Content uploaded by Marc A Sherry
Author content
All content in this area was uploaded by Marc A Sherry
Content may be subject to copyright.
A Comparison of 2 Rehabilitation Programs
in the Treatment of Acute Hamstring Strains
Marc A. Sherry, PT, LAT, CSCS
1
Thomas M. Best, MD, PhD
2
Study Design: Prospective randomized comparison of 2 rehabilitation programs.
Objectives: The objectives of this study were to compare the effectiveness of 2 rehabilitation
programs for acute hamstring strain by evaluating time needed to return to sports and reinjury rate
during the first 2 weeks and the first year after return to sport. A third objective was to investigate
the relationship between functional testing performance and time to return to sports and reinjury
rates after return to sport.
Background: Hamstring muscle strains are common in sports and often result in chronic pain,
recurrent hamstring strains, and reduced sports performance. Current rehabilitation programs are
primarily developed anecdotally and lack support from prospective, randomized research.
Methods and Measures: Twenty-four athletes with an acute hamstring strain were randomly
assigned to 1 of 2 rehabilitation groups. Eleven athletes were assigned to a protocol consisting of
static stretching, isolated progressive hamstring resistance exercise, and icing (STST group).
Thirteen athletes were assigned to a program consisting of progressive agility and trunk
stabilization exercises and icing (PATS group). The number of days for full return to sports, injury
recurrence within the first 2 weeks, injury recurrence within the first year of returning to sports,
and lower-extremity functional evaluations were collected for all subjects and compared between
groups.
Results: The average (±SD) time required to return to sports for athletes in the STST group was
37.4 ± 27.6 days, while the average time for athletes in the PATS group was 22.2 ± 8.3 days. This
difference was not statistically significant (P = .2455). In the first 2 weeks after return to sports,
reinjury rate was significantly greater (P = .00343, Fisher’s exact test) in the STST group, where 6
of 11 athletes (54.5%) suffered a recurrent hamstring strain after completing the stretching and
strengthening program, as compared to none of the 13 athletes (0%) in the PATS group. After 1
year of return to sports, reinjury rate was significantly greater (P = .0059, Fisher’s exact test) in the
STST group. Seven of 10 athletes (70%) who completed the hamstring stretching and strengthening
program, as compared to only 1 of the 13 athletes (7.7%) who completed the progressive agility
and trunk stabilization program, suffered a recurrent hamstring strain during that 1-year period.
Conclusions: A rehabilitation program consisting of progressive agility and trunk stabilization
exercises is more effective than a program emphasizing isolated hamstring stretching and
strengthening in promoting return to sports and preventing injury recurrence in athletes suffering
an acute hamstring strain. Future randomized clinical trials should investigate the potential for
progressive agility and trunk stabilization programs in the prevention of hamstring strain injury
during sports. J Orthop Sports Phys Ther 2004;34:116-125.
Key Words: agility, injury recurrence, muscle injury, physical therapy, stretch-
ing
1
Senior Physical Therapist, University of Wisconsin Health Sports Medicine Center, Madison, WI.
2
Associate Professor, Department of Orthopaedics and Rehabilitation, Division of Sports Medicine,
University of Wisconsin Medical School, Madison, WI.
The protocol for this study was approved by The Health Sciences Human Subjects Committee of the
University of Wisconsin. The University of Wisconsin Sports Medicine Research Classic Fund provided
grant support for the study.
Address all correspondence to Marc A. Sherry, 621 Science Drive, Madison, WI 53711. E-mail:
ma.sherry@hosp.wisc.edu
H
amstring strains in
sprinters and ath-
letes who perform
high-speed skilled
movements are
common injuries and pose compli-
cated rehabilitation challenges, es-
pecially when returning athletes
quickly and safely to sports partici-
pation.
1,4,5,8,13,18,22
A 4-year study
3
of injury rates for the Memphis
State University football team
showed that hamstring strains were
the third most common
orthopaedic problem after knee
and ankle injuries. Hamstring inju-
ries often result in significant re-
covery time, along with a lengthy
period of increased susceptibility
for recurrent injury.
