Journal of Athletic Training 2022;57(2):125–135

doi: 10.4085/1062-6050-0707.20
Ó by the National Athletic Trainers’ Association, Inc Current Clinical Concepts
www.natajournals.org

Hamstring Strain Injury Rehabilitation

Jack T. Hickey, PhD, AEP*†; David A. Opar, PhD*†;
Leigh J. Weiss, DPT, PT, ATC‡; Bryan C. Heiderscheit, PhD, PT§
*School of Behavioural and Health Sciences, †Sports Performance, Recovery, Injury and New Technologies Research
Centre, Australian Catholic University, Melbourne; ‡New York Football Giants, East Rutherford, NJ; §University of
Wisconsin, Madison

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Hamstring strain injuries are common among athletes and often injury, know how to perform a thorough clinical examination, and
require rehabilitation to prepare players for a timely return to progress loading to the site of injury safely and effectively. This
sport performance while also minimizing reinjury risk. Return to narrative review discusses current clinical concepts related to
sport is typically achieved within weeks of the injury; however,
these aspects of rehabilitation for hamstring strain injury, with
subsequent athlete performance may be impaired, and reinjury
rates are high. Improving these outcomes requires rehabilitation the aim of helping practitioners improve athletes’ outcomes.
practitioners (eg, athletic trainers and physical therapists) to Collectively, this knowledge will inform the implementation of
understand the causes and mechanisms of hamstring strain evidence-based rehabilitation interventions.

Key Points
 Mechanisms of hamstring strain injury likely involve a combination of high muscle-tendon unit forces (active or
passive), extensive muscle-tendon unit lengthening beyond moderate lengths, and high-velocity movements.
 Returning to high-speed running is arguably the most important aspect of rehabilitation, given that it is fundamental
to performance in many sports and a common mechanism for hamstring strain injury.
 Eccentric hamstring exercises and hip-extensor strengthening should also be implemented during rehabilitation to
prepare athletes for the demands of high-speed running and address deficits in strength and muscle structure.

R
ehabilitation practitioners (eg, athletic trainers and HSIs, promoting expeditious RTS performance while
physical therapists) regularly manage athletes who minimizing the risk of recurrent injury.
have sustained acute hamstring strain injuries
(HSIs). The aim of HSI rehabilitation is to prepare athletes CAUSES AND MECHANISMS
for return to sport (RTS) performance as soon as possible
Whether HSI occurs after accumulated repetitive micro-
while also mitigating their reinjury risk. Athletes typically
scopic muscle damage or in response to a single aberrant
complete rehabilitation and RTS within 3 weeks of HSI1;
event exceeding the limits of the muscle-tendon unit is
however, reinjuries frequently occur soon after RTS,2 and debatable.5 Some HSIs may result from an ongoing decline
subsequent performance may be impaired.3 Therefore, in tissue integrity due to repetitive damage, leaving the
rehabilitation practitioners need to be cognizant of current athlete vulnerable to an innocuous inciting event (eg,
evidence-based practices so that athletes have the best submaximal velocity running). In other instances, HSI may
opportunity for a full recovery. be caused by a single macrotraumatic event (ie, forceful
This narrative review presents a brief overview of the and rapid hip flexion), irrespective of underlying tissue
causes and common mechanisms of HSI, the important integrity. Either way, HSI mechanisms likely involve a
features of the clinical examination, a detailed breakdown combination of (1) high muscle-tendon unit forces (active
of different rehabilitation interventions and implementation or passive), (2) muscle-tendon unit lengthening beyond
considerations, and outcome measures to guide rehabilita- moderate lengths, and (3) high-velocity movements.6,7
tion and RTS prognosis; it also identifies 2 key questions to Whether all 3 factors are necessary for an athlete to sustain
inform future directions for research and practice. The an HSI remains unclear. Nonetheless, these causes should
Strength of Recommendation (SOR) Taxonomy4 was be in the forefront of the practitioner’s mind when
applied during open discussion among all authors to reach developing both HSI prevention and rehabilitation pro-
consensus on our recommendations related to clinical grams.
examination, rehabilitation interventions, and outcome In a sporting context, the most common mechanism of
measures. In this article, we aim to provide practitioners HSI is high-speed running, followed by movements
with the contemporary, evidence-based information neces- involving forceful and extensive hamstring lengthening,
sary to deliver best-practice rehabilitation for athletes with such as kicking.8 During high-speed running, the terminal

