This article is adapted from a presentation by Indi Franke, Sports & Exercise Physiotherapist at Complete Physio, delivered as part of our Hamstring Injuries in Football seminar. Indi has extensive experience in elite AFL environments, including her time as a physiotherapist with the Gold Coast SUNS AFLW.
Hamstring rehabilitation in football is not a one-size-fits-all process. The location of the injury, the grade, the mechanism and the individual athlete in front of you all shape how rehab should look. What works for one player won’t necessarily work for another.
In this article, Indi draws on her experience in elite AFL sport to walk through how she approaches hamstring rehab, from the principles that guide decision-making, through each phase of recovery, to the criteria for return to play.
For background on hamstring anatomy, injury mechanisms and risk factors, see Emma Draffin’s article on hamstring injuries in football.
Rehab Principles
Before getting into the specifics of each rehab phase, there are some guiding principles that inform the whole process.
Establish an Accurate Structural Diagnosis
Getting an accurate structural diagnosis and injury classification early is important. In some cases, getting an MRI can help, particularly in the elite sport space when we are dealing with higher pressures around timeframes for return to sport.
Multidisciplinary Collaboration
Rehabilitation occurs within an integrated health and performance model. Clear roles and responsibilities across the team are important. As a physio in elite sport, working closely and collaborating with your team of health professionals is integral.
Having a close relationship with the S&C staff is particularly important with hamstring rehab, because often you’re in the rooms treating while they’re out on the field or in the gym with the athlete. There needs to be a lot of communication about how the athlete is going when you can’t see them yourself.
In community football, this is harder to achieve, but if there is a Strength and Conditioning coach or staff members around, make the most of that relationship.
Shared Decision-Making
The medical team, the coach and the athlete should all be making decisions together. The common goal is to maximise availability for full training and competition. The medical team provides information about diagnosis, risks, and the benefits of different management strategies. Re-injury risk is always considered, and in some situations a higher-risk approach may be agreed upon to achieve performance goals.
It’s often a grey area, and there are risks you need to get your head around. That’s why communication within the team is so important.
Train Movements and Muscles
The hamstrings consist of three muscles with different functional roles. Rehab exercises should target the injured muscle and its function. Sprinting mechanics must be restored, and running drills help progressively load the hamstrings through increased velocity and increased muscle lengthening.
Post-injury changes like reduced hip flexion and increased anterior pelvic tilt need to be addressed to restore sprinting mechanics. Running drills can help retrain hip flexion and horizontal force production.
Prescribe Strength Exercises for Specific Goals
Two types of strength training play important roles in hamstring rehab:
- Eccentric training (where the muscle lengthens under load, like lowering yourself in a Nordic hamstring exercise):The goals are to develop high eccentric force, reduce injury risk associated with age and previous injury, and increase fascicle length. Fascicle length refers to the length of individual muscle fibres, and longer fascicles help the muscle handle greater forces at longer positions, which is when hamstring injuries typically happen. Even low-volume eccentric training can produce improvements. However, stopping eccentric training can quickly reduce fascicle adaptations, so consistency matters.
- Isometric training (where the muscle contracts without moving, like holding a position):Potential benefits include improving tendon-related function, increasing fatigue resistance, improving motor unit recruitment and endurance, reducing neural inhibition after injury, and helping with pain.
Address Risk Factors – Be a Detective
The athlete in front of you has multiple risk factors, some modifiable and some not. Think about their musculoskeletal factors, but also their lifestyle factors, their postures in daily life, their hobbies, and anything that could be affecting hamstring loading. In elite sport, consider things like whether the athlete spends a lot of sedentary downtime gaming on a couch, for example. Do these ergonomics play a role in rehab?
Lumbar pelvic function is important. Poor pelvic control may increase strain and reduce force production. A holistic lumbar pelvic strengthening program is recommended. Hip function is also critical, with risk factors including glute weakness, reduced activation, and reduced hip flexion strength. Some athletes also have FAI (femoroacetabular impingement) symptoms that need to be managed as part of the overall picture.
The Red / Yellow / Green Rehab Model
At Complete Physio Richmond, hamstring rehab is structured into clear phases. Every hamstring injury gets mapped into a phased model straight away. The moment an injury happens on the field or in training, the thinking begins: what’s the red phase going to look like? What’s the yellow phase? What’s the green phase?
