Case Study – Hamstring Tear Rehabilitation Physiotherapy

hamstring tear physiotherapist sydney

Hamstring tear physiotherapy.

Case study by Sydney sports physio, Chris El-Hayek.

The following case study is an overview of the assessment and rehabilitation of a patient following a hamstring injury they sustained in a football match. The purpose of this case study is to highlight the level of detail required to prepare athlete’s physically for returning to their sport confident and pain free. Ongoing assessment and rehabilitation progressions are crucial to reduce the risk of re injury, and for athletes to be physically prepared for the demands of their sport. 

How do hamstring tear injuries happen?

Hamstring strains are one of the most common injuries that occurs in competitive sport. They often occur with high-speed running, or with excessive stretch/lengthening at the hamstring muscle. ¹

Hamstring injuries are complex, and have a very high re-injury rate of 22-34%. Re injury most commonly occurs in the first 1-2 weeks on returning to sport.² Hamstring injuries constitute 24% of all injuries in male professional footballers³ and rates have recently increased, showing the need for individualised rehab, close workload monitoring and particular caution being a necessity when clearing athlete’s to return to sport.  

In this particular case, ‘Patient A’ who has been de-identified for confidentiality, presented to physiotherapy 2 days post injury to the medial (inside) aspect of their hamstring. Patient A is a 15-year-old male, semi-professional footballer. 1 week prior to this, they had been suffering from serious cramping in their calves, quad, and hamstring after an increase in workload which had them playing 2 soccer matches in a day. Increased muscle soreness is a risk factor for muscle injury and unfortunately this was the fate of the patient in their football game. Although most of their muscle soreness from previous cramping had recovered, they still had some residual soreness in the inside of their right hamstring. Early into their match, they sprinted after the ball and felt a sharp pull in their hamstring which immediately forced them out of play. 

The patient presented to physiotherapy 2 days following the injury. This case study will outline the assessment and rehab process on a week-to-week basis back until the point where they were cleared for return to play with no restrictions.  

Hamstring tear rehabilitation program. 

DAY 2

Physiotherapy Initial Assessment

  • Tenderness on palpation over a length of 10cm and width of 4cm at the mid to distal portion of the semimbranosus (inside hamstring muscle). Most painful point reaches 6/10 when palpated. 
  • On straight leg raise, pain increases as muscle is further stretched 
  • No swelling 
  • On resisted knee flexion (prone – patient lying on stomach) pain reaching no greater than 3-4/10 on various degrees of flexion 
  • Pain reaches 4-5/10 when hinging at hips 
  • Able to do 2 leg bridges and squats on own with no pain 
  • Unable to do a resisted single leg bridge on my shoulder due to pain 
hamstring tear rehab physiotherapy
Hamstring tear diagnosis: High grade 1 to low grade 2 Semimembranosus strain.

Exercises Prescribed

  • Range of Motion – knee flexions lying on back/stomach 
  • Strength – bridges, squats, hip strengthening with resistance band, and core strengthening 

Advice

Continue wearing compression over area to reduce any swelling, avoid use of anti inflammatories and icing to reduce risk of delaying muscle healing. 

Patient was referred for MRI to further determine classification of muscle injury as either;  

  • Type A (Myofascial): Tissue healing time up to 3 weeks 
  • Type B (Musculotendinous): Tissue Healing time 4-8 weeks 
  • Type C (Tendinous): Tissue healing time 2-4 months 

hamstring tear rehabilitation physiotherapy

DAY 5

An important consideration in slightly delaying the MRI, was that radiologists may prefer doing the MRI at least 48-72 hours after the injury. If the imaging is done too soon the imaging may be effected due to increased bleeding/signal. This of course is very dependent on the type of injury, imaging required, and a few other factors, so is best left to the medical specialists involved to decide what is best for the patient.   

The MRI was completed on day 5, with the report confirming a grade 1/2 musculotendinous (type B) injury over a length of 10cm to the semimembranosus. 

Based on the patient’s presentation, and MRI results, a joint discussion with them determined that if their rehabilitation was thorough, and they were able to commit to it, their targets/goals would be as follows: 

  • Week 3: Return to non-contact training with team 
  • Week 4: Return to full-contact training with team 
  • Week 5: Play in semi-finals on reduced minutes 
  • Week 6: Play ¾ of grand finals if making it  
  • Week 6+: Participate in weeklong National Youth Championships with careful consideration of minutes depending on match importance, and presentation of symptoms  

hamstring tear treatment

DAY 12

As the patient was progressing extremely well with their strength and range of motion exercises, pain free, the rehabilitation progressed to more on field, running based activities. 

