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4 Mistakes People Make When Rehabilitating Hamstring Strains

When it comes to hamstring strains, two things are certain:

  1. They are very common in athletes, with research showing almost 30% of all lower extremity injuries in sports are hamstring strains.
  2. The recurrence rate is high, with research showing up to a 30% recurrence rate for hamstring injuries.

Call me crazy but I feel like the recurrence rate is just way too high, showing that we either are rushing people back too soon, don’t have an adequate return to sport criteria, or simply are not rehabilitating these hamstring strains very well.

It’s likely a combination of the three. We can do better.

 

4 Mistakes People Make When Rehabilitating Hamstring Strains

In my experience, people often make 4 common mistakes with hamstring strain rehabilitation. By focusing on these 4 key areas, I think we can do a better job returning athletes to their sport following hamstring strains, and keep them out on the field without reinjuring their hamstrings.

 

Loading the Hamstring Too Early

The first mistake I often see is simple. People often load the hamstring tissue too early.

I think it’s obvious that contracting a strained hamstring causes pain, so this is often avoided, but for some reason people tend to want to stretch through this pain and discomfort, thinking that if they get looser it will feel better.

I don’t think this is true, and overstretching too early is just going to delay healing. In fact research has shown that too much stretching can actually delay the return to sport.

This can occur in the rehabilitation setting, but also from the athlete themselves as the constantly want to stretch or “test” the area throughout the day.

One of the easiest things you can do acutely after a hamstring strain is to avoid stretching. Don’t get me wrong. I want to start some gentle range of motion in the acute phase, but I don’t want to stretch the tissue that was essentially just damaged by an overstretch type of injury.

Trust me, take a step back in the acute phase and avoid stretching and you are putting the tissue in a position to succeed in the future phases on rehabilitation when we need to start applying more load.

 

Not Performing Eccentric Exercises

It has been theorized that hamstring strains are so common due to the large eccentric contractions observed during the swing phase of running as the hip flexes and the knee extends.

This seems to make sense.

So it also makes sense that hamstring strain rehabilitation and even prevention programs that incorporate eccentric hamstring exercises tend to have better results.

After a hamstring strain, it has been shown that eccentric hamstring strength is impaired.

The common theory is that there is a change in the force-length relationship of the hamstring after an injury, resulting in peak force at a shorter length. But, eccentric training shift this relationship and allow peak force at a longer length.

This makes is important to include eccentric exercises for the hamstring during rehabilitation. I also recommend you include eccentrics with exercises at various degrees of hip flexion, for example the Nordic hamstring exercise at 0 degrees, and a single leg RDL, which includes hip flexion.

 

Not Performing Dynamic Hamstring Exercises

While it’s important to include eccentric exercises, I’m actually surprised at how little I read about people recommending dynamic exercises.

It’s one thing to perform a slow eccentric contraction, and another to perform a dynamic and explosive contraction.

I often use lower body plyometrics for this, as it allows both a rapid eccentric contraction, followed by an explosive concentric contraction. That’s what happens in sports.

 

Returning to Sports Too Early

Several studies have been published showing that many athletes return to sport too early, showing signs of hamstring weakness and imbalances.

Part of the problem is that there is no validated criteria to determine return to sport. But, we are getting there.

It’s probably best to understand the factors that are associated with prolonged hamstring injuries, you can read a nice review of those in AJSM.

But we also may have a new clinical test that can be performed. The Askling test involves have the person rapidly perform an active straight leg raise to assess their ability to perform and pain.

It has been shown that the recurrence rate of hamstring strains that passed the Askling test was less than 4%, much lower than the normal rate.

 

How to Diagnose and Treat Hamstring Strains

For those that want to learn more about how I rehabilitation hamstring strains, including the postoperative rehabilitation follow hamstring repairs, I have an Inner Circle presentation on the Diagnosis and Treatment of Hamstring Strains that overviews my approach to these injuries. Click below to learn more:

 

 

How to Diagnose and Treat Hamstring Strains

The latest Inner Circle webinar recording on How to Diagnose and Treat Hamstring Strains is now available.


How to Diagnose and Treat Hamstring Strains

This month’s Inner Circle webinar is on How to Diagnose and Treat Hamstring Strains. In this presentation, I’m going to overview a simple 3 phase approach to rehabilitating hamstring strains. Hamstring strains can be tough, and have a really high recurrence rate. But luckily there are things you can do to assure we are helping the tissue remodel and accept load again.

This webinar will cover:

  • The anatomy and injury mechanics behind hamstring strains
  • The best way to diagnose and grade hamstring strains
  • A 3 phase rehabilitation progression to get back on the field
  • What to focus on to reduce recurrent strains in the future
  • The postoperative rehabilitation following hamstrings repair

To access this webinar:

How Pelvic Tilt Influences Hamstring and Spine Mobility

how pelvic tilt influences hamstring and spine mobilityHow many people come to you and complain that they have tight hamstrings?  It seems like an epidemic sometimes, right?  I know it’s pretty common for me, at least.  

Many people just tug away at their hamstrings and aggressively stretch, which may not only be barking up the wrong tree, but also disadvantageous.

I have really gotten away from blindly stretching the hamstrings without a proper assessment, as I feel that pelvic position is often the reason why people think they are tight.  This is pretty easy to miss.

In the video below, I want to explain and help you visualize the how pelvic tilt influences hamstring mobility and spine position.  Often times the hamstrings feel “tight” or “short” when in reality their pelvic position is just giving us this illusion.  I talk about this a lot with clients at Champion and often find myself making these drawings on our whiteboard.