Journal of Athletic Training 125

Table. Differential Diagnosis and Common Clinical Presentation of Possible Causes of Posterior Thigh Pain Other Than Hamstring Strain
Injury
Differential Diagnosis Common Clinical Presentation
Proximal hamstring tendon avulsion Severe acute-onset pain occurs near the ischial tuberosity, usually due to forceful hip flexion with full knee
extension, such as a fall while waterskiing. Athlete may have a palpable defect in the proximal
hamstring tendon and significant bruising along the posterior thigh.
Proximal hamstring tendinopathy Gradual onset of pain near the ischial tuberosity is provoked by repetitive loading of the proximal
hamstring tendon. More common in middle-aged or older adults, particularly those who participate in
activities with repetitive loading, such as long-distance running.
Lumbar spine radiculopathy Posterior thigh pain is referred from the lower back and related to the forward-slumped posture due to
sciatic nerve or lumbar nerve-root compression.
Adductor muscle injury Acute- or gradual-onset pain is close to the posterior thigh but slightly more medial. Acute mechanisms
include acceleration, change of direction, or kicking. Pain provocation during isometric adductor
squeeze or hip-abduction range-of-motion testing may help differentiate it from hamstring injury.

swing phase is considered most injurious.7,9 In the second site of maximal pain provocation by palpation and the total

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half of the swing, the hamstring are active, rapidly length of palpable pain should be measured and monitored
lengthening, and absorbing energy to decelerate the limb throughout rehabilitation. Palpable pain that is closer to the
in preparation for foot contact.6 Hamstring muscle force ischial tuberosity or of greater total length has some
increases approximately 1.3-fold as running velocity association with an increased duration of HSI rehabilita-
increases from 80% to 100% of maximum and the greatest tion.13,15 SOR: B
muscle-tendon unit stretch is incurred by the long head of
the biceps femoris.10 These findings may explain why the Range-of-Motion Testing
long head of the biceps femoris is the most injured
hamstring muscle,11 often during high-speed running. Hip-flexion and knee-extension range of motion (ROM)
should be evaluated during the clinical examination to
CLINICAL EXAMINATION determine hamstring flexibility and tolerance to muscle
lengthening. In our experience, pain may limit the accurate
When athletes experience acute-onset posterior thigh pain assessment of actual muscle-tendon unit extensibility, but
in response to a common mechanism of HSI, the clinical ROM comparison with the contralateral uninjured limb
examination is less about diagnosis and more about the may still provide an indication of HSI severity.8 Between-
rehabilitation needs or RTS prognosis.12,13 Athletes pre- limbs deficits in knee ROM and pain during the active
senting with posterior thigh pain resulting from either a knee-extension tests are useful measures in providing a
mechanism not typical of HSI or a more chronic onset prognosis for RTS16 and the progression of running
require a differential diagnosis to either confirm or rule out intensity throughout HSI rehabilitation.13 The active knee-
the presence of other pathologies (Table). In this section, extension test can be performed with the hip flexed to either
we highlight the important features of an initial clinical 908 or the maximal angle of flexion possible for each
examination of HSIs in athletes. athlete13 (Figure 1).
Assessment of hip-flexor flexibility and ankle-dorsiflex-
Subjective History ion ROM may also be warranted, as these measures have
In our collective clinical experiences, athletes with a some association with HSI risk.17,18 In a prospective study
suspected HSI typically report the sudden onset of posterior of Australian rules footballers, the HSI risk increased by
thigh pain, sometimes accompanied by an audible or 15% for every 18 increase in hip flexion during the modified
sensory pop, causing the immediate cessation of activity. Thomas test.17 The average dorsiflexion lunge test distance
Athletes should be asked to rate their pain at the time of reported by van Dyk et al18 was less in soccer players who
suspected HSI, which is associated with the RTS progno- sustained HSIs (9.8 6 3.1 cm) than in their uninjured
sis12 and may be used as a reference point when monitoring counterparts (11.2 6 3.1 cm). However, practitioners must
symptoms throughout rehabilitation. Recording a thorough be aware that these group-level associations are limited in
history of the athlete’s injuries before this incident is their ability to predict HSI at the individual level. SOR: B
important, as previous HSI increases the risk of future HSI
by 2.7 times14 and recurrence at the site is common in the Strength Testing
weeks after RTS.2 Concurrent or previous injuries to other
Hamstring strength is usually evaluated during isometric
areas, particularly the lower back, hip or groin, and knee,
contractions at the initial clinical examination,19 and
should also be noted, as these findings could alter the
practitioners should ask athletes to rate their pain on a
clinical examination or rehabilitation protocol. SOR: A
numeric rating scale (range ¼ 0–10) during these tests.20
Strength can be objectively measured if practitioners have
Palpation of the Injured Area access to equipment such as a handheld dynamometer,21
With the athlete lying prone and the knees in full load cells,22 or force plates.23 Practitioners without access
extension, the practitioner can palpate the posterior thigh to to such equipment may consider using manual muscle
assess defects in the muscle-tendon unit and identify the testing to subjectively characterize strength, but we
possible injury site by establishing the point of maximal encourage exploration of relatively cheap alternatives, such
pain provocation. Distance from the ischial tuberosity to the as crane scales, which can objectively measure force.24

