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Hamstring Rehabilitation and Running Mechanics – Part 1

– Derek M. Hansen –

A few months back, I had the opportunity to do some hamstring rehab work on an athlete I had worked with in the past. He had been training another city for the past year and had torn his hamstring in a 30 meter sprint test. Four days later, he eventually made it back to my city and we had to undergo some pretty intensive hamstring rehabilitation. He had four weeks to be ready for his first competition (bobsled). This would have been more than enough time for us to work with him. Having worked with sprinters and speed athletes for some time, it was pretty familiar territory for me. I had no doubt that we would successfully rehab him in time for him to compete in top condition. It is important to note that the process we undertook is no different from the framework I outlined in a recent article on Rehab and Dating Success.

The first day he was back under my supervision, we started with evaluation and observation. Simply speaking with the athlete and asking him about the injury and how it feels (standing, walking, sitting, getting out of bed in the morning, etc.) can yield a lot of useful information. Given that we were five days out from the initial injury, inflammation was not a significant concern for us. It was more about determining the athlete’s level of mobility and comfort.

 

Working Around the Injury

After letting the athlete walk around and passively test the hamstring, we had him lie down on his stomach. I carefully probed around the hamstring to determine the extent of the injury. He had indicated that the main injury was located around the middle to upper portion of the left hamstring, specifically in the semintendinosus. I performed light massage on the hamstring using massage cream to ensure that the passes were superficial and not stretching the muscle and fascia too much. My main intent was to determine the status of muscle tone for the strained muscle (above and below the injury site), as well as the tone of surrounding muscles (biceps femoris, semimembranosus, gracilis, adductors, soleus, gastrocnemium). As you might expect, every muscle was hypertonic and bordering on spastic. I continued to work all of these muscles, including the gluteal muscles, to not only bring down muscle tone but also increase circulation around and toward the injury site to facilitate healing and increased suppleness.

It is important to note that I did not work into the injury site on this first session. There was a lot of work to be done elsewhere in the surrounding tissues. I did not feel that it was prudent to work into the site, given that the athlete was only five days out from the injury and endured a 12 hour drive the day before. Another consideration was that I did not have to get him ready in 10-14 days. I had a much longer time-line and exercising caution was the best possible option.

 

Implementing Acceleration Work and Drills

After loosening him up sufficiently, we had him perform some easy accelerations over 5 to 10 meters to see what he could do. I made it explicitly clear to him that he only needed to exert himself in a safe manner at 50-60% of his top acceleration rate at best. As you can see from the first video below, his running stride is significantly hampered by the injury and his foot placement on the left side is very guarded. This is normal under these circumstances. The intent of each run is to run as naturally at possible, at a conservative pace, without putting the hamstring in danger of re-injuring. I tell the athlete that he should feel a slight tug on the hamstring, as if it is being worked lightly, but not to the point that it becomes sore.

 

After performing a number of sets of 5 repetitions over 10 meters, the athlete indicated that he felt the hamstring getting noticeably tired. In this situation, you have a number of choices. You could have him take longer recoveries to ensure there was little to no fatigue in the muscle, or you could change the type of work. We decided to change the type of work. In the video below, you can see that we decided to do a running high knee drill (Running ‘A’). This drill allows him to perform dynamically without putting the hamstring in danger of re-injuring. The action is primarily vertical in nature, unlike actual sprinting which requires a greater horizontal extension component. He is permitted to work aggressively in a manner that bolsters good running mechanics, builds lower leg elasticity and rigidity,and gives him the feeling of performing a full workout, as this is an important psychological factor in rehabilitation.

Initially, working over 5 meters is sufficient to work the running motion, which should work out to 15 to 20 steps when performed correctly. Recoveries between repetitions, in this particular workout, may be between 1 to 2 minutes, over 4 to 5 reps total.

 

Week Two

By the beginning of the second week post-injury, we had made significant improvements. Continuing along with the iterative process of performing running drills and accelerations, along with constant manual therapy, we were able to effect big improvements from day to day. Warm-up would include light jogging, dynamic flexibility and PNF work around the hips, and light, flushing massage throughout the lower extremities. Accelerations have gone from 10 meters in the first week, to 20-25 meters in the second week. In between sets, we are continuing to perform massage on the hamstrings, calves and glutes to ensure they are available for recruitment, and that any kinetic chain disruptions are minimized.