10,20,22
The
highest risk for injury recurrence
appears to be within the first 2
weeks of return to sports.
20
A
study that analyzed 858 hamstring
strains in Australian Footballers
showed that the rate of recurrence
was 12.6% during the first week of
return to sports and 8.1% during
the second week. The cumulative
risk of reinjury for the entire 22-
week season was 30.6%.
20
Another
study reported that 15 out of 30
sprinters who suffered hamstring
strains had previously strained
their hamstring.
13
There is a lack of clinical re-
search regarding the effectiveness
of various rehabilitation programs
for acute hamstring strains. Not
surprisingly, a lack of consensus
also exists in the content of these
rehabilitation programs. Worrell
26
116 Journal of Orthopaedic & Sports Physical Therapy
Journal of Orthopaedic & Sports Physical Therapy
Official Publication of the Orthopaedic and Sports Physical Therapy Sections of the American Physical Therapy Association
Please start my one-year subscription to the JOSPT. Please renew my one-year subscription to the JOSPT.
Individual subscriptions are available to home addresses only. All subscriptions are payable in advance, and all rates include
normal shipping charges. Subscriptions extend for 12 months, starting at the month they are entered or renewed (for example,
September 2002-August 2003). Single issues are generally available at $20 per copy in the United States and $25 per copy when
mailed internationally.
USA International Agency Discount
Institutional
$215.00 $265.00 $9.00
Individual $135.00 $185.00
Student
$75.00 $125.00 Subscription Total: $________________
Shipping/Billing Information
Name _______________________________________________________________________________________________
Address _____________________________________________________________________________________________
Address _____________________________________________________________________________________________
City _______________________________State/Province __________________Zip/Postal Code _____________________
Phone _____________________________Fax____________________________Email _____________________________
Would you like to receive JOSPT email updates and renewal notices? Yes No
Payment Information
Check enclosed (made payable to the JOSPT).
Credit Card (circle one) MasterCard VISA American Express
Card Number ___________________________________Expiration Date _________________________________________
Signature______________________________________Date __________________________________________________
To order call, fax, email or mail to:
1111 North Fairfax Street, Suite 100, Alexandria, VA 22314-1436
Phone 877-766-3450 • Fax 703-836-2210 • Email: subscriptions@jospt.org
Thank you for subscribing!
Subscription
Start/Renew Form
proposed a rehabilitation program based on the
tissue’s theoretical healing response. The 4-phase
program theorized that progressive stretching and
strengthening of the injured tissue would help to
remodel and align collagen fibers in the scar tissue.
26
The acute phase (2-4 days) consisted of control of
inflammation and early motion of the lower extremity
in the sagittal plane. The subacute period consisted
of stationary biking, isolated hamstring progressive-
resistance exercises, and pain-free stretching. The
remodeling phase consisted of continued, isolated,
hamstring progressive-resistance exercises (PREs),
with the addition of eccentric exercise and continued
hamstring stretching. The functional phase included
jogging, sprinting, sport-specific drills, and continued
hamstring strengthening and stretching.
26
Other au-
thors have described similar programs.
1,5,17
Because
the pelvis is the origin attachment site for the
hamstring muscles, it has been suggested that
neuromuscular control of the lumbopelvic region,
including anterior and posterior pelvic tilt, is needed
to create optimal function of the hamstrings in
sprinting and high-speed skilled movement. Changes
in pelvic position could lead to changes in length-
tension relationships or force-velocity relationships.
This has led some clinicians to utilize various trunk
stabilization and progressive agility exercises for ham-
string rehabilitation programs.
2,14,25
Trunk stabiliza-
tion and neuromuscular control exercises have also
been shown to be effective in promoting return to
sports in athletes with chronic hip adductor pain.
12
To date, most prospective research on hamstring
strains has focused on preventative measures and
treatment of chronic hamstring strains.