Think of it like a traffic light system:
Red means stop and protect.
Yellow means building strength and starting to run again.
Green means getting back on the field and progressing towards full contact and return to play.
Mapping this out early, including rough timeframes, helps communicate the plan to all stakeholders: the athlete, the coaches, and the medical team. It’s a big undertaking to cover everything in one conversation, which is why these kinds of visual frameworks help.
Red Phase: Regeneration (The First Few Days)
This is the early healing phase, where the body is laying down new tissue at the injury site. Getting this phase right sets the foundation for everything that follows.
Back in the day, we used to rest for 10 days and then slowly build back in. Not anymore. It’s really important to maintain anatomical function at the highest level without compromising hamstring healing.
Early immobilisation and protection for three to four days during regeneration are important because we want granulation tissue (the new tissue that forms at the injury site) with tensile strength and elasticity. We want the stumps of the injured tissue to approximate, allowing scarring. However, excessive immobilisation can create excessive fibrosis, atrophy of the muscle fibres, decreased strength, and decreased elasticity of the muscle.
The goals for this regeneration phase are to:
- prevent re-rupture
- prevent excessive inflammation and scar tissue
- increase tensile strength and elasticity of the new granulation tissue through gentle and early mobilisation
- reduce interstitial fluid build-up
- promote good neuromuscular control with restricted range of motion
- prevent atrophy
- manage pain
- restore pain-free gait
- begin controlled hamstring loading
- introduce running mechanics without high strain
Early Management
- Crutches as needed for higher grades
- Incidental walking is good if pain allows
- Compression during the day and skins at night
- No NSAIDs (anti-inflammatory medications) and no alcohol
- Referral to the team doctor and imaging to assist prognosis
Early soft tissue massage and effleurage can begin, avoiding the primary healing site. Address hip flexors, lumbar spine, pelvis and calf early. In the gym, the S&C team can get onto contralateral limb loading (training the uninjured leg for a mirroring effect) while the affected side rests. Cardio options include upper body work or swimming with a pool buoy.
How long you sit in this regeneration phase depends entirely on the player in front of you. It could be up to five days, longer, or shorter. Research has shown that returning to running within four days had a higher re-injury rate, but taking longer than four days without running didn’t delay overall return-to-play time.
Yellow Phase: Strength and Return to Running
Once the initial healing phase is underway, the focus shifts to rebuilding strength and gradually reintroducing running. This is where the bulk of the rehab work happens.
The goals are to:
- regain full voluntary neuromuscular control over the injured muscle
- regain pain-free hamstring strength from mid-range progressing to longer muscle lengths
- develop neuromuscular control of the trunk and pelvis with progressive movement speed
- gradually introduce speed exposure
- manage pain-free running up to maximal speed with direction changes
Criteria-Based vs Individual-Based Approach
Research comparing a multifactorial criteria-based approach against a general rehab protocol found less re-injury with the criteria-based approach, but return-to-play was slightly longer. The criteria commonly used in research (pain-free walk/jog, pain-free bike, pain-free submaximal isometric test before eccentric loading) are valuable, but you can get stuck in them.
If you’re waiting for someone to tick every box before starting eccentric loading, that player could end up underloaded.
It’s about being respectful of the pathology but also being a bit of a detective about what you can get out of the player.
There’s nothing wrong with trying some concentric and eccentric low-loaded exercises early to see what’s pain-free, and if that feels good, even progressing to single-leg work.
We need to be careful about the cookie-cutter approach because we could be leaving the player more likely to have recurrence.
Pain-Free vs Pain-Threshold Rehab
This is an interesting area of research. Traditionally, hamstring rehab has been guided by keeping everything completely pain-free. However, David Opar and his research group looked at pain-free versus pain-threshold rehab and found much better fascicle length with the pain-threshold approach, working up to about a 3 out of 10 on the pain scale. It didn’t accelerate return-to-play clearance but resulted in greater recovery of isometric knee flexor strength and better maintenance of biceps femoris long head. Something to consider.
Strength and Conditioning Progression
The general progression starts with isometrics (holding positions without movement) in the gym, then concentric and eccentric work at lower loads, progressing to out-of-range eccentrics depending on symptoms. Loading the coronal plane (side-to-side movements) is important. Pain-free hip abduction and adduction, Copenhagens, and standing cable work are useful. Trunk loading is obviously important throughout.
