Hamstring Strain: Prevention & Rehabilitation (Part 6)

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Guest blog by Paul Head

Paul holds a BSc Sports Therapy degree from University of Central Lancashire (UCLAN) and is a pre reg physiotherapy student. He received first Class Honours Classification (78% average) and  an award for Academic Excellence in the field of sports therapy / physiotherapy from DJO UK. Find out more about Paul here…

Physiowizz will continue to support and encourage CPD of students. If you feel your article is of good quality, evidence based and would be suitable for our public blog please send it to nicole@physiowizz.co.uk to help increase promotion of your personal blog.  Please include the following statement “I am happy for my blog to be reproduced on a physiotherapy learning site for educational purposes.”


The results of intervention studies (Arnason et al., 2008; Askline et al, 2013; Sherry and Best, 2004) and one randomised controlled trial (van Mechelen et al., 1993) question whether flexibility reduces hamstring injuries. A non-randomised intervention involving contract-relax hamstring stretches in elite Scandinavian soccer teams failed to reduce injury rates which were statistically indistinguishable from those of teams that declined to follow the program (Arnason et al., 2008). In a randomised comparison of two rehabilitation programs, Sherry and Best (2004) compared a progressive agility and trunk stabilisation approach to one that involved isolated strengthening and stretching of injured muscles. The strengthening and stretching was particularly ineffective as it resulted in significantly more injuries in the 1 year follow-up period than the alternative program. In Askling et al (2013) study they found that there C protocol which included contract relax stretching showed increased re injury rates when compared to their L protocol that involved no static stretching.

However in Malliaropoulos et al (2004) study they investigated the effect of the stretching component of rehabilitation in 80 athletes who had sustained acute hamstring injury. Their study compared two rehabilitation programmes in which the only difference was the number of stretches performed. Each stretching session consisted of a static stretch to mild discomfort applied to the hamstrings for 30 seconds and repeated four times. One of the groups had one session per day while the other group had four stretching sessions per day. The results showed that the group that performed four stretching sessions per day regained their range of motion more quickly and had a shorter rehabilitation period, with both differences being statistically significant.

Castellote-Caballero et al (2012) showed that a neural mobilization slider technique on the sciatic nerve was effective in significantly improving passive SLR range of motion after only a week which included 3 sessions, in 14 football players. The subjects sat with their trunk in thoracic flexion (slump) and while maintaining that posture, they performed alternating movements of knee extension/ankle dorsiflexion with cervical extension, and knee flexion/ankle plantar flexion with cervical flexion. Subjects performed these active movements for approximately 60 s and repeated them 5 times.  Neurodynamic slider technique could perhaps be more effective at reducing injury rates than static stretching due to 16% of hamstring injuries showing no signs of muscle damage on MRI (Mendiguchia et al, 2012).

Return to Play

With signs of damage on MRI still being shown after full rehabilitation programs and no signs of symptoms on clinical examination it seems important to utilize progressive running sessions into rehab to assess how the hamstrings are functioning and also whether people are able to return to sport. Progressive running programs were utilized in Slider et al, (2013) study which is shown in the table below.


Acceleration Distance (m)

Constant Speed 75% of Max (m)

Deceleration distance (m)

























When the subjects were able to complete a level 3 times pain free they were progressed to the next level. This programme tests out the hamstrings when they are most vulnerable to injury during acceleration and deceleration in high speed running.

Another way of doing this could be to the subject run 90 metres with the first 30 m being acceleration, middle 30 m being constant speed and final 30 m to deceleration. The acceleration and deceleration distances can then be reduced and constant speed distance being increased keeping the exercise to 90m long to progress the exercise, this is utilized by THFC.

A test devised by Askling called the Askling H test involves performing a SLR with the knee kept in full extension and ballistic hip flexion is performed. If the subject showed signs of pain or lack of subjective confidence when performing the test it was positive. It was utilized in their 2013 study where if the test was positive rehab was continued for another 5 days. This could have contributed to their low re injury rates, which could suggest that this test should be utilized when determining whether a player is fully able to return to sport.


Hamstring strains are still very prevalent and a massive problem to people participating in sport. However in recent years promising research has been shown to be effective in reducing hamstring strain injury and re injury rates. It seems to suggest that the most effective rehabilitation and prevention protocols include eccentric training with trunk musculature training included instead of concentric and stretching training. In this piece I’ve included some of the exercises that were in the most successful protocols along with progressive running drills and a progressive nordic hamstring exercise protocol for the prevention of hamstring strains.  I hope you have enjoyed reading this and comments about your experiences with hamstring strains and rehab protocols would be very welcome. With thanks to Tim Campkin: @timcampkin89 for being my model in the pictures and Paul Starrs: @starrs89 for his input.



Reference List

Arnason, A., Andersen, T.E., Holme, I., Engebretsen, L. and Bahr, R. 2008. Prevention of hamstring strains inelite soccer: an intervention study. Scand J Med Sci Sports, 18(1):40–8.

Askling, C.M., Tengvar, M. and Thorstensson, A. 2013. Acute hamstring injuries in Swedish elite football: a prospective randomised controlled clinical trial comparing two rehabilitation protocols. Br J Sports Med, 00:1–8.

Brughelli, M. and Cronin, J. 2008. Preventing Hamstring Injuries in Sport. Strength and Conditioning Journal, 30 (1), 55-64.

Brughelli, M., Nosaka, K. and Cronin, J. Application of eccentric exercise on an Australian Rules football player with recurrent hamstring injuries. Physical Therapy in Sport10, 75–80.

Castellote-Caballero, Y., Valenza, M.C., Martín, L.M., Martos, I.C., Puentedura, E.J. and Fernández-de-las-Peñas, C. 2012. Effects of a neurodynamic sliding technique on hamstring flexibility in healthy male soccer players. A pilot study. Physical therapy in sport, 1 (7).

Malliaropoulos, N., Papalexandris, S. and Papalada, A. 2004. The role of stretching in rehabilitation of hamstring injuries: 80 athletes follow up. Medicine Science Sports and Exercise36:756-759.

Mjølsnes, R., Arnason, A. and Østhagen, T. 2004. A 10-week randomized trial comparing eccentric vs. concentric hamstring strength training in welltrained soccer players. Scand J Med Sci Sports, 14:311–17.

Mueller-Wohlfahrt, H.W., Haensel, L., Mithoefer, K., Ekstrand, J., English, B., McNally, S., Orchard, J., van Dijk, C.N., Kerkhoffs, G.M., Schamasch, P., Blottner, D., Swaerd, L., Goedhart, E. and Ueblacker, P. 2013. Terminology and classification of muscle injuries in sport: The munich consensus statement. Br J Sports Med,  47(6):342-50.

Petersen, J., Thorborg, K. and Nielsen, M.B. Preventive effect of eccentric training on acute hamstring injuries in men’s soccer: a cluster randomized controlled trial. Am J Sports Med39:2296–303.

Sherry, M.A. and Best, T.M. 2004. A comparison of 2 rehabilitation programs in the treatment of acute hamstring strains. J Orthop Sports Phys Ther34(3):116–25.

Slider, A., Sherry, M.A., Sanfilippo, J., Tuite, M.J., Hetzel, S.J. and Heiderscheit, B.C. 2013. Clinical and Morphological Changes Following 2 Rehabilitation Programs for Acute Hamstring Strain Injuries: A Randomized Clinical Trial.

Thorborg, K. 2012. Why hamstring eccentrics are hamstring essentials. Br J Sports Med46, 7.


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