2,7,9,13,16,21,22
To our knowledge, there are no prospective, random-
ized studies in the literature investigating the effec-
tiveness of different rehabilitation programs for the
treatment of acute hamstring strain. The main objec-
tives of this study were to compare the effectiveness
of 2 rehabilitation programs for acute hamstring
strain by evaluating (1) time needed to return to
sports and (2) reinjury rate during the first 2 weeks
and the first year after return to sport. A third
objective was to investigate the relationship between
functional testing performance and time needed to
return to sports and to determine if these tests could
guide return to sport after an acute hamstring strain.
METHODS
Subjects
Subjects were recruited using posters and contact
with local physicians, athletic trainers, and physical
therapists. Twenty-eight subjects were enrolled and 4
did not complete the rehabilitation phase of the
study. One subject was involved in a motor vehicle
accident and could not continue the exercise pro-
gram. Two subjects sustained minor injuries, unre-
lated to their rehabilitation program, which limited
their ability to complete the rehabilitation program at
the minimum rate of at least 70%. One individual did
not follow up for his scheduled appointment or
return a phone call. His status is unknown. Of these
4 subjects excluded due to noncompliance, 3 were in
the progressive agility and trunk stabilization (PATS)
group and 1 was in the hamstring stretching and
strengthening (STST) group. All subjects were partici-
pating in sport activities (Table 1).
A 4-block fixed-allocation randomization process
was used to assign subjects to 1 of 2 intervention
groups (Table 2). This process allowed stratification
for age and sex, eliminating any potential bias these 2
variables may present. The fact that 4 subjects did not
complete the study disrupted our ability to have
exactly the same number of males and females within
TABLE 1. Sport activities performed by individuals in the stretching and strengthening (STST) group and the progressive agility and
trunk stabilization (PATS) group.
STST PATS
Subject # Sports Subject # Sports
1 Baseball, football 1 Football, track (sprinter)
2 Football, track (sprinter) 2 Running, tennis
3 Football, basketball,
soccer, track (sprinter)
3 Track (sprinter/jumper)
4 Softball, ultimate Frisbee,
racquetball
4 Soccer
5 Softball, basketball 5 Track (sprinter)
6 Softball 6 Softball
7 Triathlon training 7 Soccer
8 Tennis 8 Soccer
9 Baseball, football, hockey 9 Track (sprinter/jumper)
10 Baseball, football 10 Soccer
11 Cross-country, basketball 11 Softball
12 Baseball, basketball
13 Track (sprinter)
J Orthop Sports Phys Ther • Volume 34 • Number3•March2004 117
RESEARCH REPORT
TABLE 2. Subject demographics for the individuals in the
stretching and strengthening (STST) group and the progressive
agility and trunk stabilization (PATS) group.
STST PATS
Mean age ± SD (y) 24.3 ± 12.4 23.2 ± 11.1
Age range (y) 14-49 15-49
Males (n) 9 9
Females (n) 2 4
Males, age 14-30 y (n) 8 8
Females, age 14-30 y (n) 1 2
Males, age 31-50 y (n) 1 1
Females, age 31-50 y (n) 1 2
each group. The injuries were classified as first- or
second-degree strains based on Craig’s
6
original de-
scription (Table 3). But this classification system has
some subjectivity and there is a lack of research
correlating injury grade and time for recovery from
injury; therefore, it was not used in the randomiza-
tion process.
Eleven subjects were randomly assigned to the
STST group (Table 4), while 13 subjects were ran-
domly assigned to the PATS group (Table 5). In the
STST group, 7 subjects had a first-degree hamstring
injury and 4 subjects had a second-degree injury. In
the PATS group, 5 subjects had a first-degree injury
and 8 subjects had a second-degree injury. Subjects
were considered to have a hamstring strain if they
had a mechanism of injury likely leading to strain
injury of the hamstring muscles (Table 6), tenderness
to palpation within the muscle-tendon unit of the
hamstring, pain with resisted prone knee flexion,
pain with passive tension testing using a passive
straight leg raise test, and a limitation of daily or
sport activity. Acute injury was defined as an initial
injury that occurred within the past 10 days.
