg. It can hard very
quickly with ample band tension. This exercise also challenges the core and pelvis in a more
generalized way to stay level and not get torqued by the band.

Hamstring Rehab: Band Pulldown Progressions

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SLIDER LUNGES AND FALL OUTS
Lunges involve much more hamstring activity when they’re done with sliders. Like all of these
exercises, increasing the speed makes this signi cantly more challenging to the hamstrings.

Hamstring Rehab: Slide Outs and Sliding Lunge Progressions

BILATERAL EXERCISES
EXERCISE 1: NORDICS
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Nordic hamstring curls (eccentrics & band assisted)

EXERCISE 2: GLUTE HAM
EXERCISE 3: ROMANIAN DEADLIFTS (RDLS)
Barbell RDL's (bilateral and single leg)

At thi i t th thl t h ld b bl t l lifti th t d t t th

At this point, the athlete should be able to resume normal lifting that does not stress the
hamstrings. This exercise list includes a more shallow range of motion squats with forward
knee bend, think of a front squat, or goblet squat. Pushing a sled can also be great during this
time. The concentric work of a marching sled push can be a very effective way to tax the
hamstrings. The hamstrings require a high amount of stiffness to propel the body against a
sled pushing forward. This can also serve as an ongoing assessment tool for physical
readiness. The sled should be taxing but tolerable for hamstrings. Any sort of deadlifting or
posterior chain dominant work should be progressed under the previously stated rules as
well: gradually increasing range of motion, load, and speed.

OTHER FACTORS THAT

INFLUENCE THE HAMSTRINGS
HIP EXTENSION
If we want to explore the “WHY?” question as to hamstring strains, we might want to look at
two different areas: the opposite hip exor and the same side glute. During gait or running, as
the hamstring is lengthened, so is the contralateral hip exor. If you are having recurrent
hamstring issues, you might want to look at the opposite anterior chain. Poor hip extension
on one hip can make hip exion of the opposite hip more di cult, thus affecting the
hamstring.
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To asses hip extension and tight hip exors, we recommend performing the THOMAS TEST.

Here is an example of an active Thomas test that you can do yourself to asses hip exor
mobility and control as well. Use a box or raised bench if you don’t have access to a table.

Active Thomas Test

GLUTE STRENGTH
The glutes and hamstrings play synergistic roles as powerful extensors of the hip. It would
stand to reason that if one glute was weak, for whatever reason, that side hamstring might
have to take on more load. Training hip extension with both glute and hamstring dominant
movements is just as important as training knee exion in the rehab process.

To address glute strength: check out THIS ARTICLE for different exercises to throw into the
mix.
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HIP FLEXION
HIP FLEXION
Lastly, one important test to help look at proper hip function and screen out for future
hamstring issues is the standing hip exion hurdle test. The hurdle test is part of a
movement screen that can be helpful for bringing to light hip pathology or movement de cits
in active exion that might impact gait and running mechanics.

The video below shows three common compensations: trunk side-bending, hip hiking, and
then hip rotation compensations. One thing to notice with the hip rotation de cits is the
concomitant compensations with foot eversion and inversion.

Standing Hurdle Test with Compensations

 
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CORE STRENGTH
Often, we nd individuals with di culty controlling pelvic positions (core stability) will place
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their pelvic in an anteriorly tilted position during athletic movements. Many times, working on
better controlling pelvic positioning can have a great effect on decreasing strain on the
hamstrings. Here are some of our favorites, but you can get creative here!

Psoas March and Variations are great to work the core and hip exor strength
simultaneously with a focus on controlling pelvic positioning.

Psoas March

Dead Bugs and Variations are a killer series of exercises to get your core seriously strong.

Dead Bugs
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Band Pullover Straight Leg Raises are great to stabilize the core/pelvic while taking the
hamstring through its full range of motion.

Band Pullover SLR

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RETURN TO RUNNING
RETURN TO RUNNING
Returning to jogging after a hamstring strain injury usually isn’t too bad. It’s the sprinting and
high-velocity work that is both challenging and daunting. This can be especially true for
athletes who injured their hamstrings running at full speed.

MODIFY GAIT FOR HIGH EFFORT RUNNING (SPRINTING)

There are two ways that I like to modify the running gait during rehab. Running up a hill
effectively shortens the stride length and is a safe way to progress to a 100% effort sprint. I
always recommend starting max-effort running on an incline. The second option is to make
sprints while dragging a light sled. Start around 20% body-weight and work your way down.
Decreasing weight is a progression for sled sprints. With increasing speed, the hamstring will
be contracting faster and moving with a greater range of motion.

