Current Exercise Approaches in Hamstring Strain Injury Rehabilitation in Athletes – Review

Year 2025, Volume: 11 Issue: 2, 8 - 16, 31.07.2025

Raghad Elfarra , Rıdvan Seyhan , Demet Biçki

Abstract

A hamstring strain injury (HSI) is common in sports that involve sprinting. This injury, categorized into strain-type and sprain-type, theoretically involves the hamstring muscle-tendon unit being exposed to high force, stretching beyond its normal limits, and moving at high speed. These three factors may lead to injury, either separately or together (although not yet fully understood). This review discusses current rehabilitation approaches based on studies conducted in the last 10 years. According to the literature, an HSI rehabilitation program for athletes should include a progressive running program, Askling L protocol eccentric exercises in the early phase, and high-load exercises such as Nordic exercises in later stages. Additionally, agility training and core stabilization exercises, which significantly help prevent re-injury, are considered as essential as eccentric exercises and should be included in the program. Although evidence on flexibility exercises remains insufficient, their inclusion in the rehabilitation program is deemed harmless. For all the mentioned exercise interventions—except for flexibility—there is conclusive evidence in the literature regarding their effectiveness in reducing the risk of re-injury and improving return-to-sport timelines for athletes.

Keywords

Hamstring strain injury , Askling-L , Exercise , Risk of re-injury , Return to sport

References

• Askling, C. M., Tengvar, M., Tarassova, O., & Thorstensson, A. (2014). Acute hamstring injuries in Swedish elite sprinters and jumpers: a prospective randomised controlled clinical trial comparing two rehabilitation protocols. British journal of sports medicine, 48(7), 532-539.
• Biz, C., Nicoletti, P., Baldin, G., Bragazzi, N. L., Crimi, A., & Ruggieri, P. (2021). Hamstring strain injury (HSI) prevention in professional and semi-professional football teams: a systematic review and meta-analysis. International Journal of Environmental Research and Public Health, 18(16), 8272.
• Cuthbert, M., Ripley, N., McMahon, J. J., Evans, M., Haff, G. G., & Comfort, P. (2020). The effect of Nordic hamstring exercise intervention volume on eccentric strength and muscle architecture adaptations: a systematic review and meta-analyses. Sports Medicine, 50, 83-99.
• Danielsson, A., Horvath, A., Senorski, C., Alentorn-Geli, E., Garrett, W. E., Cugat, R., . . . Hamrin Senorski, E. (2020). The mechanism of hamstring injuries–a systematic review. BMC musculoskeletal disorders, 21, 1-21.
• Erickson, L. N., & Sherry, M. A. (2017). Rehabilitation and return to sport after hamstring strain injury. Journal of sport and health science, 6(3), 262-270.
• Hickey, J. T., Opar, D. A., Weiss, L. J., & Heiderscheit, B. C. (2022). Hamstring strain injury rehabilitation. Journal of athletic training, 57(2), 125-135.
• Hickey, J. T., Timmins, R. G., Maniar, N., Rio, E., Hickey, P. F., Pitcher, C. A., . . . Opar, D. A. (2020). Pain-free versus pain-threshold rehabilitation following acute hamstring strain injury: a randomized controlled trial. journal of orthopaedic & sports physical therapy, 50(2), 91-103.
• Jankaew, A., Chen, J.-C., Chamnongkich, S., & Lin, C.-F. (2023). Therapeutic Exercises and Modalities in Athletes With Acute Hamstring Injuries: A Systematic Review and Meta-Analysis. Sports Health, 15(4), 497-511.
• Maniar, N., Shield, A. J., Williams, M. D., Timmins, R. G., & Opar, D. A. (2016). Hamstring strength and flexibility after hamstring strain injury: a systematic review and meta-analysis. British journal of sports medicine, 50(15), 909-920.
• Mendiguchia, J., Martinez-Ruiz, E., Edouard, P., Morin, J.-B., Martinez-Martinez, F., Idoate, F., & Mendez-Villanueva, A. (2017). A multifactorial, criteria-based progressive algorithm for hamstring injury treatment. Med Sci Sports Exerc, 49(7), 1482-1492.
• O’Sullivan, L., Preszler, J., & Tanaka, M. (2022). Hamstring injury rehabilitation and prevention in the female athlete. International Journal of Sports Physical Therapy, 17(6), 1184.
• Ripley, N. J., Cuthbert, M., Comfort, P., & McMahon, J. J. (2023). Effect of additional Nordic hamstring exercise or sprint training on the modifiable risk factors of hamstring strain injuries and performance. Plos one, 18(3), e0281966.
• Ripley, N. J., Cuthbert, M., Ross, S., Comfort, P., & McMahon, J. J. (2021). The effect of exercise compliance on risk reduction for hamstring strain injury: a systematic review and meta-analyses. International Journal of Environmental Research and Public Health, 18(21), 11260.
• Severini, G., Holland, D., Drumgoole, A., Delahunt, E., & Ditroilo, M. (2018). Kinematic and electromyographic analysis of the Askling L‐Protocol for hamstring training. Scandinavian Journal of Medicine & Science in Sports, 28(12), 2536-2546.
• Silder, A., Sherry, M. A., Sanfilippo, J., Tuite, M. J., Hetzel, S. J., & Heiderscheit, B. C. (2013). Clinical and morphological changes following 2 rehabilitation programs for acute hamstring strain injuries: a randomized clinical trial. journal of orthopaedic & sports physical therapy, 43(5), 284-299.
• Vermeulen, R., Whiteley, R., Van der Made, A. D., Van Dyk, N., Almusa, E., Geertsema, C., . . . Tol, J. L. (2022). Early versus delayed lengthening exercises for acute hamstring injury in male athletes: a randomised controlled clinical trial. British journal of sports medicine, 56(14), 792-800.
• Wan, X., Li, S., Best, T. M., Liu, H., Li, H., & Yu, B. (2021). Effects of flexibility and strength training on peak hamstring musculotendinous strains during sprinting. Journal of sport and health science, 10(2), 222-229.