Exclusion criteria included nonacute hamstring
injuries, a subject not being at least 14 years of age or
less than 50 years of age, current other lower-
extremity injuries, complete muscle disruption, avul-
sion injuries, clinical findings suggesting inguinal or
femoral hernia, radiculopathy, history of malignant
disease, incomplete healing and rehabilitation of
pelvis or lower-extremity fractures, coexisting pelvis or
lower-extremity fractures, clinical findings showing
nerve entrapment, any other impairment limiting
participation in the rehabilitation program, or lack of
daily compliance (less than 70%) with a home
exercise program.
One potential subject was excluded because he had
sustained a full-thickness tear of the semimem-
branosus and semitendinosus at the proximal muscle
tendon junction, confirmed by magnetic resonance
imaging. Another potential subject was excluded
because the physical exam demonstrated posterior
thigh pain that was not consistent with a hamstring
strain. Two subjects who inquired about the study
FIGURE 1. Hamstring stretch with slow side-to-side rotation, with
rotation primarily occurring at the hips as the chest rotates from
being over the left leg to being over the right leg.
were excluded because they did not meet the age
criterion (14-49 years of age). Seven subjects were
excluded because their hamstring injury occurred
more than 10 days prior to contacting us. Ten
subjects that contacted us via the Internet excluded
themselves upon learning that they would need to be
evaluated and supervised at our clinic. All of these
subjects lived in other states.
Subjects agreed not to take nonsteroidal anti-
inflammatory medication or receive any other form
of treatment during the study. The study protocol was
approved by The Committee for Human Subjects at
the University of Wisconsin at Madison. Each subject
signed an informed consent form and the rights of
each subject were protected throughout the course of
the study. If a subject was less than 18 years of age, a
legal guardian also signed a statement of informed
consent.
Procedure
All potential subjects underwent a 30-minute initial
history and physical examination session by the lead
author to determine if they met the inclusion criteria.
Subjects were then randomly assigned to 1 of 2
intervention groups. Of note, 1 subject in the PATS
group had had a previous hamstring injury on the
contralateral leg, whereas 2 subjects in the STST
group had had a previous hamstring injury on the
contralateral leg. There were no subjects in either
group with a previous hamstring strain on the same
leg.
118 J Orthop Sports Phys Ther • Volume 34 • Number 3 • March 2004
TABLE 3. Muscle Injury Classification System.
6
Grade Pathophysiology Signs and Symptoms
First degree Represents a tearing of only a few muscle
or tendon fibers
Minor swelling and discomfort with no or
minimal loss of strength
Second degree Represents a more severe partial tear without
complete disruption of the musculotendinous
unit
Clear loss of strength with more discomfort
Third degree A complete rupture of the musculotendinous
unit
A total lack of muscle function and commonly
with massive hematomas
TABLE 4. Rehabilitation program for the individuals in the stretching and strengthening (STST) group.
Phase 1
• 10 min of low-intensity stationary biking with no resistence, primarily focusing on continous movement with minimal force re-
quired
• Supine hip flexion with knee extension stretch 4 × 20 sec (Figure 1)
• Standing hip flexion with knee extension stretch with slow side-to-side rotation during the stretch, 4 × 20 sec
• Contract-relax hamstring stretch in standing with foot on stool, 4 sets of 10-sec contraction and 20-sec stretch
• Submaximal isometric hamstring sets, 10 reps for 10 sec held at 20° knee flexion and 60° knee flexion while lying supine
• Ice in long-sitting position for 20 min
Phase 2*
• 15 min of moderate-intensity stationary biking, moderate level of resistence and moderate work level; should feel some per-
ceived exertion
• 5 min of moderate-velocity walk
• Supine hip flexion with knee extension stretch 4 × 20 sec
• Standing hip flexion with knee extension stretch with slow side to side rotation, 4 × 20 sec
• Prone leg curls, 3 × 10 reps with ankle weights for resistance
• Hip extension in standing with knee straight using Thera-Band resistance, 3 × 10 reps
• Non–weight-bearing ‘‘foot catches,’’ 3 × 30 sec (Figure 2)
• Symptom-free practice without high-speed maneuvers
• Ice for 20 min if any symptoms of local fatigue or discomfort are present
*Progression criteria: Subjects progressed from exercises in phase 1 to exercises in phase 2 when they could walk with a normal gait pattern and
do a high knee march in place without pain.
