In a previous post, it was made a conceptual clarification and classification of the types of hamstring injuries (muscular or tendinous), differentiated by severity (go to post). This post aims to specifically summarized the rehabilitation program and RTP process of Hamstring strain injury in soccer, differentiate the phases of treatment and knowing the main injury mechanisms for hamstring strain injuries with the final objective of to be able to program a recovery and progressive return to play (RTP) process with our soccer players, based on the scientist knowledge (mainly systematic reviews and meta-analysis).
The hamstring injury is the most common injury in soccer, with an injury rate of 12% of total injuries (1). In addition, the reinjury rate in soccer is high (12-33%) which, in most cases, probably indicates inadequate rehabilitation programmes and/or premature return to football (2). Of these recurrences, 59% occur within the first month after RTP. Therefore, it is of paramount importance to design an appropriate rehabilitation programme and timing to optimize the RTP process. However, to date there are not validated RTP criteria to facilitate hamstring injury management (3).
Main injury mechanisms (4,5)
- Sprinting activity
- During the latter part of swing phase, decelerating knee extension (changing from functioning eccentrically to concentrically).
- Stretching actions
- Actions of large joint excursions (high kicks, quick stretching movements, …)
Etiological factors (4)
Non-modifiable risks (internal)
- Older age
- Black or aboriginal ethnic origin
- Injury history
- Level of sport
Modifiable risk factors (external)
- Muscular imbalances (low hamstring-quadriceps ratio)
- Poor flexibility
- Fatigue (muscles are able to absorb less energy before reaching the degree of stretch that causes injuries)
- Psychological state
Phases of Hamstring strain injury treatment (4)
Phase I (acute): 1-7 days
- Goal: control hemorrhaging and minimise inflammation and pain.
- NSAIDs are accepted. Controversy with appropiate timing: 3-7 days after injury.
- Early motion exercise is important to prevent or decrease adhesion within the connective tissue.
- Active knee flexion and extension exercises (ice post-training)
- Exercises must be Pain-free.
Phase II (subacute): day 3 to > 3 weeks
- This phase begins when the signs of inflammation (swelling, heat, redness, and pain) begin to resolve.
- Continue muscle action to prevent atrophy and promote healing.
- Concentric strength exercises (when the athlete has achieved full ROM without pain).
- Multiple joint angle, submaximal isometric contraction.
- Decrease the intensity with pain.
- Other cardiovascular activities: biking, swimming.
Phase III (remodelling): 1-6 weeks
- Stretching exercise to avoid the loss of flexibility in hamstring (characteristic feature of hamstring strains due to pain, inflammation, and connective tissue scar formation).
- Eccentric exercises (always after concentric exercise are begun because eccentric contractions cause greater forces).
- the eccentric exercises are delayed until the injured muscle is well regenerated.
Phase IV (functional): 2 weeks to 6 months
- Goal: RTP without reinjury.
- Increase hamstring strength and flexibility to the normal values for the individual player (before injury).
- Pain-free running activities (from jogging at low intensity to running and finally sprinting).
- Pain-free participation in soccer-specific activities (best indicator of readiness to RTP).
- Return to competition before this time may result in recurrent or more severe injury.
Phase V (return to competition): 3 weeks to 6 months
- When the athlete has returned to competition, the goal is to avoid reinjury.
- Focus: maintaining stretching and strengthening.
Main training tasks
Generally, the rehabilitation program and RTP process of hamstring strain injury in soccer should be based on hamstrings strengthening mainly through eccentric training; the Core stability training; and the sprinting activity, focused on accelerations and high-intensity actions, becoming the most important training subjects in the last phases of RTP as it is a predominant type of activity in soccer.
- Eccentric contractions
- Core stability
- Running activity (sprint and acelerations)
- Soccer-specific actions.
To date, no consensus on RTP-criteria for hamstring strain injuries has been validated yet. The following criteria are the most important according to different systematic reviews and meta-analyses (3–10):
- Muscle strength
- Isokinetic dynamometry: Concentric, eccentric.
- Manual assessment of isometric knee flexor strength
- H:Q ratio ≥ 0.55
- Limb strength imbalance (LSI) <10% – comparing with the uninjured leg and data before injury.
- Flexibility (complete ROM)
- Complete pain-free
- Pain-free sprinting
- Pain-free palpation
- Player’s confidence
- Functional soccer-specific performance
- Single-leg triple hops
- Medical clearance
- Askling H-test
- Capacity to train with the team normally (no pain or discomfort)
Figure 1 shows the coding of criteria for RTP after hamstring strain injury retrieved from the systematic review of Van der Horst (3).
- There is a high percentage of reinjury for hamstring strain injury in soccer.
- There is a need to established a consensus RTP-criteria and recovery program for hamstring strain injuries.
- The Askling H-test shows lower percentage of reinjury, but the recovery time is longer.
For a detailed description of the rehabilitation program and RTP process of Hamstring strain injury in soccer, please refer to the studies cited.
- Ekstrand J, Hägglund M, Waldén M. Injury incidence and injury patterns in professional football: The UEFA injury study. Br J Sports Med. 2011; 45(7): 553–8.
- Askling CM, Tengvar M, Thorstensson A. Acute hamstring injuries in Swedish elite football: a prospective randomised controlled clinical trial comparing two rehabilitation protocols. Br J Sports Med. 2013; 47(15): 953–9.
- van der Horst N, van de Hoef S, Reurink G, Huisstede B, Backx F. Return to Play After Hamstring Injuries: A Qualitative Systematic Review of Definitions and Criteria. Sport Med. 2016; 46(6): 899–912.
- Petersen J, Hölmich P. Evidence based prevention of hamstring injuries in sport. Br J Sports Med. 2005; 39(6): 319–23.
- Askling CM, Nilsson J, Thorstensson A. A new hamstring test to complement the common clinical examination before return to sport after injury. Knee Surgery, Sport Traumatol Arthrosc. 2010; 18(12): 1798–803.
- Zambaldi M, Beasley I, Rushton A. Return to play criteria after hamstring muscle injury in professional football: a Delphi consensus study. Br J Sports Med. 2017; 51(16): 1221–6.
- Hickey JT, Timmins RG, Maniar N, Williams MD, Opar DA. Criteria for Progressing Rehabilitation and Determining Return-to-Play Clearance Following Hamstring Strain Injury: A Systematic Review. Sport Med. 2017; 47(7): 1375–87.
- Maniar N, Shield AJ, Williams MD, Timmins RG, Opar DA. Hamstring strength and flexibility after hamstring strain injury: A systematic review and meta-analysis. Br J Sports Med. 2016; 50(15): 909–20.
- Mendiguchia J, Martinez-Ruiz E, Edouard P, Morin JB, Martinez-Martinez F, Idoate F, et al. A Multifactorial, Criteria-based Progressive Algorithm for Hamstring Injury Treatment. Med Sci Sports Exerc. 2017; 49(7): 1482-1492.
- Brukner P, Nealon A, Morgan C, Burgess D, Dunn A. Recurrent hamstring muscle injury: applying the limited evidence in the professional football setting with a seven-point programme. Br J Sports Med. 2014; 48(11): 929–38.
S&C Coach | Rehab Therapist | Sport Scientist
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This article has been made based on the references showed, other studies reviewed but not showed and according to the experience and knowledge of the author. In this way, it may include subjective ideas and opinions not contrasted in the research.