Plyometrics (jumping and bounding exercises) can start early too. There isn’t too much hamstring contribution with vertical and horizontal hopping, so double-leg forward jumps and countermovement jumps are good to start with. As things progress, move to single-leg work and further load hamstring-specific exercises.
Once you can do a single-leg hamstring slider, that’s a good marker to progress to the Nordic. You could try the Nordic earlier, but you need to be careful with the pain response. The two-up, one-down leg curl is also a good option for getting eccentric loading in.
Hip-Dominant vs Knee-Dominant Exercises
It’s important to think about hip-dominant versus knee-dominant exercises and where you get higher activation of the different hamstring muscles. For example, a stiff-leg deadlift loads the hamstrings differently from a Nordic hamstring exercise. Both appear consistently in hamstring rehab, but they target different parts of the muscle group. A complete program needs both.
Green Phase: Return to Field and Play
This is the final stage, getting the player back to full training and match play. It’s also where rushed decisions lead to re-injury, so the criteria here matter.
Criteria to Start Running
To start walk-jog progressions, we want minimal pain with walking, the ability to perform an isometric hamstring hold, and good pelvic control. We start at 60 to 65% max speed, straight line only, progressing based on pain.
From there, it’s a progression up to 70 to 80% peak speeds as tolerated. Walk-jogs progress to short runs, controlled deceleration and acceleration, then adding agility drills and arcing.
Returning to Sprinting
Returning to sprinting involves increased stride frequency and increased demand on the hip and knee, with increased demand on the non-contractile tissue (tendons, fascia), particularly at 95 to 100% speed. The hamstrings are under particular demand above 75% speed.
Multiple completed sessions at 85%, 90%, 95%, and up to maximum sprint speed are really important. Getting back to the regular GPS targets the player had prior to injury matters. A couple of sessions at high speed before clearance is important.
Returning to Kicking
Kicking is reintroduced once the player is confident with the hamstring during change-of-direction work. Start with low-level kicking and build it back up in a similar way to running, guided by pain. As they get stronger and you’re more confident with their eccentrics, progress the kicking and integrate the drills into training.
Integration and Clearance
Hop test batteries are included in the return-to-play process. One to two full training weeks should be completed prior to clearance. In AFLW with only 10 games in the season, there’s significant pressure to get players back on the field, which makes the process even more important to get right.
Maintaining Nordics During Training
There’s some discussion around when to do Nordics as players return to training. The approach is to complete running and skill-based work first, then do gym work afterward. That way the player has their recovery day following.
Red Flags for Delaying Return to Sport
There are clear warning signs that should delay return to sport. If a player is experiencing any of these, they’re not ready:
- Pain during terminal swing (the forward leg swing phase of running)
- Reduced sprint mechanics
- Hamstring tightness the next day
- Being unable to hit high sprint speed
These are predictors of re-injury.
Ongoing Prevention
Once the player is back, prevention is an ongoing process. Monitoring accelerations and high-speed running, weekly isometric strength testing, eccentric loading, lumbar and hip mobility and conditioning, and ongoing testing and monitoring of strength all matter.
You can read more about hamstring strains, treatment and recovery timelines on our hamstring strain conditions page.
Key Takeaways
Hamstring injuries are diverse and rehab should be modified based on location, grade, mechanism and category. Use research to inform your choices, but don’t be a slave to strict criteria. Be a detective about what the player can do and contributing factors to the presentation. Respect biology and tissue loading early, especially with tendon involvement.
Consider frontal plane exercises and isometrics early in rehab. Be cautious about using strength metrics and pain provocation tests alone to guide rehab. Get the most out of the tissue at every stage while ensuring you don’t cause further injury. Consider psychological readiness with every case, and continue to monitor and prevent injury with targeted training.
Get Help with Your Hamstring Injury
Dealing with a hamstring injury? Our sports physiotherapists can help you get back on the field safely.
Book an appointment at Complete Physio, 656 Bridge Road, Richmond VIC 3121.
Call (03) 9882 2020 or book online.
This article is based on a presentation from our Hamstring Injuries in Football seminar. We regularly run professional development events for clinicians. Check our clinician education page for upcoming sessions.
