Hamstring injuries are among the most common muscular issues athletes face. Despite the abundance of information on prevention, rehabilitation, and training, hamstring problems remain prevalent. If you've been fortunate enough to avoid a hamstring strain, consider yourself lucky. For the rest of us, we know how frustrating and persistent these injuries can be, often sidelining us longer than anticipated.
In this article, we'll explore the journey of an individual who made a rapid recovery from a hamstring strain and successfully returned to compete at a national level. By sharing his experience, I hope to provide valuable insights and strategies for overcoming this challenging injury.
Hamstring injuries are a significant concern in soccer, causing players to miss an average of 15-21 matches per season at the professional level, translating to roughly 90 days of recovery. (1) These injuries are common in activities that involve high-speed running, sprinting, sudden stops and starts, and quick changes of direction. The risk is particularly high during the latter stages of a match when fatigue sets in and muscles are more susceptible to strain. Factors such as inadequate warm-up routines, insufficient strength training, and improper conditioning can further elevate the risk.
Moreover, the nature of the sport itself—with its intense physical demands and frequent bursts of speed—makes hamstring injuries a recurrent issue. Research has shown that previous injuries can significantly increase the likelihood of reinjury, up to 60% in some cases, with peak incidence during the first 3 weeks after return to play. (2) underscoring the importance of comprehensive rehabilitation programs and effective prevention strategies. In addition to physical factors, external elements like the quality of the pitch, weather conditions, and the intensity of the match can influence injury rates. Ensuring proper recovery time and individualized training plans tailored to each player's needs are crucial in mitigating these risks.
The Case Study
Athlete X suffered a hamstring strain during a crucial sprinting moment in a game, diagnosed as a grade 2 proximal hamstring strain by the attending physiotherapist. Following a thorough evaluation of the player's history and the specifics of the injury, I formulated a comprehensive recovery plan designed to progress him through three distinct phases. A pain score indicator was used, on a scale from 1-10 with 10 being the worst possible pain, and 1 being minimal to none. Our goal is to expedite his return to training, ensuring he is ready for the upcoming national tournament his team has qualified for. Given the high risk of re-injury in such cases, our approach prioritizes both the speed of recovery and the athlete's long-term health. The aim is to reintegrate Athlete X into game-like activities efficiently and safely.
Phases of Progression
Phase 1
Goal:
Protect Tissue
Minimize Atrophy
Improve Range of Motion (ROM)
Test & Progress:
Normal Gait, with no pain
Isometrics, with no pain
Knee Flexion at 90 degrees, Manual Strength Test
Phase 1 – The Goal
The goal of phase 1 is to protect the tissue first and foremost. Minimizing any atrophy to the muscle and keeping as well as possibly improving range of motion (ROM). For conditioning purposes, we used a stationary bike, as well as isometric training, which has shown to have recovery benefits.
Phase 1 – Exercises
The initial phase focuses on improving strength and hypertrophy. The goal is to re-strengthen the muscle to handle varying loads in multiple positions. Since the injury is proximal, occurring near the top of the hamstring, the muscle will be under the most strain when lengthened. This suggests that we can train the muscle in its shortened position, working short to long - regarding hamstring muscle length. Isometric (Isos) training, focuses on maintaining a consistent muscle length, this type of training has been shown to aid in enhancing recovery and potentially yielding more significant performance benefits. In this scenario, its primary purpose was for recovery and conditioning. In an isometric exercise, both the agonist and antagonist muscles contract and co-contract, where one muscle must relax while the other one contracts. Speed is the ability to quickly turn muscles on and off, rapidly. It has been suggested that isometric training could be considered velocity training. Athletes can adapt in different positions, as they build fatigue in the iso they are creating a bigger adaptation, thereby better preparing the body for upcoming sessions in phases 2 and 3. Additionally, after reviewing research findings, I decided to introduce a Blood Flow Restriction (BFR) regimen to help the athlete prevent muscle loss and enhance performance, using lighter training loads. I implemented the 30-15-15-15 BFR protocol, using the Dumbbell Romanian Deadlift (DB RDL) exercise. These training sessions were tailored to the athlete's feedback, advancing only when he felt comfortable, with pain levels ideally below 3; typically, he reported experiencing pain levels of 1 or 2.
Here are a few examples of the exercises we did during Phase 1:
Phase 1 – Test & Progress
In order to advance to Phase 2, Athlete X needs to successfully complete all tests, which include demonstrating a normal gait pattern without experiencing any pain. He must also perform the isometric training without pain, pass the Manual Strength Test, achieving strength in a shortened position (90 degrees) with the aim of gradually increasing the length without experiencing any pain.
Link: Manual Strength Test - Hamstring
https://www.youtube.com/watch?v=McKN7iTxUNk&ab_channel=prohealthsysPhase 2
Goal:
Pain-Free – Hamstring Strength
Neuromuscular Control (Trunk) / Balance
Increase Speed and Movement Tasks
Test & Progress:
Full Strength Prone Knee Flexion
Forward and Reverse Running, (No Pain)
Leg Asymmetry Test – Under 15%
Eccentric Strength
Phase 2 – The Goal
The aim of Phase 2 is to advance Athlete X towards achieving complete hamstring strength across all ranges of motion without experiencing any pain. Additionally, there will be a focus on enhancing trunk stability and balance to enhance resilience in the affected area, while also enhancing coordination and the ability to contract and co-contract effectively. In the event of an injury, the brain perceives threats; therefore, by training the injured area, the objective is to communicate to the body that the threat has dissipated, enabling us to gradually increase stress on the tissue in the injured region to promote strength development and eventually improve the ability to engage the muscles at higher speeds, as observed in rapid movements typical of sports.