Having base line measurements is a critical part of return to play considerations, and rehabilitation goals. Fortunately, patient A had seen me earlier in the year to complete some sprint testing prior to their season. The results could be used as a performance benchmark to indicate if they were at baseline again. 

Pre-Injury Sprint Test Results (earlier in year)

  • 20m Sprint – 3.35 seconds
  • 40m Sprint – 5.68 seconds
  • Max speed – 32.33kmph

Important Consideration

When rehabilitating a hamstring injury, strength and range of motion is of course crucial to encourage quality tissue healing and movement, however what is important to note, is that nothing works the hamstrings more than sprinting. 

Therefore, at some stage, the patient needs to be sprinting, at max speed, and it should be tracked to see if they are reaching high speeds, and if they are able to repetitively. If they aren’t, then they should not be cleared to return to play, and this is potentially the downfall to a lot of athlete’s rehab, and where their re injury risk increases significantly. 

Structure of Field Rehab Session #1

NOTE: Not all exercises have been included, but this is a general outline of the structure followed to gradually expose the patient to relevant running, strength, landing, and strength-based movements of their sport, with exposure to multi directional planes of movement. The exercises are specific to the patient’s stage of healing, and presentation of symptoms through ongoing assessment. This structure forms the foundation of their ongoing rehab, and the speed, volume, and intensity of all gym and field sessions should progress accordingly. 

hamstring tear exercises 1

Pre-Hab Exercises 

  • Strength:  Bird dogs, squats & Copenhagen’s (not shown), hip flexions, single leg bridges, reverse Nordic curls, knee flexions, walking lunges, single leg squats, single leg hip hinges. 
  • Mobility: Hamstring extenders & straight leg raises.
  • Core:  Superman planks & side planks + leg raises 

Running / Mobility Drills 

    • Speed/Postural Drills: Ankle Pops, A skips, B skips, D skips
    • Multi-Directional Movements: Side steps and jogging backwards (not shown)
    • Mobility: Hamstring scoop variations, open/close the gate, knee pull to chest (not shown), jogging and touching floor (not shown)
    • Plyometrics + Ball Work: Exercises are not at maximal intensity, and aimed to re-introduce patient to multi directional movements and higher loading with and without the ball in a non-reactive environment. The exercises included mini hurdle jumps (not shown), ladder combinations (not shown), and light dribbling in and out of cones. All exercises were pain free for the patient.
    • Aerobic Capacity: Within these runs, the repetitions need to be completed in 15 seconds, then the patient has 15 seconds rest before going again. The aim of these short interval aerobic runs was to expose patient to slightly higher speed running, and improve their overall endurance.  Poor aerobic conditioning, and increased fatigue increases the risk of muscle injury.4

Being conditioned enough to maintain a certain level of performance without breakdown of technique is crucial.  Therefore, training aerobic capacity should be incorporated within not only rehab, but training in general to reduce the likelihood of injury occurring from the mentioned risk factors.

hamstring tear exercises 2

Aerobic Capacity
15 seconds on, 15 seconds off

  •  Set 1: 55m x 10 reps
  • 2 mins rest
  • Set 2: 60m x 10 reps 

HAMSTRING REHAB SESSION SUMMARY 

hamstring tear physio sydney results 1

Important Considerations for Patient

  • Has not decelerated yet 
  • Has only ran at 64.8% max speed 
  • Only achieved 20m of high-speed running (HSR) which is any distance over 19.8 kmph.

DAY 14 

Patient given home exercises over weekend, including static stretching, self-massage. These were advised so patient can build confidence in stretching to end range positions, and knowing that pressure application would be pain free to build confidence. 

It was also advised that the patient increased the loading of their strength exercises for squats, Romanian deadlifts, and hip thrusts. 

DAY 17

Pre-Hab Exercises 

Similar to day 12, with some exercises loading hamstrings more, and incorporating more plyometric exercises.

