Table 1

Criteria-based rehabilitation programme for hamstring injury

Stage	Content	Criteria to progress
Stage 1	All 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: Painless single leg squat Painless bike, 150W 5 min Full knee extension supine
Stage 2	Any 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-Jog 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. ‘A’ drill 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 Stretching 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: Run ≥70% patient rated ROM hamstrings ≥75% uninvolved side ROM SLR ≥75% uninvolved side
Stage 3	Any 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): 100% running speed Painless high-speed direction changes
Stage 4	Any 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 5	Passes 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 6	Passes 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.