The average time from date of injury to date of
program initiation was 3.4 days (range, 1-10 days) for
the PATS group and 4.1 days (range, 2-10 days) for
the STST group. Each group had 2 treatment phases.
In the first phase of treatment for each group, ice
was applied to the posterior thigh for 20 minutes
after completing the daily rehabilitation sessions.
Subjects progressed from exercises in phase 1 to
exercises in phase 2 when they could walk with the
same stride length and stance time on the injured
and uninjured leg, and do a high knee march in
place without pain. The STST group (11 subjects)
performed static stretching, isolated progressive resis-
tance exercise, and icing. Exercises in phase 1 fo-
cused on static stretching and isometric
strengthening of the hamstrings (Table 4). In phase
2, dynamic stretching was incorporated with concen-
tric and eccentric hamstring strengthening (Table 4).
This program was developed through exercises sug-
gested in various review articles.
1,5,17
The PATS group
(13 subjects) performed a rehabilitation program
consisting of progressive agility and trunk stabilization
exercises and icing. For the purposes of this paper,
‘‘trunk stabilization’’ refers to muscular activity of the
trunk and pelvis to maintain the spine and pelvis in a
desired neutral posture or alignment. The progressive
agility exercises begin with movements primarily in
the frontal and transverse plane (Table 5). In phase
2, subjects progressed to performing movements in
the transverse and sagittal plane (Table 5).
Both rehabilitation programs were completed as a
daily home exercise program. Subjects were asked to
independently track their exercise compliance by
recording days they performed the complete pre-
scribed rehabilitation program on a log and to report
their compliance at each follow-up visit. If subjects
performed their exercises on less than 7 of the past
10 days, they were not included in the study. To
promote honesty, subjects would be allowed contin-
ued guidance in their rehabilitation. The 4 subjects
who were excluded from the study because of non-
compliance had outside influences that prevented
them from doing their exercises (such as motor
vehicle accident). All subjects were highly motivated
to return to sports and were eager to perform the
rehabilitation. A minimum compliance of 70% was
required and statistical analysis of compliance over
70% was not carried out.
J Orthop Sports Phys Ther • Volume 34 • Number 3 • March 2004 119
RESEARCH REPORT
TABLE 5. Rehabilitation program for individuals in the progressive agility and trunk stabilization (PATS) group.
Phase 1
• Low- to moderate-intensity sidestepping, 3 × 1min
• Low- to moderate-intensity grapevine stepping (lateral stepping with the trail leg going over the lead leg and then under the
lead leg), both directions, 3 × 1min
• Low- to moderate-intensity steps forward and backward over a tape line while moving sideways, 2 × 1min
• Single-leg stand progressing from eyes open to eyes closed, 4 × 20 sec
• Prone abdominal body bridge (performed by using abdominal and hip muscles to hold the body in a face-down straight-plank
position with the elbows and feet as the only point of contact), 4 × 20 sec
• Supine extension bridge (performed by using abdominal and hip muscles to hold the body in a supine hook lying position with
the head, upper back, arms, and feet as the points of contact), 4 × 20 sec
• Side bridge, 4 × 20 sec on each side (Figure 3)
• Ice in long sitting for 20 min
Phase 2*
• Moderate- to high-intensity sidestepping, 3 × 1min
• Moderate- to high-intensity grapevine stepping, 3 × 1min
• Moderate- to high-intensity steps forward and backward while moving sideways, 2 × 1min
• Single-leg stand windmill touches, 4 × 20 sec of repetitive alternate hand touches (Figure 4)
• Push-up stabilization with trunk rotation (performed by starting at the top of a full push-up, then maintain this position with 1
hand while rotating the chest toward the side of the hand that is being lifted to point toward the ceiling, pause and return to
the starting position), 2 × 15 reps on each side
• Fast feet in place (performed by jogging in place with increasing velocity, picking the foot only a few inches off the ground), 4
× 20 sec
• Proprioceptive neuromuscular facilitation trunk pull-downs with Thera-Band, 2 × 15 to the right and left
• Symptom-free practice without high-speed maneuvers
• Ice for 20 min if any symptoms of local fatigue or discomfort are present
Key: Low intensity, a velocity of movement that is less than or near that of normal walking; moderate intensity, a velocity of movement greater
than normal walking but not as great as sport; high intensity, a velocity of movement similar to sport activity.
