Tyler, T. F., Schmitt, B. M., Nicholas, S. J., & McHugh, M. P. (2017). Rehabilitation After Hamstring-Strain Injury Emphasizing Eccentric Strengthening at Long Muscle Lengths: Results of Long-Term Follow-Up. Journal of Sport Rehabilitation

Progressive criteria based rehabilitation protocol emphasising eccentric exercises at long hamstring muscle length is effective in reducing injury recurrence.

50 athletes who enrolled in the study, those who completed the structured strengthening programme and met return to sport criteria (N42) remained pain free to years after return to play, whereas athletes who was non compliant with the exercises suffered a re injury in the following 3-12 month,

Phase 1


• Protect healing tissue.

• Minimize atrophy and strength loss.

• Prevent motion loss. Protection

• Avoid excessive active or passive lengthening of the hamstrings.

• Avoid antalgic gait pattern.


• 2–3 times daily Therapeutic Exercise (3 d/wk, Isometric Exercise Performed Daily at Home)

• Stationary bike (10–20 min)

• Submaximal isometric at 3 angles (100°, 45°, 20°), 3 sets of 12 repetitions with 3-second hold • Single-leg balance 30″ to 90″, adding unstable surface as tolerated

• Balance Board 30″ to 90″

• Soft-tissue mobilization (STM)/instrument-assisted STM

• Progressive hip strengthening consisting of sidelying hip abduction, prone hip extension, straight-leg raise 3 sets of 12

• Pain-free isotonic knee flexion in seated using cable column 3 sets of 12

• Sciatic nerve flossing in seated (extend knee, dorsiflex foot, flex spine, the reverse steps) • Ice with sensory electrical stimulation using premodulated current 10 to 15 minutes Criteria for Progression to Next Phase

• Normal walking stride without pain

• Pain-free isometric contraction against submaximal (50–70%) resistance during prone knee flexion (90°) manual strength test


Phase 2


• Regain pain-free hamstring strength, progressing through full range. • Develop neuromuscular control of trunk and pelvis with progressive increase in movement speed, preparing for functional movements. Protection

• Avoid end-range lengthening of hamstrings if painful. Ice

• Postexercise, 10 to 15 min Therapeutic Exercise (Performed 3 d/wk)

• Stationary bike 10 to 15 min

• Treadmill at moderate to high intensity (progressive increasing intervals), pain-free speed and stride

• Isokinetic eccentrics in nonlengthened state using Biodex isokinetic dynamometer at 0.5 rad/s (20°/s)

• Single-limb-balance windmill touches without weight, 3 sets of 12

• Single-leg stance with perturbation (eg, ball toss, reaches)

• Supine hamstring curls on Swiss ball, sets of 12

• STM/instrument-assisted STM

• Nordic hamstring lowers, 3 sets of 8 to 12 reps, with therapist stabilizing at ankles

• Shuttle jumps, 3 sets of 12

• Prone leg drops (therapist holds bent knee in hip extension and drops leg with patient attempting to “catch” leg before it touches table), 10 to 15 repetitions

• Lateral and retro band walks 60 to 120 feet, rest as needed

• Sciatic nerve flossing as in phase 1 Criteria for Progression to Next Phase

• Full strength (5/5) without pain during prone knee flexion (90°) manual strength test

• Pain-free forward and backward jog, moderate intensity

• Pain-free maximal eccentric in shortened state


Phase 3


• Symptom-free (eg, pain and tightness) during all activities.

• Improve neuromuscular control of trunk and pelvis.

• Integrate postural control into sport-specific movements. Protection

• Train within symptom-free intensity.


• Postexercise, 10 to 15 minutes, as needed Therapeutic Exercise (Performed 3 d/wk)

• Treadmill moderate to high intensity as tolerated

• Hamstring dynamic stretching in standing, kicking leg straight up (eg, Rockette-style kick) • Isokinetic eccentric training at end range of motion, begin with 3 sets of 10 reps and progress to 15 reps performed at 0.35 rad/s (20°/s)

STM/instrument-assisted STM

• Plyometric jump training (double-leg hops progressing to single-leg hops, progressing to single-leg hops in multiple directions)

• 5- to 10-yard accelerations/decelerations

• Single-limb-balance windmill touches with weight on unstable surface 3, sets of 12

• Sport-specific drills that incorporate postural control and progressive speed


Criteria for Return to Sport

• Lengthened-state eccentric training pain free at 0.35 rad/s (20°/s) throughout available range of motion while resisting with maximal effort

• Replication of sport-specific movements at competition speed without symptoms