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Figure 1. Active knee-extension tests performed with the athlete lying supine and holding the thigh at either A, 908 or B, maximal hip
flexion. Range of motion can be assessed by placing an inclinometer on the anterior tibial border and instructing the athlete to extend the
knee until the maximal tolerable stretch is achieved.

Given the biarticular nature of the hamstring, knee- muscle-injury classification and grading systems have been
flexion and hip-extension strength should be tested with the proposed and applied to HSI to provide the RTS
athlete lying both prone and supine (Figure 2), ideally with prognosis.28 Prolonged RTS after HSI may occur when
the hamstring in a lengthened position,19,21 which appears MRI scans show signs of tissue damage compared with no
most useful for RTS prognosis.12,13 Internal and external damage or if the proximal tendon is disrupted compared
rotation of the tibia can be added to knee-flexion strength with intact.29 However, further detailed classification or
tests to differentiate between medial and lateral hamstring grading of HSI based on MRI findings appears to offer
muscle injury, respectively.25 Hip-extension strength can be negligible prognostic value beyond that of routine clinical
assessed with the knee flexed to identify muscles other than examination.12
the hamstring, such as the gluteus maximus, that require An emerging recommendation is that HSI rehabilitation
strengthening during rehabilitation.26 Practitioners may also should be more conservative when MRI reveals disruption
consider testing the strength of movements not involving to the intramuscular tendon,30,31 which was originally based
the hamstring based on the athlete’s injury history (eg, hip on retrospective observations of prolonged RTS and greater
adduction in those with hip and groin pain27), which may recurrence rates with this diagnosis.32 More recent
inform exercise selection during rehabilitation. SOR: A prospective work31 has shown that when rehabilitation is
informed by the MRI diagnosis, recurrence rates can be
Magnetic Resonance Imaging
kept similarly low across all types of HSI, but RTS time is
prolonged by at least 2 weeks in athletes with intramuscular
Beyond the subjective and physical clinical examinations tendon disruption. This prolonged RTS was likely the result
mentioned, magnetic resonance imaging (MRI) may be of the 2-week delay in progression of eccentric loading and
used to confirm the HSI diagnosis by identifying the running intensity that was applied to HSIs with intramus-
location and extent of tissue damage. Several MRI-based cular tendon disruption in the study by Pollock et al.31 Yet

Journal of Athletic Training 127

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Figure 2. Isometric strength testing of the knee flexors in A, prone position at 08 of hip and 158 of knee flexion and B, supine position at
908 of hip and 908 of knee flexion and of the hip extensors in C, prone position at 08 of hip and 908 of knee flexion and D, supine position at
08 of hip and 08 of knee flexion.