Phase 2 – The Exercises
The exercises in phase 2 are an extension of the previous phase, particularly focusing on isometric training. We introduced an upper body medicine ball circuit, which served as an effective method to initiate movement, elevate heart rate, raise body temperature, and provide conditioning for an athlete with limitations. Additionally, Athlete X progressed from using the stationary bike to engaging in tempo runs on foot, aiming to enhance multidirectional movement and prepare for simulating sporting movements. Altitude drops were incorporated to help Athlete X adapt to absorbing force at higher loads and gradually increase drop heights, laying the groundwork for basic hopping, jumping, and skipping in phase 3.
Examples:
Phase 2 – Test and Progress
With the enhanced strength and work capacity of Athlete X, he is now ready to assess leg asymmetries using Exsurgo gFlight. Exsurgo Technologies suggests that a 10-15% difference between limbs is considered normal or acceptable for sports performance, based on their analysis of existing literature. (4) The assessment involved a single-leg countermovement jump with hands on hips, results are shown below.
“A large unilateral asymmetry can be detrimental to sport and injury risk. In a study published in the Am. J of Sports Med, researchers found that in 687 soccer players, those with large asymmetries were 4-5x more likely to sustain a hamstring injury. This is important because we know that hamstring injuries are extremely common in sport and ways to prevent them are constantly being explored.”
As we progress to phase 3, Athlete X can now move confidently in all directions, as well as increased eccentric strength, or "breaking power". For testing purposes, using Exsurgo we want to be between 10-15% leg asymmetry. As these metrics are met and improved, we can now begin the transition from general strength to more specific strength and speed training.
Phase 3
Goal:
Symptom Free (No Pain/Tightness)
Normal Eccentric and Concentric Strength – Full ROM
Sport Specific Movements
Test & Progress:
Full Strength (in lengthened state)
Leg asymmetry test (under 10%)
Full ROM (No Pain)
Replicate Sport Movements w/ Confidence
Phase 3 – The Goal
The goal of phase 3 is for Athlete X to be symptom-free, with no pain or tightness in the hamstring. We also want the athlete to have built up his ability to absorb force and handle heavier eccentric loads, so now in this phase, we can start to express the concentric side, creating movement and increasing the rate of force and speed while working toward sport-specific training. The end goal would be to have Athlete X begin to train with the team but limited and with a low training load that can be built up leading to the tournament.
Phase 3 – The Exercises
During phase 3, Athlete X is increasing the intensity of the exercises by incorporating more plyometric movements and introducing sprinting. The sessions began with dynamic movements that seamlessly transitioned into pogo hops, skips, and jumps. The sprinting regimen emphasized acceleration and deceleration, starting with short distances and gradually progressing to longer ones, while also including max velocity training.
Athlete X incorporated tempo runs into his solo training days to enhance his conditioning and boost his high-speed running performance. Tempo runs have shown some potential in aiding the recovery process as well. Upon rejoining his club team for training, he initially focused on lower-intensity sessions and gradually progressed over the following weeks. Throughout all three phases, we consistently monitored his pain levels to identify any trends or changes.
Phase 3 – Test and Progress
During the training process, I incorporated soccer-specific drills that emphasized change of direction and agility. Athlete X achieved his best leg asymmetry score of less than 10%, indicating significant improvement, along with experiencing minimal pain. He demonstrated confidence in performing explosive movements, particularly when subjecting his hamstring to high stress levels.
Although phase 3 has come to an end, the journey is far from over. Sustaining health and match fitness is a continuous endeavor in competitive sports. It is crucial for Athlete X to persist with training, not only to maintain the progress achieved but also to ready his body for the rigors of competing at the national tournament.
Conclusion
In conclusion, the journey of recovering from a hamstring strain underscores the importance of tailored rehabilitation programs for athletes, particularly those preparing for high-level competitions whether it be a league game or national tournament. By following a structured recovery plan with distinct phases focusing on tissue protection, strength development, and sport-specific movements, the athlete in this case study not only overcame the injury but hopefully minimized the risk of re-injury as well. This highlights the critical role of comprehensive rehabilitation and injury prevention strategies in ensuring a safe and successful return to play for athletes with hamstring injuries.
Resources
1. Bisciotti, Gian Nicola et al. “Hamstring Injuries Prevention in Soccer: A Narrative Review of Current Literature.” Joints vol. 7,3 115-126. 25 May. 2020, doi:10.1055/s-0040-1712113
2. Woods, C et al. “The Football Association Medical Research Programme: an audit of injuries in professional football--analysis of hamstring injuries.” British journal of sports medicine vol. 38,1 (2004): 36-41. doi:10.1136/bjsm.2002.002352.
3. Cognetti, Daniel J et al. “Blood Flow Restriction Therapy and Its Use for Rehabilitation and Return to Sport: Physiology, Application, and Guidelines for Implementation.” Arthroscopy, sports medicine, and rehabilitation vol. 4,1 e71-e76. 28 Jan. 2022, doi:10.1016/j.asmr.2021.09.025
4. Bishop, Chris & Read, Paul & Lake, Jason & Chavda, Shyam & Turner, Anthony. (2018). Inter-Limb Asymmetries: Understanding how to Calculate Differences From Bilateral and Unilateral Tests. STRENGTH AND CONDITIONING JOURNAL. 40. 10.1519/SSC.0000000000000371.
About the Author:
Nathan Albright is the owner of XI Sports Performance, where he works with youth, high school, and college-level athletes offering a wide variety of training with various sports, including Soccer, Football, Basketball, Baseball, Volleyball, and more. Nathan has a BSc. in Exercise Kinesiology from the University of Toledo, and currently resides in Northwest Ohio.
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