  • Added exercises: jump lunges, Nordic curls,
  • Running/Mobility Drills: Similar exercises to day 12, with some exercises added being more plyometric/explosive and multi directional in nature.
  • Speed/Postural Drills: Added exercise – high knees (shown below), C skips, straight leg marches
  • Multi-Directional Movements: Exercises added – Forward/backward shuffles, karaoke
  • Mobility: Same as day 12, encouraged to increase range of motion
  • Landing: Skater hop variations & mini jump for header
  • Ball Work + Change of Directions: Exercises now incorporating more change of directions and agility-based movements with and without ball. Exercises include cutting around cones/poles, forwards/backwards turns (shuttle runs), and free-range dribbling with small accelerations out.

hamstring tear exercises

High Speed Running Exposure

  • 3x10m (60-65% max speed)
  • 3x20m (65-70% max speed) 
  • 3x30m (70-80% max speed) 
  • 1x40m (80% max speed) 

As mentioned previously, high speed running is one of the most important factors with hamstring injuries that needs to be rehabilitated properly. The patient’s max speed, and high-speed distances were both being increased week by week to better prepare them for the demands of their sport, level, and position on the field. 

Being an attacking fullback, the patient covered high distances in their speed and were required to do a lot of sprints within a game. This was therefore an important consideration in their rehab plan.  

Aerobic Capacity
15 seconds on, 15 seconds off:

  • Set 1: 65m x 11 reps
  • 2 mins rest
  • Set 2: 60m x 11 reps 

HAMSTRING REHAB SESSION SUMMARY 

hamstring tear physio sydney results 2

Important Considerations for patient

  • Significant increase in accelerations and decelerations with no symptoms 
  • Has now ran at 88.5% max speed 
  • Achieved 290m of high-speed running (HSR) which is any distance over 19.8 kmph. 

 DAY 20

Prehab and speed drills same as last rehab session, with some added plyometric complexity, and postural demands; including hops on the spot, and high knees with pole overhead 

Ball Work + Change of Directions
Agility/speed demands increased in the following exercises:

  • Cutting at poles (with/without ball)
  • Long ball with 10-20m accelerations in between
  • Ball dribbling + Resistance band accelerations 

hamstring tear exercises

High Speed Running Exposure

  • 3x10m (70% max speed)
  • 3x20m (80% max speed) 
  • 3x30m (90% max speed) 
  • 2x40m (90% max speed) 

Aerobic Capacity
15 seconds on, 15 seconds off

  • Set 1: 65m x 12 reps
  • 2 mins rest
  • Set 2: 60m x 12 reps 

HAMSTRING REHAB SESSION SUMMARY 

hamstring tear physio sydney results 4

Important Considerations for Patient

  • Consistent with accelerations & decelerations and has no pain  
  • Has now ran at 95.48% max speed 
  • Achieved 544m of high-speed running (HSR) which is any distance over 19.8 kmph. 
  • Now needs to complete max speed testing, faster decelerations, and more reactive agility 

 Advised to complete higher loading based eccentric strength exercises for hamstring (hamstring sliders), and power-based exercises including weighted jump squats and lunges. Encouraged to do light ball work to get more touches on ball 

DAY 23 & 24

Advised to participate in team training, and to complete non-contact drills including passing, crossing shooting, and to be cautious with over stretching, and to not be tackled/tackle anyone yet. 

More demanding exercises completed in prehab/speed drills, including high knees with weight overhead, and broad jumps for distance. 

More demanding ball specific drills completed, patient completed crosses, long balls, and driven shots.  

Agility drills were more reactive in nature, and change of direction difficulty was increased. 

Some of the agility exercises included a square reaction drill, and the T & Y agility runs. 

hamstring tear exercises

Max Speed Testing: As part of being cleared to return to competitive sport, it is critical that sprint speeds and times are tested. If the patient is unable to match what they were doing prior to injury, they are either not physically, or psychologically prepared, or both.  

In this session, the following sprints were completed: 

  • 2x10m (90-100% max speed) 20m Sprint – 3.35 seconds 
  • 3x20m (100% max speed) 
  • 2x30m (100% max speed)
  • 2x40m (100% max speed) 

Hamstring Injury Sprint TrainingHamstring Injury Sprint Training

10m Sprint time: 1.91s
20m Sprint time: 3.14s (0.21 seconds improvement from results pre-injury)

Hamstring Injury Sprint Time

40m Sprint time: 5.44s (0.24 seconds improvement from results pre-injury)

Hamstring Injury Sprint Time

 

Aerobic Capacity: To ensure patient was going to be physically prepared for their finals series and national tournament, they were pushed hard to improve their aerobic capacity within rehab.

Aerobic Capacity
15 seconds on, 15 seconds off:

  • Set 1: 70m x 13 reps
  • 2 mins rest
  • Set 2: 70m x 13 reps

HAMSTRING REHAB SESSION SUMMARY 

hamstring tear physio sydney results 4

Important Considerations for patient: 

  • Completed an extremely demanding session pain free 
  • Has now beaten his previous max speed record prior to injury, achieving 100.49% max speed. New max speed now 32.49kmph 
  • Achieved 914m of high-speed running (HSR) which is any distance over 19.8 kmph. This is well above what the patient would need to complete in their matches.  
  • Now needs to complete full contact for entire training week to be available for match next weekend 

DAY 27

Patient pulled up sore in both thighs, completed some light stretching and did light cycling/swimming. On day 28 all soreness was gone. 