I have found that hamstring rehabilitation is primarily about restoring proper intra- and inter-muscle coordination. When a hamstring is injured, the involved and surrounding muscles tend to seize up and minimize range of motion in a protective response. The massage repetitions we are performing help to reduce spasticity and enhance circulation in the region, while the acceleration reps and drills help to re-activate and re-educate the hamstrings and connected muscles (glutes, calves, hip flexors) to recruit in proper amounts and the proper sequence. I am a firm believer that if you free up the muscles to do their proper job, the appropriate sequence of movement will return. While many individuals will say that the prescription requires strengthening protocols, I would go much further to say that an appropriate coordination pattern must be restored. Obviously strengthening is part of the process, but it is a very specific form of strengthening (specificity of velocity, load and order of recruitment). This is why sprinting must be the primary source of work in a hamstring rehabilitation program. It is not a problem that can be adequately resolved in the weight room or physio clinic.

The acceleration repetition in the video clip below shows the athlete not only running faster, but striding through more naturally, with much less apprehension than the previous week. If you look very closely, you can see that the left leg is still not extending as it normally would. Prior to ground contact, you can see the stride shortening on the left side, whereas the right foot extends and lands slightly in front of the center of mass. Similarly, on the extension phase of the stride, the left leg is shortening the cycle ever so slightly and not extending as fully as the right leg. The result is a slight anomaly in the stride cycle that you can pick up through a visual sampling of the entire 20 meter run.

 

Feedback from the athlete revealed that he felt only a slight, subtle stiffness in an isolated area of the hamstring, but not any pain or discomfort. By this time in the rehabilitation process we were beginning to work deeper into the tissue with massage techniques to break up and mobilize any scarring in the area. It is important to remember that we were not constrained by a short timeline and we had enough time to gradually effect a positive result. I was determined to make sure that when the athlete was ready to push at 100%, there would be no doubt in my mind or his mind that the hamstring would be ready to handle the load over many repetitions. This meant that the sprint workouts were drawn out gradually in terms of adding both distance and intensity for the runs. The same approach applied to manual therapy on the hamstring. We did not force the issue with deep tissue massage until I was sure that the muscle tone had appropriately been reduced through a gradual means. In some sense, we had to “peel the layers of the onion” until the whole of the muscle had been stripped of spasticity and discomfort.

One measure that always seems to work well with muscles that have not fully “released” or joints that still feel tight is to have the athlete apply a heat rub on the injury in the evening and then lightly wrap it with a tensor bandage. The athlete then sleeps with the light wrapping. This basically enhances blood flow to and through the injury site. I always use Tiger Balm ointment for this process, as I’ve had very good personal success with it. It does, however, smell pretty bad and I recommend showering it off in the morning. This process is akin to the wrapping of the legs of thoroughbred horses after intense workouts and when a trainer suspects there may be a slight strain or sprain. In the case of horses, they may refer to wrapping of the legs as stable bandages or sweat wraps.

So the first 8-10 days of rehabilitation went very smoothly with no mistakes on my part. I have learned over the years to be extremely explicit in my descriptions of intensity and velocity to the athlete when preparing him for runs. I would say that I significantly overstate the need to be cautious in each individual run. I have had too many occasions when the athlete told me that he was feeling good and then proceeded to push it a little too hard on the very next repetition, resulting in a minor re-strain of the muscle. Placing significant restrictions on the athlete is critical, regardless of how good or normal they feel. The coach is always the best judge of the rate of progression, whether it is through visual assessment, tactile sensation of the muscle itself or even something as simple as the amount of time that has passed. The progression must always be smooth and gradual.

In Part 2 of this discussion of hamstring rehabilitation, I will discuss how we progressed the athlete to full speed runs. We will also cover the other types of work that were being done in the weight room and with explosive work, taking into consideration the status of the hamstring and the stage of rehabilitation.