128 Volume 57  Number 2  February 2022

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Figure 3. Example of 3-stage progressive running protocol over 100 m, accounting for greater acceleration distances and more gradual-
intensity increases at higher percentages of maximal velocity.

it remains unclear if delayed progression of eccentric related to different exercise interventions and passive
loading and running intensity is truly necessary in HSIs treatments used in HSI rehabilitation and considerations
with intramuscular tendon disruption, as the rehabilitation for their implementation.
practitioners were not blinded to the MRI findings.31
In a prospective study that did blind rehabilitation Exercise Interventions
practitioners to the MRI findings, time to RTS and
recurrence rates were not different when comparing HSIs Progressive Running. A progressive return to high-
with and those without intramuscular tendon disruption.33 speed running and sprinting is likely the most important
However, RTS was prolonged in participants with full- aspect of rehabilitation, given that it is fundamental to
thickness intramuscular tendon disruption (31.6 6 10.9 performance in many sports and a common HSI mecha-
days) versus those with no disruption (22.2 6 7.4 days) as nism. Figure 3 provides an example of a 3-stage progressive
well as in participants with waviness of the intramuscular running protocol based on our collective clinical experi-
tendon (30.2 6 10.8 days) versus those with no waviness ence, understanding of biomechanical demands placed on
(22.6 6 7.5 days).33 Nonetheless, athletes can successfully the hamstring during running,6,10 and application of similar
RTS despite persistent signs of intramuscular tendon protocols in HSI rehabilitation.20,35 Stage 1 can be safely
disruption on follow-up MRI scans without increasing their introduced after athletes can walk with minimal pain (eg,
risk of reinjury.34 pain 4 on a numeric rating scale ranging from 0 to 10),20
Based on current evidence, practitioners who can refer progressing from a slow jog (approximately 25% of
patients for MRI may be able to provide a more accurate maximal velocity) to moderate-speed running (approxi-
prognosis for RTS by differentiating between HSIs with mately 50% of maximal velocity) as tolerated.35 When
and those without visible tissue damage or proximal tendon moderate-speed running is tolerated, athletes can gradually
involvement. Still, the need to alter rehabilitation and RTS progress through stage 2 but should only advance to stage 3
decision making based purely on other MRI findings, such when high-speed running (approximately 80% of maximal
as intramuscular tendon disruption, requires further inves- velocity) can be performed without pain to minimize the
tigation before being recommended as standard practice. HSI risk. During stage 3, progression toward maximal
SOR: B sprinting (100% of maximal velocity) should occur in
relatively small increments (approximately 5%) to account
for the substantial increase in negative (ie, eccentric) work
REHABILITATION required by the hamstring at running intensities .80% of
As soon as HSI has been confirmed, rehabilitation maximal velocity.10
interventions aimed at preparing the athlete for a timely, When high-speed running and sprinting have been
safe, and effective RTS should be implemented without achieved, subsequent exposure during HSI rehabilitation
delay. In this section, we discuss the current evidence and RTS should be individualized to the needs of each

Journal of Athletic Training 129

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Figure 4. Example of progression of exercises targeting eccentric knee-flexion (white) and hip-extensor strength at long (black) and short
(gray) hamstring muscle lengths. Abbreviation: ROM, range of motion.

athlete. Where possible, large spikes in high-speed running such as the NHE after HSI. Eccentric hamstring exercises
volume should be avoided to reduce the subsequent HSI are often avoided in the early stages of HSI rehabilitation
risk.36 The emergence and availability of wearable sensors and only introduced after pain and between-limbs strength
(eg, global positioning systems, inertial measurement units) deficits during isometric knee flexion have resolved.35,38
and other technologies (eg, timing gates, smartphone apps) Nevertheless, eccentric loading can be safely progressed
make quantifying progressive running during HSI rehabil- based on individual exercise performance, regardless of
itation easier.37 Practitioners can use these approaches to pain and between-limbs strength deficits during isometric
gather outcome measures at RTS to objectively individu- knee flexion after acute HSI.20 For example, the submax-
alize running progressions, safely reintegrate athletes into imal bilateral eccentric slider exercise can be introduced at
regular training, and prepare them for sport performance. the very start of HSI rehabilitation (Figure 4), and when
SOR: A athletes can perform this exercise through full ROM, they
Eccentric Hamstring Exercises. Eccentric hamstring can progress to a unilateral variation and begin the NHE
exercises are a common HSI rehabilitation intervention to (see Supplemental Video 1, available online at http://doi.
prepare athletes for the demands of high-speed running and org/10.4085/1062-6050-0707.20.S1).20 This progressive
address deficits in strength and muscle structure. Empha- approach to eccentric loading has been shown to increase
sizing mainly eccentric actions and hamstring lengthening hamstring strength and long head of the biceps femoris
via the extender, diver, and glider exercises, the Askling L- muscle fascicle length in relatively brief periods of
protocol reduced RTS time compared with conventional15 rehabilitation after acute HSI.20 Examples of these eccentric
and multifactorial38 interventions. However, none of the hamstring exercises and descriptions of when they should
Askling L-protocol exercises load the hamstring to a high be introduced and progressed on an individual basis during
intensity during eccentric contractions,39 and high-intensity HSI rehabilitation are provided in Figure 4 and Supple-
loading appears to be a key component of interventions mental Video 1. SOR: A
proven to increase hamstring strength, lengthen long head Hip-Extensor Strengthening. In addition to eccentric
of the biceps femoris muscle fascicles, and reduce the HSI knee-flexor exercises, hip-extension exercises should be
risk.40,41 As deficits in hamstring strength and long head of used to load the hamstring at longer muscle lengths.
the biceps femoris muscle fascicle length are seen after Submaximal exercises, such as the Askling diver,15 can be
RTS,42 more progressive eccentric loading, such as the introduced at the start of HSI rehabilitation (Figure 4)
Nordic hamstring exercise (NHE), should be implemented before progressing to hamstring bridges,20 458 hip exten-
during rehabilitation. sions,41 or Romanian deadlifts (see Supplemental Video 2,
Although eccentric loading is frequently recommended as available online at http://doi.org/10.4085/1062-6050-0707.
a rehabilitation intervention, the challenge for practitioners 20.S2). Apart from the hamstring, single-joint hip exten-
is knowing how and when to safely introduce exercises sors, such as the gluteus maximus and adductor magnus,