WEEK 5

Patient completed 3 full contact training sessions and reported no issues.  

DAY 34

First game back. Patient played 30-35 minutes in semi-final performing at a high level. Patient set up 2 goals and team made grand finals. 

WEEK 6

Patient completed full contact training week again with no issues. They started their grand final, and played 60 minutes. The game went into extra time but the patient had started to develop cramps in both calves so was subbed off.  

DAY 42

Calf cramps treated in physiotherapy appointment. Patient felt a lot better after treatment.

WEEK 7

Patient was involved in the National Youth Championships in Coffs harbour over the entirety of this week. There was at least 1 match per day. The patient was monitored throughout this tournament, but reported no symptoms in their hamstring, and performed with no issues.  

Their team won the tournament in the end, and 5 months on, the patient has reported no symptoms in their leg since the injury. 

Hamstring Injury Winners

Hamstring physiotherapy rehab summary

This case study highlights the high level of detail required to objectively rehabilitate hamstring injuries. Because of the high risk of re injury, ongoing strength & conditioning is necessary to reduce the risk of reoccurrence. More importantly, measures should be taken even prior to injuries occurring, to reduce the risk of them occurring to begin with. 

We can never fully eliminate the risk of hamstring injuries occurring, but some important considerations to minimise the risk, include: 

  • Very High-speed running exposure 1-2x a week (reaching at least 90% max velocity) 
  • Ensure you have a good level aerobic endurance to cope with the demands of your sport, level, and position 
  • Listen to your body, if you are extremely sore, consider reducing your load 
  • Make sure you are strong. The hamstrings are a 2 joint muscle group which flexes the knee, and extends the hip. Ensure you strengthen the hamstrings in both knee flexion (e.g., Nordic or hamstring curls), and hip extension (Romanian Deadlifts) 
  • When strength training, expose yourself to bilateral (2 legs) and unilateral (1 leg) exercises 
  • Be powerful. Ensure you complete plyometrics, so you are fast, explosive, and coordinated in jump/hop based movements which can be quite fatiguing 
  • If you are involved in a multidirectional sport, expose yourself to some exercises outside the sagittal plane (e.g., rotational or side to side movements) 
  • Monitor your training loads, try not to have sudden increases/reductions in your load beyond 10% per week. 
  • Static stretching does not reduce risk of hamstring injury 5
  • Be confident in your body! If you aren’t, physiotherapy can certainly help with your concerns and goals.  

If you are looking for comprehensive rehabilitation following a sporting injury, or want to minimise the risk of an injury occurring, contact us directly or book online for a thorough physiotherapy assessment and treatment plan. 

Speak to a Physio

 

References 

1. Chu SK, Rho ME. Hamstring Injuries in the Athlete: Diagnosis, Treatment, and Return to Play. Curr Sports Med Rep. 2016 May-Jun;15(3):184-90. doi: 10.1249/JSR.0000000000000264. PMID: 27172083; PMCID: PMC5003616. 

2. Schmitt B, Tim T, McHugh M. Hamstring injury rehabilitation and prevention of reinjury using lengthened state eccentric training: a new concept. Int J Sports Phys Ther. 2012 Jun;7(3):333-41. PMID: 22666648; PMCID: PMC3362981. 

3. Ekstrand J, Bengtsson H, Waldén M, et al. Hamstring injury rates have increased during recent seasons and now constitute 24% of all injuries in men’s professional football: the UEFA Elite Club Injury Study from 2001/02 to 2021/22 British Journal of Sports Medicine Published Online First: 06 December 2022. doi: 10.1136/bjsports-2021-105407 

4. Barte, J., Nieuwenhuys, A., Geurts, S., & Kompier, M. (2017). Fatigue experiences in competitive soccer: development during matches and the impact of general performance capacity. Fatigue: Biomedicine, Health & Behavior, 5(4), 191-201. https://doi.org/10.1080/21641846.2017.1377811 

5. Small K, Mc Naughton L, Matthews M. A systematic review into the efficacy of static stretching as part of a warm-up for the prevention of exercise-related injury. Res Sports Med. 2008;16(3):213-31. doi: 10.1080/15438620802310784. PMID: 18785063.