Muscle strengthening, ice and heat, and plyometrics (late stage), are the best treatments for hamstring strains.
Hamstring strains most often happen during the eccentric portion (lengthening phase) of running sprinting, and other movements and can be a very long process when recovering.
Where you should start in the rehab process is going to largely depend on what your goals are. A collegiate or high school sprinter is going to likely start and progress in a much different way than a middle-aged man who tore his hamstring during a pickup basketball game (weekend warrior).
Where you start in terms of exercises will also depend on your prior fitness level and your pain response to activities.
In this article, we’ll go into a few different starting points for a hamstring strain and how to progress through each one.
I’ll also answer some frequently asked questions at the end of this article. You can skip around using the links in the table of contents, as well.
Let’s hop on in!
- If you follow the six steps shared below you will give yourself a much better chance of full recovery and preventing hamstring injuries from happening again.
- Low and slow. Start with low weight and low movements and progress to heavier weight and faster movements as you are able.
- Acute strains that are not severe can take as little as 2 weeks to fully recover or 3 months all the way to a year if chronic and not rehabbed properly.
- Rehab properly from the start and you can avoid most of these longstanding issues
Treatment/Rehab starting point: I recommend everyone start at step one and then if you feel fine (no increase in symptoms) the next day you can progress through to the next steps, up to step 3.
Before progressing to step 4, you should give it a couple of weeks if the injury was severely painful.
The time between steps 4 to 5 is also variable, but a good barometer for this is if you can do the exercises with minimal to no pain even with increased weight.
For a severe hamstring strain that is a grade two or three with severe pain and the inability or high difficulty of bending the knee, your recovery will be longer and you will need to start at a much lower intensity level of exercise.
With this level of pain and discomfort, there is almost always bruising either in the mid substance of the muscle belly (mid-thigh on back of the leg).
If you have this severity of pain and lack of strength and range of motion I do recommend first taking a couple of days off and using the RICE method.
GUIDELINES TO PROGRESSION (DON’T SKIP THIS!!)
- There is no timeline for each step. If you’re stuck in one step for longer than a month (other than the last few steps), then you should seek professional help.
- In order to progress to the next step your symptoms should not significantly worsen from the exercises in your current step
- If you experience a flare-up reduce your volume and intensity of work and take a step back for a few days until symptoms calm down.
- If it’s a severe injury with high levels of pain it can take 4+ months to really start to feel better. Best to set your expectations realistically and adopt a long-term mindset.
Rest, ice, compression, elevation. This allows for the initial inflammatory process to do its thing and then see where things are at after two days. Generally, symptoms have become more manageable through the use of anti-inflammatory medications and with the RICE method after a couple of days.
This is when I recommend to my clients to start with gentle range of motion exercises in addition to increasing walking (if it doesn’t flare symptoms up)
Exercises to start with:
- Seated knee bends: Sit in a chair or seat where your foot cannot reach the floor. Practice bending and straightening your knee. Perform three sets of ten repetitions.
- Walking: Walk 2-10 minutes. Use crutches if you have to.
I’m a big proponent of early mobilization even with fairly large tears and high levels of pain. We just want to find methods of movement that don’t severely increase pain (as I’ll highlight below)
IMPORTANT: YOU SHOULD NOT DO ANYTHING THAT SEVERELY FLARES YOUR SYMPTOMS UP. It’s fine if you experience a slight increase in pain after moving more, but this shouldn’t be severe. If it is you need to reduce the amount you are doing or change the exercise.
This is why if your symptoms are highly irritable (you flare up easily) then it’s a good idea to work with a physical therapist.
Okay, so at this point, you’re able to walk 5-10 minutes with or without crutches (you may have a limp), and you can straighten and bend your knee with minimal discomfort through 90 degrees of knee flexion to fully or close to straight. You might even be able to bend further than 90 degrees.
The reason I’m not putting a timeline on this is that everyone is different.
- Supine knee flexion: With this exercise you will lay on your back with the unaffected leg bent and the foot planted under your. You will then straighten your affected leg and keep it flat on the table/surface. Place a towel, pililow case, or other low-friction material under your foot and slide it towards your bottom. This adds some resistance to the hamstring as you are pulling it towards you. Complete three sets of ten repetitions
- Straight leg raises (small range of motion): The only thing to note on this one (watch the video) is that you will wan to keep the range of motion small in the beginning, meaning you don’t need to lift your leg all the way up to where your foot is pointing at the ceiling, particularly if this is causing a lot of pain.
