Hamstring Strain Grade 3: Rehabilitation Protocol (Sports Medicine)

This protocol outlines a comprehensive physical therapy rehabilitation program for a Grade 3 hamstring strain in athletes. It is a guideline and should be adapted based on individual patient presentation, pain levels, and progress. Close monitoring and communication with the athlete, physician, and coaching staff are essential. Remember to follow the principles of pain-free progression and avoid exacerbating symptoms.

Pathophysiology

A Grade 3 hamstring strain represents a complete rupture of one or more of the hamstring muscles (biceps femoris, semitendinosus, and semimembranosus). It typically occurs due to a sudden, forceful eccentric contraction, often during sprinting, kicking, or rapid changes in direction. The rupture leads to significant pain, swelling, bruising, and loss of function. Palpable defects may be present. Scar tissue formation is a crucial part of the healing process, and rehabilitation aims to optimize this process for maximal tissue strength and flexibility.

Common Special Tests

• Palpation: Careful palpation of the hamstrings to identify the location and extent of the tear. Grade 3 strains often present with a palpable defect.
• Active Knee Extension: Significant pain and inability to extend the knee against gravity.
• Passive Knee Flexion: Limited and painful passive knee flexion.
• Resisted Knee Flexion: Significant weakness and pain with resisted knee flexion, especially at the affected muscle belly.
• SLR (Straight Leg Raise): Limited range of motion and pain during straight leg raise.
• Modified Thomas Test: To assess hip flexor tightness, which can contribute to hamstring strain.
• Hamstring Length Test: Assessment of hamstring flexibility.

Phase I: Protection (Days 1-7, potentially longer depending on pain & swelling)

Goals: Control pain and inflammation, protect healing tissues, initiate gentle range of motion.

• RICE Protocol: Rest (avoid weight bearing as needed, use crutches), Ice (20 minutes every 2-3 hours), Compression (elastic bandage), Elevation (above the heart).
• Pain Management: Pharmacological interventions as prescribed by the physician (e.g., NSAIDs).
• Assistive Device: Crutches or other walking aid as needed to minimize weight bearing on the injured limb.
• Gentle Range of Motion (ROM): Initiate pain-free active assisted range of motion (AAROM) exercises for knee flexion and extension. Focus on preventing stiffness. Examples: Heel slides, pendulum exercises.
• Ankle Pumps & Calf Stretches: To promote circulation and prevent blood clots.
• Isometric Hamstring Contractions (Submaximal): Begin with very low intensity isometric contractions in a pain-free range. Focus on activating the muscles without causing pain. Example: Gently pressing heel into the ground while lying supine.
• Core Activation: Gentle core exercises (e.g., pelvic tilts, abdominal bracing) to maintain core stability without stressing the hamstrings.

Phase II: Loading (Week 2-6, progression dependent on pain and healing)

Goals: Restore pain-free range of motion, gradually increase strength and endurance, begin closed-chain exercises.

• Progressive ROM: Gradually increase the range of motion with active and passive stretching. Focus on achieving full, pain-free knee extension and flexion. Examples: Towel stretches, standing hamstring stretch (gentle, no bouncing).
• Strengthening Exercises:
  • Isotonic Hamstring Exercises: Begin with light resistance exercises (e.g., seated hamstring curls with light weight or resistance band). Focus on controlled movements and proper form.
  • Bridging Exercises: Progress from double-leg bridges to single-leg bridges as tolerated.
  • Standing Hamstring Curls (Bodyweight, then with weights): Once pain-free.
  • Romanian Deadlifts (RDLs): Introduce RDLs with light weight, focusing on proper form and hamstring engagement. Progression to heavier weights as tolerated.
  • Hip Extension Exercises: Glute bridges, hip thrusts to strengthen the glutes which synergistically support the hamstrings.
• Closed-Chain Exercises:
  • Mini Squats: Begin with shallow squats and gradually increase the depth as tolerated.
  • Lunges (Forward, Lateral, Reverse): Introduce lunges, focusing on maintaining proper alignment and control. Start with shorter steps and gradually increase the step length.
  • Step-Ups: Begin with low step heights and gradually increase the height as tolerated.
• Balance and Proprioception Exercises: Single-leg stance, wobble board exercises to improve balance and coordination.
• Soft Tissue Mobilization: Gentle massage to the hamstrings to improve tissue mobility and reduce scar tissue formation.
• Cycling (Low Resistance): Begin with stationary cycling at low resistance and gradually increase the resistance and duration.

Phase III: Return to Function (Week 7-12+, depending on sport and severity)

Goals: Restore full strength, power, agility, and sport-specific function; prevent re-injury.

• Advanced Strengthening:
  • Nordic Hamstring Exercises: Begin with assisted Nordic hamstring exercises and gradually decrease the assistance.
  • Plyometrics: Introduce plyometric exercises such as jump squats, box jumps, and bounding.
  • Sprint Drills: Begin with low-intensity linear sprints and gradually increase the speed and distance.
  • Agility Drills: Introduce agility drills such as cone drills, shuttle runs, and cutting maneuvers.
• Sport-Specific Training: Gradually integrate sport-specific activities into the rehabilitation program. Simulate movements and drills specific to the athlete's sport.
• Eccentric Hamstring Strengthening: Emphasize eccentric hamstring strengthening exercises to improve the muscle's ability to absorb force during high-speed movements.
• Progressive Overload: Continue to progressively increase the intensity and volume of training exercises.
• Functional Testing: Perform functional tests (e.g., single-leg hop test, T-test, shuttle run) to assess the athlete's readiness to return to sport.
• Gradual Return to Sport: Implement a gradual return-to-sport program, starting with limited participation in practices and gradually increasing the participation level.
• Maintenance Program: Develop a maintenance program to maintain strength, flexibility, and proprioception and prevent re-injury. This should include regular stretching, strengthening, and core stability exercises.

Criteria for Return to Sport:

• Pain-free range of motion
• Symmetrical strength (within 90% of the uninjured leg)
• Successful completion of functional testing
• Physician clearance

Important Considerations:

• Listen to the athlete's feedback and adjust the program accordingly.
• Monitor for signs of overtraining or re-injury.
• Address any underlying biomechanical issues that may have contributed to the injury.
• Educate the athlete about proper warm-up techniques, stretching, and injury prevention strategies.