130 Volume 57  Number 2  February 2022

should be targeted if clinical examination shows weakness as excessive anterior pelvic tilt, which is often linked to a
in these muscles, as they are key contributors to horizontal risk of HSI because of increased hamstring length in this
force production during sprint acceleration.43 These single- position. Some prospective evidence has shown an elevated
joint muscles may be preferentially loaded over the injured HSI risk in athletes who sprint with greater anterior pelvic
hamstring during HSI rehabilitation by performing hip- tilt and lateral trunk flexion49 or less gluteus maximus and
extension exercises with greater knee-flexion angles.26,44 trunk muscle activity.50 Yet, similar to PATS exercises, no
Bilateral body-weight hip thrusts can be introduced at the direct evidence supports the use of technique drills to
onset of rehabilitation (Figure 4) and progressed to reduce HSI risk, improve running performance, or alter any
unilateral, loaded, and explosive variations (see Supple- other rehabilitation outcomes. Therefore, technique drills
mentary Video 3, available online at http://doi.org/10.4085/ should be viewed as a nonessential accessory to progressive
1062-6050-0707.20.S3), which have been linked to in- running that may be implemented if a sound clinical or
creased hip-extensor strength and improved sprinting performance-oriented rationale is provided. SOR: C
performance in uninjured athletes.45 Figure 4 and Supple-
mental Videos 2 and 3 supply examples of these hip- Passive Treatments
extensor strengthening exercises and describe when they
should be introduced and progressed on an individual basis Platelet-Rich Plasma Injections. Some athletes may

