The three do's and don't for runners after hamstring injury

A hamstring injury takes an average of 20 days to recover from with a 30% chance of re-injury in the first two months. Use these three “do’s and Don’t” to aide recovery and reduce re-injury risk

Female proximal hamstring.jpeg

Hamstring injuries are all too common in the running community, a very unwelcome pang in the back of the leg that I’ve certainly felt a few times. However, there are proven ways that you can aide or hinder the recovery & return to running process. To that point, I’ve laid out three key DO’s and DON’Ts during different stages of the injury that will help you recover quicker while reducing the risk for re-injury.

Lets start with what to do and not do immediately after a hamstring strain:

#1 Do – POLICE the hamstring

In the acute aka immediate phase after a hamstring injury, the old adage of PRICE - Protect, Rest, Ice, Compress, Elevate - is outdated. Instead, the more effective technique is POLICE -Protect, Optimal Loading, Ice, Compress, Elevate^1.

No, not them.

No, not them.

Similar to PRICE, you still want to protect the hamstring such as using crutches to aide with walking if walking is painful, use compression like ACE bandage or taping for support, ice - 10 minutes on, 10 minutes off^2-5 - and keep it elevated to reduce pain & inflammation^6. However, rather than rest, you want to “optimally load” the hamstring by moving the leg through pain-free range of motion to aide with healing, blood flow, and maintaining strength and mobility^7.

#1 Don’t – Stretch the hamstring

Hamstring Stretch, not in acute phase.jpeg

In the acute (immediate) phase, stretching does much more harm than good. That’s because any hamstring strain involves some tearing of the muscle fibers and stretching interferes with their healing process. Stretching out torn muscle fibers during this healing phase is akin to yanking on a frayed rubber band.

The research shows two to six days of restricted motion (note, this doesn’t mean NO motion. Optimal loading!) reduces scar tissue formation and re-injury rates^8–13. Further, in one randomized control study, athletes treated with static stretching and progressive resistance exercises demonstrated significantly worse outcomes after two weeks and one year compared to those athletes treated with progressive agility, trunk stability, and resistance exercises.

If you’re itching to stretch something, stretch your quadriceps and hip flexors. Studies have shown that tight quads and hip flexors can increase the risk for hamstring injury^14,15.

Once you’re able to walk normally & take the hamstring through its full range of motion without pain, you’re into the intermediate phase. That brings us to the next DO & DON’T:

#2 Do – Step-wise rehab progression

Steady and methodical wins the race…

Steady and methodical wins the race…

To get the hamstring back to 100%, it’s critical to rebuild strength in the hamstring, improve control of the trunk & pelvis, & methodically re-acclimate to running. Based on the latest hamstring rehab research^10,16–19, I created a detailed stepwise plan that consists of four progressive phases. Once you can complete the allotted sets and reps/time of the current phase with ease, without soreness/tightness for more than 2 days after, and a pain level lower than 5 out of 10 (if you ever feel sharp or radiating/electrical pain, stop), move onto the next step.

Phase 1 (do this daily)

  • Strength

  • Conditioning and agility

    • Stationary bike x 10 mins, building up to 30 minutes

    • Side-step x 10 yards each way for 3 sets of 1 minute, low to moderate (mod) intensity

    • Grapevine walk x 10 yards each way for 3 sets of 1 minute, low to mod intensity

Phase 2 (do this five to seven days per week)

  • Concentric strengthening

  • Conditioning, agility, return to running

    • Low-speed jog, without pain x 5 minutes, building up to 20 minutes

    • Side-shuffle x 10 yards each way for 3 sets of 1 minute, mod to high intensity

    • Grapevine jog x 10 yards each way for 3 sets of 1 minute, mod to high intensity

    • Boxer shuffle x 10 yards for 2 sets of 1 minute, low to mod intensity

Phase 3 (five to seven days per week)

  1. Eccentric strengthening, 3 sets x 12 reps. Begin with exercise one, working your way up to the maximum sets and reps. Once you can complete those without issue, progress to the next step at your next session. The final exercise has its own protocol that’s illustrated below.

