Return to Sports Following a Hamstring Strain
Hamstring strains are one of the more common non-contact injuries in athletes—particularly athletes that participate in sports with sprinting, kicking, or sudden direction changes and accelerations. Whether you are the greatest shooter in NBA history or soccer playing dad who owns a physical therapy clinic in Alameda, the journey from injury to peak performance requires more than rest and stretching. A structured, evidence-informed rehab process that restores function, minimizes reinjury risk, and builds long-term resilience is the only way togo. Let’s explore the rehabilitation and return-to-sport (RTS) process for hamstring strains through the lens that we incorporate at OSO Physical Therapy here in Alameda.
Understanding the Injury: Mechanisms and Classification
Most hamstring strains occur during the terminal swing phase of running, when the hamstrings are contracting eccentrically to decelerate the limb (Askling et al., 2007). The biceps femoris (the long head, to be exact) is the most commonly injured site, likely due to its high activation during late swing and its unique anatomy.
Hamstring Strains are broken down into 3 categories -
Grade I: Mild discomfort, minimal loss of strength or motion
Grade II: Partial tears with moderate functional limitations
Grade III: Complete rupture, often requiring surgical intervention
MRI findings can be helpful, but not everybody gets one, and clinical decision-making—guided by pain, function, and performance tests may be more practical for grade 1 and 2 tears. If there is tissue deformity or significant bruising, a visit to the Ortho or Sports Medicine Physician may be appropriate. We are happy to help facilitate that if appropriate! A modern rehab approach includes criteria-based progression, not just timelines. You are a pretty cool organism, but every strain is different and so is every person!
Here's a breakdown of what we look at and when :
Phase 1: Protection & Early Activation
Goals: Reduce pain/swelling, protect tissue, maintain adjacent joint mobility and strength, maintain fitness level with non irritating activities and lifts, initiate gentle hamstring activation if well tolerated - Isometric contractions at varying lengths (Opar et al., 2013), and avoid over stretching the hamstring (let it rest a bit)
Modalities: Ice, compression, and short-term relative rest. We have lots of friends that love dry needling and acupuncture, but at this stage its really not something we recommend.
OSO Interesting Fact: Early introduction of lengthened position exercises (such as isometrics in hip flexion) may reduce time to return and improve strength outcomes (van der Made et al., 2018).
Phase 2: Rebuilding Strength & Capacity
Goals: Restore eccentric strength, neuromuscular control, and progressive load tolerance.
Eccentric Strength: Begin with exercises like sliding leg curls, then hip hinging on dual and single legs, then maybe some RDL’s and then the world’s favorite Hamstring exercise - Nordic hamstring curls.
Lumbopelvic Control: Emphasize glute, adductor, and trunk coordination and strength. Glutes and adductors are huge force producers and stabilizers when it comes to the hip, so it is super important to keep them strong as you try to feather back in hamstring exercises and use in athletic movements.
Running Drills: Initiate submaximal linear running (Askling et al., 2013). Once it is well tolerated without gait deviations. Linear means straight line.
Evidence-Based Tip: The Askling H-test (hip flexion with knee extension at high speed) can be a valuable clinical indicator for progression readiness.
Phase 3: High-Speed Loading & Plyometrics
Goals: Prepare the hamstring for high-velocity demands, restore sprint mechanics.
High-Speed Running: Gradually increase sprint distances and intensities.
Plyometrics: Emphasize horizontal force production.
Deceleration & COD (change of direction): Add cutting drills relevant to the athlete’s sport.
Strength & Conditioning Crossover: Emphasize rate of force development (RFD) and eccentric overload training (e.g., flywheel devices) to match sport demands (Suchomel et al., 2018).
Return-to-Sport Criteria: Not a matter of time
Returning to sport after a hamstring strain should be guided by objective criteria rather than arbitrary timelines. Key benchmarks include: Pain-free sprinting at >95% effort Near Symmetrical hamstring strength (90+%), particularly in eccentric testing (e.g., NordBord) Completion of high-speed running acceleration and decelerations in training without pain Negative response to provocative drills (e.g., Askling H-test) Pain-free full ROM and symmetrical flexibility Symmetrical hop tests (single leg, dual leg, broad jump, Triple Jump, etc) Completion of sport-specific drills in a controlled environment with confidence (if you don’t think you are ready, you are probably right!) Psychological readiness confirmed OSO interesting fact: Athletes who return with a >10% asymmetry in eccentric strength have a significantly higher reinjury rate (Opar et al., 2015).
Prevention and Long-Term Resilience
The same exercises used in late rehab—Nordic hamstring curls, sprint drills, and posterior chain lifts—become the foundation for ongoing injury prevention. Rehabilitating a hamstring strain is a progressive process that blends tissue healing, functional restoration, and performance readiness. By anchoring rehab in scientific principles and sport-specific demands you can be confident in your return to the court, or the backyard.
Askling, C. et al. (2007). Hamstring injury mechanisms during sprinting: A clinical and biomechanical approach. BJSM.
Askling, C. et al. (2013). High-speed running vs. conventional rehab after hamstring strain. AJSM. Brukner, P. et al. (2014). Clinical relevance of MRI in hamstring injuries. BJSM.
Opar, D. et al. (2013). Eccentric hamstring strength post-injury. MSSE.
van der Made, A. et al. (2018). Hamstring injury rehab in lengthened position. JSCR.
Suchomel, T. et al. (2018).Importance of RFD in performance and rehab. JSCR.
Dan Hirai
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