Keep this in mind next time you think someone has tight hamstrings or has too much thoracic kyphosis.  Often times the key is in the hips!

 

How Pelvic Tilt Influences Hamstring and Spine Mobility

 

Strategies for Anterior Pelvic Tilt

If you are interested in learning more, I have a couple of great webinars for my Inner Circle members that you may find helpful:

The Use of Non Motorized Treadmills to Facilitate Gait and The Posterior Chain

We’ve recently started playing more with non motorized treadmills at Champion and have been very happy with the results.

Non motorized treadmills have gained popularity in the fitness realm as alternatives to self-powered conditioning machines like bikes and rowers. The Assault Air bikes and Concept 2 rowers have long been popular for their ability to produce amazing workouts.

I am a big fan of conditioning machines that increase their intensity based on the amount of effort exerted. Essentially, the harder you go, the harder they push back!

These have done wonders for high intensity interval training and sprint conditioning work.

Woodway has recently developed the Woodway Curve self-powered manual treadmill. Past non motorized treadmills seemed really cheap to me, but Woodway, who makes some of the best treadmills, has really made an exceptional machine with the Curve. I started using them for sprint work with the Red Sox, but have recently been using it more and more with my rehabilitation clients at Champion.

Because it is nonmotorized, your posterior chain is nicely engaged while walking and running on the Curve. A simple period of ambulation on the Curve does a great job engaging the hamstrings and glutes. I’ve been using these in everyone with diagnoses like patellofemoral pain, low back pain, and even postoperative. We start with a slow walk and slowly build up the speed and eventually get to running.

In the video below I explain more. I’m a big fan of nonmotorized treadmills to facilitate a proper gait form and engage the posterior chain.


Can Tight Hip Flexors Cause Tight Hamstrings?

I like the title of this article – Can Tight Hip Flexors Cause Tight Hamstrings?  It is sort of like a riddle, isn’t it?

I was working with a client recently that is knowledgable and understands anatomy fairly well.  He came to see me for several reasons, but high on the list was “my hamstrings are tight” followed by a poor attempt at touching their toes.  His hands were about 3 inches from the floor with his knees bent!  He added, “I don’t know why I can’t touch my toes, I have been stretching and working on my hamstrings for months!”

After spending time assessing him from head-to-toe, I shared with him that I thought his hamstrings were “tight” because his hip flexors were tight.  He thought about it for a second and then tried to call BS, stating “If my hamstrings are tight, shouldn’t my hip flexors be loose?”

My answer was “I don’t think your hamstrings are tight.”  At this point, he was about ready to leave the session, thinking I was the craziest person in the world, stating “but I can’t touch my toes?!?”

 

How Tight Hip Flexors Can Cause Tight Hamstrings

I bet you’ve had clients like this in the past.  They know just enough to be dangerous.  The answer to my riddle is more semantics than anything else.  Yes, hamstring tightness can limit your ability to touch your toes, but that isn’t the only cause.

We have actually done a great job understanding this concept over the last several years.  People like Gray Cook, Lee Burton, Brett Jones, and others have done wonders teaching many people that sometimes there are other reasons why you can have a limited toe-touch, specifically because of poor motor control and core stabilization.

However, hip flexor tightness can be a contributor as well, as backwards as that seems.  Again, it comes down to semantics.  I am actually talking about anterior pelvic tilt limiting your ability to touch your toes.

Here is an interesting an example.  Which hamstring is shorter in the below image?

hip flexor hamstring tightness

If you answered the left leg, you are guessing!  Without a comprehensive exam, you are just guessing.  What if his left pelvis was anterior tilted?  This would cause the proximal attachment of the hamstring to move superiorly and look just like a tight hamstring, such as in this example:

tight hamstring anterior pelvic tilt

Whenever someone appears to have tight hamstrings or can not touch their toes, I look first at pelvic alignment to see if they are in excessive anterior tilt.  Everything revolves around assessing your starting point.

As you can see in the example below, if you are starting in a large anterior pelvic tilt, then you are theoretically starting with the hamstrings long.  I used the simple math numbers of 45 degrees and 90 degrees, which is pretty excessive, but you see what I mean.  In a large anterior pelvic tilt, your normal starting position in this example would already be close to 45 degrees!

Anterior Pelvic Tilt

So, can having tight hip flexors cause tight hamstrings?  I’m not sure about that.  But I know that being in anterior pelvic tilt can limit your ability to touch your toes.  Again, it always comes down to:

Functional-Stability-Training-Lower-Body

Assess, Don’t Assume

This is one of my major concepts from the Functional Stability Training for the Lower Body program.  Assess alignment before you just start treating.  Resist the urge to just foam rolling, massaging, and stretching your hamstrings without truly assessing if this is the reason why you can’t touch your toes.  Sometime having tight hip flexors and an anterior pelvic tilt can limit your ability to touch your toes just as much.

The Influence of Pelvic Position on Lower Extremity Stretching

Inner Circle Premium Content

The latest webinar recording for Inner Circle members is now available below.

 

The Influence of Pelvic Position of Lower Extremity Stretching

The below webinar will help you understand:

  • Why lower extremity stretching is essentially flawed
  • Why we aren’t always in neutral position or symmetrical
  • The influence of pelvic tilt on pelvic position
  • Simple assessments to see if you are “neutral”
  • How to adjust stretches to assure proper form and alignment
  • How to individualize lower extremity stretching based on pelvic alignment
  • What to avoid while stretching to maximize movement quality

 

To access the webinar, please be sure you are logged in and are a member of the Inner Circle program.