Sled Drags for Hamstring Rehab

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Both of these methods reduce stride length and maximum velocity for sprinting. They can
also be helpful for reviewing and teaching sprinting mechanics. An example of how a sled
drag progression might look is to gradually decrease the weight over 3-4 weeks to return
unweighted sprints. With hill sprints, the hill volume can gradually subbed in for at ground
sprinting until the sprinting volume is all on at ground.

Hill Running for Hamstring Rehab

RE-CONDITION WITH TEMPO RUNS AND CROSS-TRAINING

Proper conditioning is critical when returning from hamstring strain injuries. A fatigued
hamstring is a weak one, and this can make it susceptible to re-injury. Conditioning of the 
muscle itself is just as important as the cardiovascular system. The hamstring needs to be
repeatedly conditioned for max velocity running gait. A signi cant part of rehab for high-level
thl t i tti b k th d t i t i hi h l l f f th h t
athletes is getting back the endurance to maintain a high level of performance throughout a
game or practice. It is for this reason that cardiovascular conditioning should be maintained
as much as possible during rehab.

RETURN TO RUNNING
Tempo running and a gradual return to running and practice drills are helpful. Often athletes
want to re-condition by jogging; they’ll go out and run 4 miles in 30 minutes and think they’re
helping their hamstring. Jogging is not su cient. That’s an 8mph pace. During a competitive
event, most high-level athletes (men & women) will be achieving speeds between 14 and 18
mph. Hamstring injuries happen during higher velocity running, and these conditions must be
re-created in rehabilitation to fully prepare the athlete.

During a tempo run, the athlete should be brie y hitting 10-12 mph and should strive for a full
cycling range of motion similar to max velocity running. By the time the athlete is returning to
practice and movement, they should be well-conditioned, extremely in touch with their body,
and constantly self-monitoring to avoid extreme fatigue and scenarios that can potentially
cause a re-injury. Returning from a muscle pull or tear requires self-limiting behavior and
discipline: pain is subjective, and the athlete is the only one that knows how they feel.

One nice way to do tempo runs is on a Woodway curve. The curve gives you a speed reading
and allows you to run as fast as you like and easily accelerate to 10 or 12 mph. If you don’t
have access to this kind of equipment, any eld or open area will do. A normal belt powered
treadmill is not ideal for tempo runs. Using a radar gun to gauge the athlete’s speed and
assign objective numbers is a helpful way to control tempo runs on the eld. 

Woodway Curve Tempo Run

 

THE LAST PART OF

HAMSTRING STRAIN REHAB
This is the hardest part, and it’s where the most injury recurrences and mistakes happen.
Conditioning is extremely important; this non-negotiable. One session with a few 100% effort
sprints at the end does not equate to being physically ready for full game play. This 100%
effort must be sustained for longer and longer each session. Film and slo-mo video can be
helpful here to analyze the running form. Pick one thing to analyze each time you watch and
compare side to side. Look at front-side mechanics: how’s the knee drive? Back-side
mechanics: where does each heel end up, are they getting full extension? This video analysis
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is an objective way to look at the athlete’s physical readiness.

There are some other locomotive ways to challenge the hamstring strain in the last part of
There are some other locomotive ways to challenge the hamstring strain in the last part of
rehab. Bounding running, galloping, and running downhill or Overspeed running will increase
the stretch on the hamstring and potentially expose the injured area. During this last phase of
rehab, you need to expose the injury to ensure it’s strong enough for return to sport.

EXPOSE AND PROTECT

This concept of exposing and protecting the injury is what the entire rehabilitation process is
based on. At rst, we protect while the injury heals, we then expose by strengthening the
insulted tissue. In later rehab, we expose by increase running speeds and introducing new
stimuli, while we simultaneously protect through modi cations like sled drags and hill
running. Expose vs. Protect that is the continuum that all rehabilitation is based on.

ABOUT THE AUTHOR

Dr. Teddy Willsey is a sports medicine physical therapist and performance coach at Healthy
Baller Speed & Performance Center. Healthy Baller is the premier strength and conditioning
and rehabilitation sports medicine center in the Washington D.C. metro area. As a former
high-level powerlifter and strength coach himself, Teddy specializes in bringing strength &
conditioning principles to the rehabilitation world and lling the void that often exists
between therapy and training.

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