      

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Comments

  1. Great article!

  2. It definitely worked for me. It seems like it is very agressive and risky, but you know how fast is too fast and how far is too far. Havent had a problem in 3 years

  3. Thanks for the comment Richard. I think good rehab is “risky” where you are walking along a fine line – but everything you do is based on what you have seen through the preceding progression. As long as you know what speed and distance the athlete can handle (based on their previous workouts), they should be safe carrying our your explicit instructions. I often have athletes tell me that they can go faster and they feel good. I do not rely on what they tell me – only what I know we have done and where it is safe to go from there.

  4. christian says:

    Hi, I pulled and tore my hamstring – Bicep Femoris 6 to 7 weeks ago (Scan indicates that it is a partial thickness tear and collection of fluid), I have been doing a couple of strengthening work as advised by the physio. My next event is in four weeks time maybe five weeks. I am yet to go back onto the track, I have been to the gym for two weeks now just on low weight and more reps and saw your of programme here, which is adaptable so am considering doing such things. Please any advice will be hugely appreciated.

    • Christian – progressive work on the track using the steps I’ve outlined is critical. You must condition your hamstrings to handle the loads of sprinting, but also allow for you to regain the coordination required to sprint. Weights alone will not improve your hamstring.

      Start with the marching, skipping and running drills, then proceed to easy, but short, accelerations. And, throughout the progression, the hamstring needs to be worked on manually (i.e. massage, myofascial release, etc.).

      • christian says:

        Thank you Derek, I will flow your guide and progress easy. Only if I had found your article early but am very delighted. I look forward to starting after easter bank holiday.
        Your Advice is hugely appreciated.

  5. You may have to work on it daily for the first 7-10 days. It is low intensity work so you won’t have too much residual fatigue. In your case, you may want to go 3 days on, one day off, 3 days on, one day off, etc. But you need to be persistent.

  6. christian says:

    Excellent. Copy that.

    roughly how many hours a day (duration wise please)

    Thank you very much

    • Should only take 30min per day. 4x10m for drills, and 3-4x 10m accels for the first days. Err on the side of lower intensity/velocity for the first 3-5 sessions.

      • christian says:

        Copy that
        Thank you very much. Greatly appreciated.

        • christian says:

          Hello Derek, sorry to bother u again – is their any advise you can give with regards to patella maltracking (knee cap rubbing on the femur). am starting to get that bit by bit since i stopped training due to my injury, though I have never had it before. Physio exercises doesn’t seem to be helping.

          • Usually a problem with the quads or adductors (too tight). Try taking a foam roller and working on your vastus lateralis and vastus medialis. Then, lie on your side and put the roller between your legs to trigger your adductors. Start up high, then work down the adductors at 60 seconds per trigger point.

  7. Johnny Kelley says:

    Derek, Thankyou for posting this valuable regimen. I look forward to running my old long distances again.

  8. christian says:

    Awesome, I will add them all to my regime.

    Thank you very much Derek

  9. christian says:

    Hi Derek how is it going? Are you eve on your twitter? Am starting my proper rehab next week hopefully, because i started and stopped earlier during april for various reasons. Although my sports club physio is happy to work with me on daily bases so I can get back to my running as soon as possible. She has had a look at the plan posted above interns of what I will be doing and I also explain how it all came about and stuff. She wondered if you have got an email address so that she could contact you with regards to more information with regards to the rehab and see if there is anymore stuff you could recommend interns of other stuffs she could add to the rehab and so on, though that is as long as you are happy with that idea. My email add is c.okeke@yahoo.co.uk
    If you don’t mind emailing me and I will pass your email address to her, again that is if you’re happy with it. Look forward to hear from you.

    Thank you and Kind regards
    Christian

  10. christian says:

    Good day Derek, Not long I got from my 1st day for a good while, used the indoor facility, following the guide. My left hamstring does feel quite noticeably weak than my right hamstring although I was very cautious. it wasn’t really as fluent as my right hamstring. I hope its not a bad idea to ice it cos after I got in, I iced it for a duration of about 15 – 20 mins.

  11. Hi Christian. The idea is to perform the runs at a low intensity, but still accumulate work over distance. As the hamstring gets stronger, you can increase the velocity of the runs because of the prior workload that the hamstring as adapted to. It is always best to err on the side of caution for the initial sessions. Remember, your injured hamstring initially had a “hardware” problem that jumbled up your hamstring’s “software”. Now that the hardware is repaired (to some degree with scar tissue), you are reprogramming the software side of things by gradually re-educating it to run properly (teaching the muscle to activate and de-contract at higher speeds — essentially working on coordination).