- Walking: 10-15 mins (more if able)
Now you should be able to comfortably perform supine knee flexion and straight leg raises.
We are going to incorporate some more challenging exercises now that involve you bending your knee against gravity and adding more resistance.
- Prone hamstring curl: Lying on your belly without an ankle weight, attempt to bring your heel to your butt. No need to force the range of motion, just go through the range of motion that you can, comfortably. If you can do three sets of ten easily with this without weight, add an ankle weight of between two to five pounds. If you can still do this easily, move on to the next exercise.
- Seated or prone hamstring curl (machine): If you have access to a gym this is when I start recommending including a hamstring curl machine that will directly target your hamstrings. Start with lightweight and perform three sets of ten repetitions.
- Walking or cycling for 15-30 minutes. You are now free to add cycling to the mix if you’d like. Keep the resistance at a lower level to start with and increase it as you feel comfortable.
Once you’re able to complete hamstring curls and you’ve increased the weight twice because symptoms are manageable, it’s time to move on to the fun stuff.
- Box squats
- Romanian Deadlifts
- Walking or cycling 30-45 minutes
Continue with the same exercises from step four, but increase the intensity.
- Nordic hamstring curls
- Supine “tantrum” kicks with physioball
- Begin return to running program: Start with 30 seconds on, 30 seconds off at a low speed, low intensity. Perform 5 repetitions of this.
- Squat jumps
- Split squat jumps
- Box jumps
A sample return to running program after a hamstring injury would look like this:
- Week 1: 2x/week. 30 seconds on, 30 seconds off, 5 reps.
- Week 2: 2x/week, 40 seconds on, 40 seconds off, 5 reps.
- Week 3: 2x/week, 60 seconds on, 60 seconds off, 5 reps
- Week 4: 2x/week, 60 seconds on, 60 seconds off, 8 reps
- Week 5: 2x/week, 60 seconds on, 60 seconds off, 10 reps
- Week 6: 2x/week, 2 minutes on, 3 minutes off, 5 reps
- Week 7: 2x/week, 2 minutes on, 3 minutes off, 8 reps
- Week 8: 2x/week, 2 minutes on, 3 minutes off, 10 reps
There are many different ways to program a return to running program and this is going to largely depend on your previous fitness level and how your body responds to increased training load.
Returning to sprinting after a hamstring strain is the last thing that we work on.
In this step, we will return to sprinting (if you don’t care about returning to sprinting, don’t worry about this step).
You should continue with all the prior exercises in step 4 and 5 as those are crucial to maintain and increase the capacity of your hamstring muscles (among other muscles)
- Sprint training: Warm up well, and then proceed to perform five sprints at 60% capacity. My recommendation is to stay at 60%-70% for the first two weeks and then progress by 5-10% each week depending on symptoms.
- It should take ~2-3 months before you are back to full speed or close to full speed sprinting. There is no need to rush this and you want to make sure that your hamstring is completely ready for this high output, once again. Ideally, your hamstrings are much stronger than they were prior to the injury as you’ve been doing nordic hamstring curls, Romanian deadlifts, and other movements that have built your hamstring robustness.
Is physical therapy a better option than surgery?
In the majority of cases, physical therapy is a better option than surgery for a hamstring strain. Most hamstring strains will be recoverable without surgery.
Is surgery ever recommended?
If you have a severe grade three tear resulting in an avulsion from the attachment point either distally or proximally, you may need a surgical repair. This avulsion can sometimes also cause a piece of bone to be released, too.
In this case surgery is usually necessary. This is very rare.
How is the diagnosis made?
A hamstring strain diagnosis is made by determining the mechanism of injury:
- Blunt force trauma (fall, accident)
Additionally a physical exam will be done by asking you to flex and extend your knee to determine if there is pain or a diminished range of motion. You’ll likely also be asked to resist pressure while the therapist or doctor is placing pressure on your heel trying to pull your lower leg away from your body. If this produces significant levels of pain at the hamstring then it’s likely hamstring related.