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during HSI rehabilitation. SOR: B receive platelet-rich plasma injection therapy during HSI
Hamstring Flexibility Exercises. Exercises aimed at rehabilitation, depending on their access to resources and
improving hamstring flexibility are regularly prescribed the practices of medical personnel involved in their
during rehabilitation to address deficits in hip-flexion and management. Platelet-rich plasma injections have been
knee-extension ROM seen immediately after HSI.46 suggested to enhance tissue healing and have been
However, these acute ROM deficits typically recover evaluated in the treatment of acute muscle injuries, with
within the first 2 weeks after HSI46 and may not require multiple studies including athletes with HSIs.51 In a recent
direct intervention. Yet hamstring flexibility exercises may meta-analysis, Seow et al51 showed no reduction in the RTS
be required if deficits persist during rehabilitation, as time or reinjury rate when platelet-rich plasma injections
were added to exercise interventions during HSI rehabil-
greater deficits in active knee-extension ROM at RTS have
itation. They also reported a lack of consensus on the
been associated with an increased risk of subsequent HSI.47
timing, volume, and composition of platelet-rich plasma
Recovery of active knee-extension ROM can be slightly
injections,51 and there is potential for resulting muscle
accelerated by implementing passive hamstring stretching 4
soreness, which could affect exercise rehabilitation.
times per day, compared with once daily, starting at 48
Platelet-rich plasma injections appear, at best, to be a
hours after HSI.16 Other hamstring flexibility exercises
nonharmful yet ineffective treatment in accelerating RTS or
prescribed in HSI rehabilitation include supine active knee
mitigating the subsequent HSI risk. SOR: A
extensions15 and dynamic hamstring mobility exercises,38
Manual Therapy. Evidence endorsing manual therapy as
although the effectiveness of these interventions is not
a rehabilitation intervention after HSI is scarce. Acute
clear. SOR: B
increases in knee-flexor torque have been observed after
Progressive Agility and Trunk Stability Exercises.
sacroiliac-joint mobilizations were applied to individuals
Exercises proposed to improve agility and trunk stability with a recent HSI, but these findings were limited by
came to prominence after they were shown to lead to fewer preintervention differences between those who did and
reinjuries versus a relatively conservative hamstring those who did not receive this treatment.52 Lumbar spine
strengthening and stretching intervention during HSI facet-joint mobilizations and soft tissue massage were
rehabilitation.48 In a subsequent HSI rehabilitation study, included in a multifactorial HSI rehabilitation algorithm;
RTS time and reinjury rates were no different between fewer reinjuries were noted but RTS was slightly prolonged
progressive agility and trunk stability (PATS) exercises and compared with the Askling L-protocol exercise interven-
an intervention emphasizing progressive running and tion.38 Mendiguchia et al38 did not assess outcomes often
eccentric strengthening.35 The purported benefits of PATS thought to be influenced by manual therapies (eg, pain or
exercises are that they promote controlled early loading ROM), and the extensive nature of the rehabilitation
through frontal-plane movements while avoiding end-range algorithm made it difficult to know if these passive
hamstring lengthening.48 It has also been argued that PATS interventions were of any value.38 In the absence of clear
exercises target other muscles of the lumbopelvic region, evidence, practitioners need to consider the potential time
which could reduce the stretch placed on the hamstring cost of implementing manual therapies during HSI
during high-speed running, at least according to biome- rehabilitation against any perceived benefit of these
chanical models.10 Although these potential benefits have interventions. SOR: C
not been directly investigated after implementing PATS
exercises, relative success in achieving timely RTS and
acceptable rates of recurrence35,48 strengthens this other- Implementation Considerations
wise theoretical rationale for their inclusion in HSI Implementing any rehabilitation intervention requires
rehabilitation. SOR: B careful consideration of factors both intrinsic (eg, age and
Running Technique Drills. Practitioners may implement injury history) and extrinsic (eg, pressure to expedite RTS)
running technique drills as tolerated during the early stages to the athlete. Older athletes with a history of HSI or
of HSI rehabilitation to replicate discrete phases of the injuries to other areas may require longer rehabilitation
sprinting gait cycle at reduced intensities and in a times because of the need to address preexisting deficits and
controlled environment. Running technique drills are account for their increased risk of subsequent injury.14 Elite
perceived to reduce potentially unwanted movements, such and professional athletes may be under more pressure to

Journal of Athletic Training 131

RTS, which can truncate HSI rehabilitation. Practitioners performing explosive unilateral hip flexion with the knee
must consider these factors in various aspects of rehabil- fixed in extension by a brace.59 An electric goniometer can
itation in collaboration with coaches, the athlete, and other also be used to quantify hip-flexion ROM during the
stakeholders in the shared RTS process.53 Askling H-test, which may identify deficits that are
As rehabilitation progresses to include more sport- otherwise undetected via clinical examinations of ham-
specific training and high-speed running, it is important to string flexibility during the later stages of HSI rehabilita-
avoid neglecting key exercise interventions. Complete tion.59 Implementing the Askling H-test as a final RTS
cessation of eccentric hamstring exercise leads to shorten- criterion is associated with a low risk of reinjury but
ing of long head of the biceps femoris muscle fascicles,54 prolonged HSI rehabilitation time,56 and practitioners may
which can be averted by continuing to perform these need to consider which outcome is a higher priority for
interventions, even at low training volumes.55 The effects each athlete. SOR: B
of fatigue and muscle soreness must be considered when
implementing both high-speed running and eccentric Eccentric Hamstring Strength
hamstring exercises. For example, eccentric hamstring
Depending on resources, eccentric hamstring strength can
exercises may cause fatigue and muscle soreness, which
be objectively tested using several tools, including
make high-speed running difficult during the subsequent 48