  12. christian says:

    Excellent explanation
    Copy that, I will continue with the programme for sure. Generally I am a very cautious individual.

    Will the like KT tape offer any help?

    Thank you again

  13. No KT as it will not allow you to feel what is going on. It is a band aid solution that restricts ROM and does not provide a long term solution.

  14. christian says:

    That is alright, second day went according to plans, didn’t use kt tape and will not attempt one. I believe there is no point in icing the hamstring after the sessions?

  15. christian says:

    This is my guide, adapted from you article.

    Hamstring Workout and Drills – Implementing Acceleration
    NOTE TO SELF:
    • 50% – 60% strength
    • 1 – 2 minutes rest in-between drills
    • 2 – 4 minutes rest in-between accelerations
    • Manual work – Massage and Myofascial Release for the hamstring and surrounding areas
    • Progress weekly and don’t bother about time constrains
    • I have to be persistent

    CAUTION:
    • No working out the lower body in the gym i.e. no dead lifts or no hamstring Curls

    Week – One
    Everything for the first 5 to 7 days is lower intensity/velocity work.
    4 x10m for drills and 3 – 4 x10m accelerations for the first days.
    • Drills (High knee, marching, skipping and running drills)
    • Heavy bench press in the gym

    Week – two
    Warm up:
    • Light jogging
    • Dynamic flexibility
    • PNF work around the hip
    • Flushing massage throughout the lower extremities

    Increase accelerations to 20 – 25 meters (massage in-between sets on hamstring, calves and glutes).

    Drills to be continued.

    Work deeper into the tissue to break up scarring (with precaution).

    Week – Three/Four
    Refine sprint mechanics.

    Accumulate a foundation of sprint work to strengthen the hamstring and consolidate technique.

    • 30 – 60 meters sprint with 90% – 100% of top velocity
    • Hands on therapy throughout the workout as part of the warm up routine and in between sets
    • Speed work with flying 20’s (change speed drills (fast – easy – fast over 60meters))
    • Normal heavy lifting workout has to be restored.

  16. christian says:

    Hi Derek, is it alright for the hamstring muscle to feel like its bait draggy and perhaps get like a twinge sometime too?

  17. Hi Christian. What I’ve been doing lately with my athletes who are rehabbing their hamstrings is to make them do a set of 10 accels, then conduct some massage in between sets to help increase circulation to the hamstring, reduce fatigue and eliminate stiffness. This seems to prevent many problems and ensure we can get some quality work accomplished without too much stress on the hamstring.

    If it does start to feel “draggy” – it means that the hamstring is getting fatigued. Your best option is to take longer breaks between sets and employ some sort of self-massage to loosen up the hammy between sets. But don’t try to keep running, as it can only lead to more problems.

    Derek

  18. christian says:

    Thanks Derek, Note taken

    its a large tear on the hammy with scan indication of the size of tear as 27 x 51 x 16 (all in mm) area of superficial muscle disruption. nearly 8 weeks though I think the muscle recovery is somewhat slow though my physic classed it as grade 2 tear.

  19. I would say that 8 weeks is a long time. Grade 2 tears should not take longer than 3-5 weeks from my experience. What have you been doing for rehab prior to contacting me?

  20. christian says:

    All I have been doing is some exercises (about 5) recommended by my physic to strengthen it on daily basis like 10 reps of 3 set. Gym to mainly work out the upper body and very light squats on smith machine, not accurately angle 90 though, dead-lift on very light weights as well and massage on weekly basis. That is all I have done on it really because I was somewhat really cautious as I have never been injured before.

  21. The running element is so critical in successfully rehabilitating the hamstring. The weights can strengthen the hamstring, but not provide the much needed coordination and rapid lengthening and shortening requirements.

  22. christian says:

    Excellent advice Derek. All is taken on board and I will work cautiously to get the hamstring back. I will be keeping you updated. please do not hesitate do add any other useful and positive info

    Thank you.
    Christian

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