    1. Elevated eccentric hip bridge

    2. Dual-leg eccentric physioball rollout

    3. Single-leg eccentric physioball rollout

    4. Nordic hamstring curl

      • The Nordic hamstring curl is the most effective strengthening exercise to help rehab and prevent future hamstring injuries^20–26. It’s an exercise you want to include even after returning to 100%. Here’s a 10+ week protocol to use:

Nordic HS curl protocol.png
  • Conditioning, agility, return to running

    • Mod speed jog, without pain x 5 minutes, building up to 20 minutes

      • I’d recommend shortening your stride and increasing your cadence (5 to 10% max) during this phase to decrease the stress on the hamstrings. A shorter stride/higher cadence results in less force through the leg and less tension on the hamstrings (due to decreased knee extension during terminal swing phase)

    • Side-shuffle x 30 yards each way for 3 sets of 1 minute, mod to high intensity

    • Grapevine jog x 30 yards for 3 sets of 1 minute, mod to high intensity

    • Boxer shuffle x 10 yards for 2 sets of 1 minute, mod to high intensity

    • A skips x 3 sets of 1 minute (start slow and go faster as able), progressing to B skips x 3 sets of 1 minute (start slow & go faster as able)

    • Backward and forward acceleration/deceleration x 3 sets of 1 minute, starting at 5 yards then progressing to 10 yards and finally 20 yards

Phase 4 (Full return to running)

  • Full range of motion without pain

  • No symptoms (tightness, soreness, pain) from phase 3

  • Walk-Sprint interval without pain x 5 sets, 50 yard walk-50 yard sprint

#2 Don’t – “Just Rest”

Just resting doesn’t address the underlying cause…

Just resting doesn’t address the underlying cause…

I cannot emphasize this enough (if you haven’t noticed) but rest does not address the underlying reason why the hamstring was injured in the first place. Hamstring strains in runners occur nearly exclusively because the hamstring was unable to handle the amount of stress placed on it, resulting in tears in the muscle fibers. Therefore, we have to re-strengthen the muscle and improve or develop neuromuscular control of the trunk and pelvis, all the while respecting the biology of the healing process.

If you do not address the underlying causes, there’s a significantly higher chance you will re-injure the hamstring and have to start the entire process all over again.

Overlying all of the guidelines I’ve given thus far are the last, but certainly not least, DO and DON’T:

#3 DO – See a running expert medical provider

I understand that seeing a medical provider, ideally a running-centric one in this scenario, isn’t always practical for a variety of reasons. To that point, I’ve done my best to give you enough information and tools to get you through the rehab process yourself. However, if able, I highly recommend seeing a medical provider because what I’ve touched on is just the tip of the iceberg. The expertise and information from in-person assessment, guidance, and treatment provides many benefits in the short, medium, and long-term.

For example, hamstring strains vary not only by severity but also by location. The specific muscle that’s injured – the hamstrings are a group of four muscles – or the location of the strain (eg in the muscle belly vs at the tendinous insertion of the muscle) can change the plan of care and shorten or lengthen the expected timetable for return.

Hamstring Injury Locations.jpg

Additionally, your hamstring injury may be influenced by previous injuries or workload which can be teased out by an expert. Further, although the hamstring rehab protocols I’ve laid out for you are good foundations for rehab & recovery, I had to omit numerous details that require expert assessment, observation, and would be beyond the scope of someone not trained in the field.

Further, seeing a running focused medical provider is going to benefit you even more. For one, they understand how important running is to your identity and health, both mental and physical. For two, there are running specific elements that can influence your recovery. I’ll use my own process as an example:

Whenever a runner comes in with a hamstring injury - in addition to the elements I’ve covered in this piece - I place a heavy emphasis on running gait analysis.

Running gait analysis should be standard for all runners in my opinion.

Running gait analysis should be standard for all runners in my opinion.

Running form, technique, and efficiency modulates the extent and duration of stress on key muscles, including the hamstrings. For example, research shows that changes in running gait biomechanics from previous injury and running with lower back lordosis and anterior pelvic tilt predisposes a runner to more stress on the hamstrings & therefore higher risk for injury^27–29. To identify those factors, and many more, I use dual-angle video for running gait analysis combined with manual evaluation to identify root causes and create a plan of action.

#3 DON’T – Take hamstring injuries lightly

On average, a hamstring injury takes a little under twenty days to recover from^30 and even if you’re on the faster end of recovery, at least two weeks^10. Further, nearly 30 percent of people with a hamstring injury develop recurring hamstring strains, with some studies reporting rates as high as 60 to 70 percent^9,29,31,32. The majority of these hamstring re-injuries occur within the first two months after return to sport, with an increased risk thereafter^33–35. In one study, that increased risk was three times that of an uninjured athlete for up to one whole year following the initial injury^36.

For all these reasons, it’s critical to take any hamstring injury seriously. Appropriate healing & recovery, progressive rehab that addresses symptoms and underlying causes, and a methodical return to running are key to keeping you out of the injury-reinjury downward spiral. A spiral I’ve witnessed far too many times. My hope is this article will help youget back to 100% after a hamstring strain, avoid re-injury, and back to doing what you love & identify with, running.

Feel free to reach out with any questions and you can read more blog posts here.

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