Hamstring pulls, tears or strains, though 100% preventable, are a common non contact injury amongst rugby athletes. Without thorough rehab they can be an extremely frustrating injury, that can hamper a player’s career for months or even years. Following the positive reception for my guide to ACL rehab, in the following blog post I will be sharing the rough outline of the rehab model that I use for my players following a hamstring pull.
As I stated in my ACL post, what I am sharing here is a result of my experience and knowledge as a strength and conditioning coach. I am writing about when players are released by medical practitioners and I return to being fully responsible for their training. This is not intended to take the place of medical advice from a doctor or physiotherapist.
First things first: why do hamstring pulls happen?
Hamstring injuries are like any other non contact injury; they arise as a result of an imbalance between the stress demands of the environment and the tolerance of the athlete for that stress. Essentially you have asked the hamstring to tolerate forces that it is not capable of handling. Ignoring short term variables like hydration, sleep and recovery, this is usually because of one or more things from the following list:
- Lack of strength. This is specific to the conditions under which the injury happens, which most of the time is during sprinting or rapid deceleration, typically during eccentric contraction. This will be even more prevalent if the athlete is having to react to an environmental stimulus, which increases the forces associated with the skill.
- Improper positioning. Often an athlete may have the necessary force to tolerate the demands of their environment, but improper placement of the limbs puts them in mechanically disadvantageous or risky joint positions e.g. over-striding during top end sprinting. Again this may be exacerbated by reactive elements being introduced to a skill e.g. picking up a low pass or kick during top speed sprinting.
- Poor work capacity. Again the athlete may initially have the necessary force to tolerate their environment, and the necessary movement skill to maintain safe joint positioning, but lose this as the game goes on and fatigue sets in. This leads to an inability to continue to produce force at the required level, or assume the positions to do so, and the risk of injury progressively rises as the activity continues.
The rehab steps outlined will be framed in terms of the above, where the goal of the programme is to increase athlete force, positioning and work capacity relative to the demands of the game, so that they are able to eventually return to and master the activity that injured them in the first place.
Step 1: regain function
The goal of the first phase is to regain low level function of the hamstring. Without this, it is impossible to develop the broad foundation on which speed, strength, power and work capacity are built on. For this reason, before anything else can be achieved you must regain full PAIN FREE range of movement at the joint, and be able to contract the muscle properly. If you cannot do this, it doesn’t mean you can’t do anything, but it means you aren’t ready to progress to the next stage.
In this stage you should also be concentrating on regaining balance, proprioception and control in all three planes of movement (where appropriate) in fundamental movement patterns, on both one leg and two. The re-gaining of muscle mass with lower level resistance work (compex assisted weight training, and occluded weight training are both very useful here) should also be targeted if you have suffered from any atrophy.
Step 2: regain strength and power
Once you are moving like a human being again, your focus in the gym should switch to development of force, specifically maximal strength as this will be beneficial in its own right to performance but it also lays the foundation for the development of more specific forms of strength and power down the line.
There should also be a heavy emphasis on the development of eccentric strength as the research is fairly unequivocal here- if you lack eccentric strength, you are far more likely to suffer from hamstring injuries. Though Nordic curls get a lot of love in the research on hamstring injuries, I personally am not convinced there are any more special than any other exercise. I think any exercise that allows you to get a good stretch in the hamstring, go heavy and concentrate on the eccentric portion is a good candidate. Triphasic style training can also be very helpful in this stage.
Power should also be targeted alongside strength development, as we have to remember that sporting movement requires force to be produced in a short space of time and at high movement velocities. Again, many people advocate the Olympic lifts to achieve this, but I am not convinced as most athletes butcher them even after years of coaching, and I think to coach them is an in appropriate use of training time. For me stuff like heavy KB swings, speed deadlifts, jump squats and between the legs med ball throws are fine.
Step 3: regain speed in a closed environment
After the base of strength and power has returned the next thing that must be re-gained is speed, both acceleration and top speed. This should be reintroduced gradually, with the focus being on sprint drills and tempo only in the initial stages. The reasons for this are a few fold:
- To re-learn the important positions that you need to get in and stay in to run as fast as possible.
- To progressively increase the force, speed and stretch the hamstrings are exposed to.
- To indicate which movements if any within the sprint action may be more problematic, and need more caution within the rehab process.
As the athlete becomes more and more comfortable with drills, and the intensity of tempo work is increased, the focus should shift progressively more towards higher force and speed activities. In the intermediate stage this will take the form of sled sprints, hill sprints and band resisted sprints for acceleration, and build ups for top speed sprinting. The culmination of this phase is full intensity accelerations and flying sprints. Longer sprints may also be added in to stress sprinting mechanics under a moderate amount of fatigue.
Note that at this stage no temporal or spatial reactivity is added to the skill. This is because such tasks represent a step up in force, speed and technical demands which the body is not yet prepared for. You have to earn the right to perform such work by first returning to and mastering sprinting at full speed in a closed environment. The same principles underpin the reintroduction to agility training.
Step 4: perform speed in an open environment
After you have returned to your pre-injury values for acceleration or top speed, the force, speed and technical demands of sprinting and changing direction tasks must increase closer to those seen in the field of play. This means adding in stimuli to the training environment which you or your athletes must react to, which pushes up the forces the hamstrings are exposed to, but also draws attentional focus away from maintaining safe joint positioning.
The stimuli you expose yourself or your athletes can take many forms e.g. visual cues, auditory cues, as can the tasks you have to perform e.g. change gears, decelerate, change direction etc. however my advice is to keep it simple. This is especially true in the earlier stages of the phase, where it is best to work with pre-planned outcomes and low numbers of environmental stimuli that have to be attended to.
As technical mastery improves and the hamstrings are being exposed to progressively higher levels of force and speed, it will be appropriate to increase the number of stimuli you have to attend to (e.g. from one whistle to multiple players), and the possible motor responses (e.g. beating a defender with whatever pattern you want). The phase should culminate with the most game realistic situations being performed at full speed (and at full contact as I will assume you are running your return to tackle/contact protocol alongside this!).
Step 5: perform all the above under fatigue, then re-integrate into rugby
The final piece of the puzzle is to take everything that has been done in the first 4 phases, and stress all the elements under fatigue. Progressively reduce the rest periods down to those seen in the game (at its worst) and pay close attention to the ability of you or your athletes to continue to produce force and maintain technique under fatigue. If you can do this pain free and with good technique, it is time to reintegrate back into rugby.
Reintroduction to rugby should be progressive. The athlete should begin with the most controllable, predictable forms of practice e.g. set piece practice or 2 vs 1, then progressed to semi controlled forms e.g. semi opposed, small sided opposed drills, then finally to full intensity practices e.g. full and small sided game scenarios. Lastly, the player should be introduced to lower level games (if possible) firstly as a sub, then building up the game time until a full 80 minutes is played (or your regular maximum for your position), before the process is repeated again at your regular level of rugby.
It goes without saying that pain or significant deterioration in technique or force production at any stages means the athlete must regress back to the previous level. There is also no set time limit for each phase. The progression here is performance based, and you do not progress until you master your current level of training.