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isokinetic dynamometry60 and handheld dynamometry,21
hours. The timing of these interventions may depend on the or during the NHE using externally fixed load cells.61 The
number of days an athlete can complete rehabilitation evidence for eccentric hamstring strength as a risk factor for
around other commitments. We advise that, if these HSI is conflicting,14 and asymmetries after RTS were not
interventions are prescribed for the same day, high-speed associated with reinjury.60 Eccentric hamstring strength is
running should be performed before eccentric hamstring associated with sprint acceleration mechanics,43 which are
exercise to ensure that maximal sprinting is not compro- important for performance in running-based sports.62
mised by fatigue or muscle soreness. Therefore, maximizing eccentric hamstring strength and
relative between-limbs symmetry is currently considered a
OUTCOME MEASURES desirable rehabilitation outcome for sports performance but
Throughout rehabilitation, follow-up clinical examina- not an essential RTS criteria to reduce the reinjury risk.63
tions and additional outcome measures should be used to SOR: B
monitor an athlete’s recovery and inform the shared RTS
decision-making process.53 In this section, we briefly cover FUTURE DIRECTIONS FOR PRACTITIONERS AND
pain, patient-reported outcomes, apprehension, and eccen- RESEARCHERS
tric hamstring strength, along with assessment tools that Despite the proliferation of HSI research in recent times,
can be used during HSI rehabilitation. key questions related to improving rehabilitation outcomes
for athletes remain unanswered. In this section, we identify
Pain 2 key questions for both practitioners and researchers to
Rehabilitation is most commonly progressed after HSI consider in shaping the future directions of HSI rehabili-
when the athlete reports no pain during exercise, clinical tation.
examination, or functional tasks.56 A numeric pain rating
scale (range ¼ 0–10) can be used to evaluate the level of Are There Key Rehabilitation Interventions or Is a
pain reported by the athlete. As opposed to the conventional Multifactorial Approach Essential?
practice of pain avoidance,56 allowing exercise in the The concept of multifactorial rehabilitation is logical,
presence of pain rated 4 on this scale during HSI given the plethora of known and potential contributors to
rehabilitation is safe and may allow earlier exposure to and HSI risk and athletic performance. Implementing multiple
progression of beneficial stimuli.20 SOR: B intervention types increases the likelihood of reducing the
HSI risk and improving athlete performance but requires
Patient-Reported Outcomes more time to implement during rehabilitation, which could
The importance of patient-reported outcomes is high- delay RTS.38 Practitioners dealing with time constraints
lighted by findings that RTS prognosis was associated with need to prioritize rehabilitation interventions that actively
self-predicted time to RTS and the number of days taken contribute to improved outcomes for athletes over those
for the athlete to begin pain-free walking.12,57 In addition to that may add little benefit. However, it can be difficult to
asking the athlete these questions, practitioners can use the identify the most effective interventions when these are
Functional Assessment Scale for Acute HSIs, a self- implemented as just one part of a multifactorial approach to
administered questionnaire, to assess the severity and effect rehabilitation. In the future, researchers need to better
of symptoms.58 Initial research into psychometric testing delineate the individual components of HSI rehabilitation to
has shown this scale has good reliability and validity,58 but identify key interventions and their minimum effective
the minimal clinically important difference is unknown. dosage to improve outcomes for athletes.
SOR: B Unfortunately for practitioners, many interventions still
lack an evidence base to support or refute their implemen-
tation during HSI rehabilitation. Still, the absence of
Apprehension
evidence does not necessarily equate to the evidence of
The Askling H-test can be used to evaluate an athlete’s absence. In these cases, practitioners need to carefully
apprehension during rapid hamstring lengthening by apply critical thinking and consider a sound rationale for

132 Volume 57  Number 2  February 2022

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Address correspondence to Jack T. Hickey, PhD, AEP, School of Behavioural and Health Sciences, Sports Performance, Recovery,
Injury and New Technologies Research Centre, Australian Catholic University, 115 Victoria Parade, Fitzroy, VIC 3065 Australia.
Address email to [email protected].

Journal of Athletic Training 135