Hamstring strains continue to be one of the most common injuries in sports. Returning these athletes to play can sometimes seem daunting.
When is it safe to start running? Do you have to wait until they are pain-free?
We answer these questions and more in this episode.
To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 329: When is it Safe to Start Running After a Hamstring Strain?
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Yeah, it’s me. So, a really great question from Brad from Santa Fe. He asked, “One thing that I struggle with is knowing when to start running after a hamstring strain. Is there any criteria that you guys use?”
Thank you. All right, good job, Tara. Brad, good question. I’d like to know this answer too, because this sometimes seems like a mystery to all of us. But you know what I like about this is Brad’s a little specific too. So, when to start running after a hamstring strain? Great, great question. And by the way, I’ll just start the episode with this. Hamstrings are bananas right now, right? There’s so many hamstring strains going on in professional sports and stuff. You see it in all the field sports. If you watch the NFL, it looks like there’s several every week, right? Some of us are losing our star first-round wide receiver, Justin Jefferson.
It’s a challenging thing that happens in all of sports right now that we’re not controlling. So, Major League Baseball, we’re starting a task force to try to figure this out because it’s getting so carried away and we’re going to the other leagues that already have a task force and still aren’t controlling it. So anyway, this is a tough subject, Brad. So anyway, who would like to start this? I know Kevin’s been dying for this. You want to jump in on, Kevin? Kevin’s kind of been doing a bunch of great hamstring work with us at Champion, but Kevin, why don’t you start this off?
Yeah, I was excited to see this question just because I feel like I’ve had so many of these on my caseload recently and I’ve learned a lot in the process of trying to figure out when to get back to running. So, it does seem like if we could say the grade of the hamstring strain will dictate when you’re going to start, maybe just a higher grade will take longer. But the criteria that we try to use is mostly derived from the Aspetar Protocol. And after talking with Mike, your PT at the White Sox, Brooks, had some good insight and he seems to mostly use that protocol as well. And it has a lot of good indicators on when to start running. So, kind of the first criteria, regardless of the grade, is the person should have some pain-free walking. So, what we’ve found is you can really start exercising these people very, very early.
And I think in the past, I would’ve been too conservative and waited too long to start doing some higher-level exercises. So, when you’re doing basic concentric/eccentric exercises, the total EMG load and the stress through the hamstring isn’t even nearly as high as it is when you’re sprinting. So when those people strain their hamstring, it’s usually with sprinting, changing direction, standing on one leg, and reaching in soccer for a ball. They’ll get a strain that way. So, those high-force, high-speed movements are where they’re straining. So, eccentric/concentric exercises are usually tolerated pretty early. And so I think about that from a strength standpoint. And then from a cardiovascular standpoint, they can do some work on the bike. Once they’re pain-free with walking, if we think about an RPE scale where zero out of 10 is the slowest speed that they can jog, that’s not a walk.
We start with that, and depending on the sport and how far they need to run, we could say, “All right, maybe start at something arbitrary like 90 feet or 120 feet and we have them do eight or 10 reps of that zero out of 10 effort.” And depending on monitoring pain and how they feel next session, which could be the next day, we go up to one out of 10. And that would be the most conservative approach where going up each time, you’re going up on a percentage of sprint RPE. So, 10 out of 10 max effort sprint. That’s usually a pretty nice linear progression until they get to the later stages, eight, nine out of 10 when they’re into higher levels and you’re getting more EMG of the hamstring. And then we are a little more conservative, but other criteria that I use aside from pain-free walking to start running is we’re measuring very often, every session. Essentially if I’m seeing the person once a week, we’re measuring different positions of the hamstring with the dynamometer and we’re measuring muscle length.
So, the way that we do that is supine hip 90, knee 90. We’ll measure the hamstring strength there and then we’re going to measure prone, 30 degrees of knee flexion, and prone, 90 degrees of knee flexion, for muscle strength. And then for muscle length, we do the max hip flexion, active knee extension measurement. So, the patient’s supine, we stabilize the contralateral leg, and then the leg we’re testing. They hug into their chest and kick their leg straight and we’re measuring the degree of knee flexion. So, those give us baselines and those are something we track all the time, and we’re looking for something like less than 10% asymmetry where we’re looking at their pain as well and trying to get a gauge for how that is. And I believe a couple studies have shown that with daily tracking of the max hip flexion, active knee extension, and the supine 90/90 strength… As those metrics improve in testing, the person seems to subjectively feel better running.
So, we know if those two things are improving, we’re confident that going out into the gym that day, their running is going to feel probably better than it did the previous session. So, I think it’s frequent testing. We’re making sure that these things are improving, but we’re trying to give the person as much as they can do without pushing too much. I mean, it’s definitely a balance. And sometimes I might feel like I’m going a little too slow, but I think I’d rather go a little too slow when restrains happen so often. But again, that does depend where they are in their season. If they’re really trying to get back, you just talk to the person like, “All right, we’re running. It seems a little risky given the numbers, but if you understand the risk and you want to take it, that’s totally fine with me.” I leave it up to the patient, but as long as they know it’s a little earlier than we want to, but shared decision making, this is your time to get back, then we’ll try to push it a little bit.