*Progression criteria: subjects progressed from exercises in phase 1 to exercises in phase 2 when they could walk with a normal gait pattern and
do a high knee march in place without pain.
Follow-up visits were scheduled according to pa-
tient progress and report of symptoms, which was
monitored by phone calls or electronic mail every few
days. Subjects had a clinic visit to monitor exercise
technique and to re-evaluate their status at least every
7 days. The lead author supervised the rehabilitation
programs for both groups. Subjects were allowed to
return to sports when they demonstrated 5/5
strength when manually resisting knee flexion in
prone with the hip in neutral extension, had no
palpable tenderness along the posterior thigh, and
when they demonstrated subjective readiness after
completing agility and running tests.
On the day of return to sports, a functional testing
profile was also performed. The functional tests were
administered by the lead author and included a
hop-for-height test, hop-for-distance test, 4-hop cross-
over test, and a 40-yard sprint. The hop tests allowed
for comparison between the injured and uninjured
limbs. The 40-yard sprint was not comparable be-
tween limbs, but because sprinting is the most fre-
quent mechanism of injury, we felt it provided a good
indicator of readiness for sports. If subjects reported
posterior thigh ‘‘tightness’’ or ‘‘twinges’’ during their
running tests, they were not allowed to return to
sports. Subjects were encouraged to continue their
rehabilitation program at least 3 days per week for 2
months after returning to sports.
Subjects were asked to contact the principal investi-
gator if they sustained a reinjury. Subjects that did
not contact the principal investigator within 2 weeks
after return to sports were called to inquire about
injury recurrence. Due to subject schedules, the
timing of these completed calls fluctuated between 14
and 16 days. Subjects were also contacted after 1 year
of their return to sport date. A reinjury within the
first year after return to sport from the initial injury
did include the first 2 weeks of return to sport. A
subject was considered to have a reinjury if there was
a specific mechanism of injury that caused a return
of posterior thigh pain, pain with resisted knee
flexion, tenderness to palpation along the muscle-
tendon unit, and decreased ability to do sport activi-
ties (perceived strength and power).
There were a total of 8 reinjuries for both groups.
Four of these reinjuries were evaluated in the clinic
by the primary investigator. Three other athletes were
initially seen as high school seniors and, at the time
of their reinjury, were attending college and there-
fore unable to return to the clinic. The other subject
chose not to return to the clinic because of personal
reasons. The 4 subjects that were not physically
evaluated did undergo a phone interview and con-
firmed a specific mechanism of injury, unilateral
posterior thigh pain similar to the location of the
initial injury, pain lasting longer than 2 days (subjects
120 J Orthop Sports Phys Ther • Volume 34 • Number 3 • March 2004
TABLE 6. Mechanism of injury responsible for causing ham-
string strains in the athletes participating in this research study.
Mechanism of Injury n
Sprinting 13
Acceleration (transitioning to a full sprint
from a relatively stationary position)
5
Lunging for tennis ball or first base 2
Plant and kick in soccer 2
Slip and fall 1
Stretching 1
TABLE 7. Incidence of reinjury for the individuals in the stretch-
ing and strengthening (STST) group and progressive agility and
trunk stabilization (PATS) group.
