Appendix: Proposed guideline for the rehabilitation of acute hamstring strain

injuries

Phase 1 (0-4 weeks)

Protection
 Avoid direct stretching of the hamstrings
 Shorten stride length to ambulate pain free
 Use crutches if necessary

Management of pain and swelling

 Avoid non-steroidal anti-inflammatory drugs (NSAIDs) and glucocorticoids
 Cryotherapy 2 to 3 times per day
 Compression thigh wraps and elevation above heart
 Activity modification to reduce tension

Therapeutic exercises
 Stationary biking for easy motion
 Progressive agility and trunk stabilization
o Low-to-moderate-intensity side stepping
o Low-to-moderate-intensity grapevine stepping
o Low-to-moderate-intensity boxer shuffle
o Single-leg stance, eyes open and eyes closed
o Prone abdominal bridge
o Supine extension bridge
o Side bridge, performed on each side

Criteria for progression to the next phase

 Normal walking stride without pain
 Very low-speed jogging without pain
 Pain-free isometric contraction against submaximal (75%) resistance during
prone knee flexion (90°) manual muscle test

Phase 2 (2-8 weeks)

Protection
 Avoid end range lengthening if weakness persists

Management of pain and swelling

 Cryotherapy after rehabilitation as needed

Manual therapy techniques

 Normalize ankle dorsiflexion ROM (posterior talar glides, mobilization with
movement, calf stretching)
  Addressing spinal mobility limitations
 Addressing pelvic and sacroiliac joint restrictions
 Manual, instrumented, or self-directed soft tissue mobilization to limit
excessive scar tissue formation
 Neuromobilization94 techniques if the athlete displays adverse limb tension93

Therapeutic exercises
 Progressive agility and trunk stabilization
o Moderate-to-high-intensity side stepping
o Moderate-to-high-intensity grapevine stepping
o Moderate-to-high-intensity boxer shuffle
o Single-leg windmill touches
o Supine extension bridge walk outs
o Push-up stabilization with trunk rotation
o Side plank stabilization with trunk rotation
o Fast feet in place
o High-to-low and low-to-high wood chops
o Progressive balance training (balance board/unstable surface)
 Eccentric resistance training
o Supine extension bridge bilateral heel slides
o Modified single-leg chair bridge
o The Diver75,76
o The Glider75,76

Criteria for progression to the next phase

 Pain-free isometric contraction against full resistance during prone knee
flexion (45°) manual muscle test
 Forward and backward jogging at 50%-70% speed without pain

Phase 3 (4-8 weeks and beyond)

Protection
 Avoid full intensity if pain or stiffness persists

Management of pain and swelling

 Cryotherapy after rehabilitation as needed

Manual therapy techniques

 Address remaining limitations in ankle, spinal, or pelvic mobility
 More aggressive manual, instrumented, or self-directed soft tissue
mobilization to limit excessive scar tissue formation
 Neuromobilization94 techniques if the athlete displays adverse limb tension93

Therapeutic exercises
 Emphasize agility involving quick direction changes and sport-specific drills
with technique training
 Progressive agility and trunk stabilization
o Side shuffle
o Carioca
o Boxer shuffle
o A skips
o B skips
o Forward and backward accelerations
o Repetitive hop for distance
o Single-limb windmill touches with dumbbells (Fig. 1)
o Single-limb dead lift
o Single-limb dumbbell hang clean (Fig. 2)
o Lunge walk with trunk rotation and opposite hand dumbbell toe touch
o T-lift lunge walk (Fig. 3)
 Eccentric resistance training
o Forward and backward running with anterior directed resistance band
at waist
o Forward and backward fast feet with anterior directed resistance band
at ankles (Fig. 4)
o Single-leg chair bridge
o Modified Nordic curls with resistance cables to facilitate greater range
of motion (ROM) (Fig. 5)
Fig. 1: Single-limb windmill touches with dumbbells: begin in (A) single-limb stance

position with dumbbells overhead and (B) perform windmill motion under control

with end position of touching dumbbell near floor.

Fig. 2: Single-limb dumbbell hang clean: begin in (A) single-limb stance position

with touching dumbbell near floor, (B) powerfully extend through the hips, knees, and

ankles, driving the dumbbell upward, “catching it” at shoulder height in a slight squat

position, and ending by (C) standing and pressing dumbbell overhead.

Fig. 3: T-lift lunge walk: begin by (A) stepping into a forward lunge position, (B) lift

one leg off of the ground while maintaining a level pelvis, (C) follow through, and

(D) step through with the same leg to an opposite sided forward lunge position.

Fig. 4: Forward and backward fast feet with anterior directed resistance band at

ankles: move the involved limb backward, then the uninvolved limb backward, then
the involved limb forward, and finally the uninvolved limb forward; repeat the same

pattern and continue at running tempo.

Fig. 5: Modified nordic curls with assistance: begin in (A) tall kneeling position, (B)

slowly and under control lower trunk forward without flexing at the hip or arching the

low back until (C) maximum motion occurs; return to starting position using push

from floor and resistance cables to assist.