Awesome. Gosh, Kevin, that was a great answer. I really appreciate that. Really thorough and great stuff. I do have an article on my website on evaluating hamstring strains that actually shows some of the concepts that Kevin just talked about from our friend Brooks Klein, our old friend from Champion. But just so people are clear, if you need some visuals on some of that stuff, it could be really helpful there. Big thing I think that Kevin said right there that I think we all have been guilty of, including Kevin himself, he said, is that “Sometimes we do almost feel like we wait too long.”
And I think it’s important we do start doing some stuff when there is a little discomfort. And I think that’s one of those things. It’s almost like a leap of faith at the beginning, but remember a hamstring strain man, hamstring strains happen with max sprints all the time. It’s very rare that they happen with a jog, right? It’s in an athletic population. So, there is a huge scale of intensity of hamstring from walking to jogging, to running to sprinting. It is an enormous scale. So, keep that in mind. But who else? I mean, Kevin nailed that. Anybody else have any other input they want to add? I mean, it’s hard to top that from Kevin, but I like it. Dan, what do you think?
Yeah, and what I will say, and like you said, who knows if this is actually right. Oftentimes these strain injuries are happening in the middle of the season and there’s very important stuff coming up. So, we don’t always have the opportunity to be conservative. Obviously, you can stop and miss all those games, right? But that’s not really what the patient wants. What I will say is there’s tremendous variation from patient to patient, and oftentimes people improve very, very quickly. So, usually for these folks, I like to see them a couple times per week early on just because if you see them a couple days after a strain, then let’s say two to three days past that, they’re quite a bit better. So oftentimes I will, if they’re feeling good, walking well, strength is decent, doesn’t seem like it’s that aggravated, I start running that day and I actually try a little bit of acceleration, a little kind of top end stuff, not very high, and just kind of see where they’re at.
If they’re tolerating that decently well, that’s what I’ll prescribe. I don’t want that person to de-condition at all if possible. We want to get them back as fast as possible and then a couple of sessions later, I retest and we can just kind of go up based on their symptoms. Is this the best, safest way to do it? I don’t know. But I think the other part is that oftentimes we’re not in these perfect situations. We can slowly ramp up. Like I said, it’s happening in the middle of a season and there’s important things coming up that we’re trying to meet. So, I think it’s very much you see what the patient is kind of presenting as, and just prescribe things to them based on whatever level they’re at.
Yeah, Dan. And if you’re gradual and you just start some jogging and it’s a little too uncomfortable, then I don’t think you’ve done any damage either, right? All you’ve done is just… It’s almost like checking hamstring length and like, okay, yeah, it’s a little sore now at this end range. The intensity or the stress on the hamstring is so low with a jog that I think that’s fairly safe. I’ve never had anybody restrain their hamstring by doing some early jogging, and I think that’s a way of doing it. So, awesome. Great stuff. I mean, that was a good episode. Strength coach wise, do you guys have any input from your end? And I think this is maybe where we like some of the later-stage transition stuff, but I don’t know. Jonah, any thoughts on anything you’d do different in the gym or how you would approach this with your athletes?
Yeah, I guess kind of two different parts. One is within the actual running, I think it’s important to figure out what aspects of sprinting or running they can tolerate. So, I’ve seen cases where athletes can handle early acceleration at a pretty high intensity in maybe only three to five yards. So, three steps, four steps, but that’s totally tolerable. So in those cases, I think I would want to keep working on that early acceleration and possibly also do some resisted sprinting because that keeps you in those acceleration postures longer. And then over time, gradually increase how far you’re running, how close to upright sprinting you’re getting. Whereas in other cases, I have seen actually where the acceleration postures don’t feel good, but a little bit more upright running feels fine, in which case something like a Woodway Sprint works really well because you start upright right away and you just gradually pick up your speed.
So, finding the running that feels tolerable is one piece. And then the other is what are things we can do in the gym that work very similar to our sprinting positions without actually running? So, when it comes to acceleration-based stuff, maybe band resisted marching, band resisted switch drills where you’re in those exact same postures, same movements, but the overall loads are lower. And then that’s something that easily can transition into sprinting over time. Whereas on the top-end speed, it might be more of our plyo type stuff. So, single leg hurdle hops with quick ground contact times where again, it’s very similar positions to what you’re getting from sprinting, but it’s going to be less stress on the hamstring. So that way when we, like Dan was talking about, we don’t want to let our athletes get de-conditioned. So, when they can start to tolerate sprinting, we’ve been working a lot of those exact same qualities and that transition back to running will be a lot easier.
That’s great. And the exercise is part of the assessment, right? As you go through that, their tolerance to the exercise and their performance of the exercise is part of the assessment. So, great stuff. I love it. Brad, great question about hamstring strains that we’re all dealing with. If you have a question like that, head to mikereinold.com and please head to Apple, Spotify and be sure to rate, review, subscribe, and we’ll see you on the next episode. Thanks so much.