Table 1

Criteria-based rehabilitation programme for hamstring injury

StageContentCriteria to progress
Stage 1All activity to be pain-free
2 leg squat, or if able, single leg squat
Maintain pelvis control, hip and knee alignment, squat to 45°, hold, return to start
Supine Bridge—2 leg
2 s up, 2 s down (4 s total per rep.) Begin at 45°. Must reach knee-hip-shoulder in alignment. 4×15
supine isometric heel digs
In supine, painlessly pull heel into bed through range. Can bias with tibial IR/ER when painless.
Exercise bike
Upright or recumbent, can substitute with elliptical trainer.
Isometric manual-resisted hamstring
Therapist applied resistance isometrically in varying angles in prone
Soft tissue massage
Proximal and distal to injury site, lymphatic drainage.
Active range of motion exercises
Supine active knee flexion and extension then Prone active flexion and extension
Criteria to progress to stage 2:
  1. Painless single leg squat

  2. Painless bike, 150W 5 min

  3. Full knee extension supine

Stage 2Any exercise from stage 1 permitted, additionally:
Supine bridge—1 leg
Same rate as for 2 legs, other knee in full extension, thighs parallel throughout exercise. 4×15
Walk 20 m corners, jog the 30 m straight, painless. Begin at 25% (self-rated) jog, progress to max 70%.
Triple extension walk
100 m laps, every third step triple extension—ie, alternating legs.
Walking late swing knee extension, painless. Alternating legs, 100 m lap.
Soft tissue massage
Can massage injured area. Maximum allowed pain VAS: 4/10. Therapist uses caution with any report of discomfort, monitor symptoms, adjust accordingly
Hamstring (supine, 90° hip flexion, knee extension);
SLR (supine to onset of discomfort add ankle DF)
Initially active, patient-controlled, progress to passive, end range. SLR mobilisation if indicated.
Resisted hamstring
Note tibial rotation as indicated. 4×15 repetitions, aiming for fatigue
Criteria to progress to stage 3:
  1. Run ≥70% patient rated

  2. ROM hamstrings ≥75% uninvolved side

  3. ROM SLR ≥75% uninvolved side

Stage 3Any exercises from stages 1 and 2, additionally:
Single leg bridge
1 s repetition, 2 s recovery. 4×8 repetitions.
Single leg bridge, foot on Swiss ball
2 s up, 2 s down. 4×8 repetitions.
Interval running
20 m jog 30 m run. Begin running at 70% (patient rated), progressing by 10% steps, painlessly. At 90%, progress by 5%. Monitor performance by hand timing.
Modified T-Drill
Direction changing running over T-Drill course. Begin at patient rated 70%, progress as able by 10% until 90%, then by 5%. Monitor performance by hand timing.
Eccentric exercises
Nordic Hamstrings, manual-resisted eccentric, prone catches, Arabesque (single leg stance, trunk flexion)
Criteria to progress to stage 4 (sport-specific rehab):
  1. 100% running speed

  2. Painless high-speed direction changes

Stage 4Any exercises from stages 1–3, additionally on-field, football-specific drills:
Direction change drills
With and without the ball, 40 min
Jumping drills
10–15 min
Criteria to progress to stage 5 (sport-specific rehab): 1. Painless completion of stage 4
Stage 5Passes and run
Long passes progression
Crosses (static)
Corner kicks
Crosses (dynamic)
Criteria to progress to stage 6 (sport-specific rehab): 1. Painless completion of stage 5
Stage 6Passes and run
Shooting scenarios
Competitive 1 versus 1 drills
Shooting scenarios
Scoring scenarios
Criteria to progress to medical review for return to sport: 1. Painless completion of stage 6
  • DF, dorsiflexion; ER, external rotation; IR, internal rotation; Modified T-Drill, (always) forward running over the course of the Agility t test; ROM, range of motion; SLR, straight leg raise.