Additionally, if you have any bruising that is noticeable this will be factored into your diagnosis.
As you can see, the diagnosis is generally made by looking at:
- How it happened
- What it feels like
- What it looks like
- And what movements make it feel better and worse
What questions should you ask your doctor or physical therapist?
- How long should I expect for this to take to improve?
- What can I do to prevent this from happening again?
- How often should I do my exercise?
- How much pain is okay during the rehab process?
- Is it okay if I have pain during the rehab process?
- When should I be concerned and give you a call?
- What are normal sticking points in the rehab process so I can anticipate them and not be surprised, later?
When should you get an MRI?
You should get an MRI if there is a suspected full-thickness tear with avulsion and your medical team feels that a surgical procedure may be the most appropriate option.
There is no reason to get an MRI if you are going to participate in physical therapy. This will not aide in the treatment, whatsoever.
Other Lifestyle and Home Remedies
An ounce of prevention is worth a pound of cure, am I right?
You should seek to work to increase your hamstring strength past what it was prior to the injury. This will decrease the likelihood that this will happen, again.
Warming up prior to an athletic event and also practicing for athletic events routinely is an important component of preventing these injuries, too.
You can’t expect your body to perform at its highest level and be robust if you never challenge it with regular practice.
What does a hamstring strain feel like?
Initially, a hamstring strain feels sharp and is very painful. Over time as it improves it will likely feel dull and achy, potentially even burning. If you overstretch it or over-exert during the recovery you will likely feel a sharp pain again. This doesn’t mean you’ve return it, it’s just your body telling you to take it slower.
How long will a hamstring strain take to feel better?
A grade one hamstring strain that is not too painful can recover in as little as two weeks. If you have a more severe strain or this is a recurrent issue you could be looking at 3 months all the way to 9 months depending on the level of activity that you are performing.
Competitive athletes in sprinting and multidirectional sports will have the longest recovery period.
How can you prevent a hamstring strain?
The best way to prevent a hamstring strain is through the routine practice of nordic hamstring curls, Romanian deadlifts, and high-intensity eccentric loading at rapid speeds outside of sprinting.
What is the function of the hamstrings?
The function of the hamstrings is to flex the knee and when sprinting it provides a deceleration force to the tibia (lower leg), ensuring that your lower leg doesn’t fly away from you.
What are the grades of a hamstring strain?
Grade one is a small tear.
Grade two is a moderate-sized tear.
Grade three is a full-thickness tear. A full-thickness tear can be in the muscle belly itself or it can be detached from either the ischial tuberosity (proximal attachment) or distally at the posterior tibia.
Who is most likely to injure their hamstring?
The most common hamstring injuries occur in sprinting athletes who do not perform any eccentric hamstring strength training.
Hamstring strains are also common in weekend warriors who do not routinely train their hamstring.
Does a hamstring strain hurt?
Yes, this goes without saying, or else no one would read this article, ha!
What makes a hamstring strain worse?
If you are constantly pushing your hamstring beyond its limit during rehab then it is very likely that you’ll continue to aggravate and potentially make it worse.
This is why it is important to take rehab “low and slow.” Low weight, low speed, to start with and then progressing to high weight (resistance) and high speed later on.
What’s the outlook (prognosis) for people with a hamstring injury/strain?
The outlook for someone with a hamstring strain is good if you follow a rehab plan and don’t rush it.
If you rush it and continually irritate yourself you could be dealing with this for much longer than you have to.
Don’t be that guy or gal.
Is it common to injure your hamstring again? (recurrent hamstring strains)
Yes, it is common to have recurrent hamstring injuries. This usually happens because people do not properly rehab and instead of continuing with exercises at a high intensity, they go back to their sport too soon and with an already diminished hamstring strength.
This diminished strength and robustness of the tissue are then asked to perform high-load activities and then re-strains.
You can avoid this by taking your time with the rehab process.
If you want to improve your hamstring strain and make sure this doesn’t happen again (or at least a much lower likelihood), you’ll want to follow the steps above and take it slow.
If you are having recurrent issues and aren’t sure what to do, reach out to me by filling out the form by clicking on the link below.