Reinjury Rate
Group 2 wk 1 y
STST (n = 11) 6 (54.5%) 7 (70.0%)
PATS (n = 13) 0 (0%) 1 (7.7%)
TABLE 8. Time required for return to sports for the individuals
in the stretching and strengthening (STST) group and the pro-
gressive agility and trunk stabilization (PATS) group.
Group Injury to Return to Sports
Start of Rehabilitation to
Return to Sports
STST 37.4 d (SD, 27.6; SE, 8.3;
range, 10-95 d)
33.3 d (SD, 25.9; SE, 7.8;
range, 8-88 d)
PATS 22.2 d (SD, 8.3; SE, 2.3;
range, 10-35 d)
18.8 d (SD, 9.4; SE, 2.6;
range, 5-33 d)
were asked whether the pain was only unilateral and
had lasted longer than 2 days to prevent confusion
with delayed-onset muscle soreness), and pain with
resisted knee flexion.
Data Analysis
All analyses were conducted using SAS statistical
software (SAS Institute, Inc., Cary, NC). A Wilcoxon
rank sum test was used for statistical analysis of time
to return to sport, days of rehabilitation, and func-
tional testing. Fisher’s exact test was used to assess
reinjury rates between the 2 groups. Injury severity
was analyzed with Fisher’s exact test and a Wilcoxon
rank sum test. A P value of .05 was considered
significant for all cases.
RESULTS
Sprinting was the most common mechanism of
injury (Table 6). This is consistent with previous
research documenting the mechanism of hamstring
strain.
19,21
Six of 11 athletes (54.5%) who completed the
STST program and none of the 13 athletes (0%) in
the PATS group suffered a recurrent hamstring strain
within the first 16 days of returning to sports. Seven
of 10 athletes (70%) who completed the STST
program and 1 of the 13 athletes (7.7%) in the PATS
group suffered a recurrent hamstring strain within
the first year of returning to sports after their initial
hamstring strain (Table 7). One athlete from the
STST program died in an unfortunate accident unre-
lated to this study and was unable to complete the
1-year follow-up. The likelihood of reinjury was sig-
nificantly less for the athletes in the PATS group at 2
weeks after returning to sports (P = .00343, Fisher’s
exact test) and at 1 year after returning to sports (P =
.0059, Fisher’s exact test).
Time needed to return to sports showed no signifi-
cant difference (P = .2455, Wilcoxon rank sum test)
between the 2 groups (Table 8). Average time re-
quired to return to sports from date of injury for
athletes in the STST group was 37.4 days (SD, 27.6;
SE, 8.3; range, 10-95 days), while the average for
athletes in the PATS group was 22.2 days (SD, 8.3; SE,
2.3; range, 10-35 days). The difference for time to
return to sports was also compared between the
athletes who suffered reinjury within 2 weeks of
return to sport (6 subjects) and those who did not
suffer reinjury (18 subjects). The average time re-
quired to return to sports for the 6 athletes who were
subsequently reinjured was 35.2 days (SD, 26.7 days),
while the average for athletes who were not reinjured
was 25.4 days (SD, 19.5 days). This difference was not
significant (P = .789, Wilcoxon rank sum test).
The number of days of rehabilitation was also
analyzed. The athletes in the STST group had an
average of 33.3 days (SD, 26.0; SE, 7.8; range, 8-88
days). The athletes in the PATS group had an average
of 18.8 days (SD, 9.4; SE, 2.6; range, 5-33 days). This
FIGURE 2. Foot catch exercise. This exercise was described and
pictured in a review article by Worrell
26
; ‘‘The athlete stands
parallel to a wall, using the upper extremity on the wall side as
needed for stability, and simulates the swing phase of walking or
running. During the swing phase, the athlete performs a quick
quadriceps contraction and then attempts to catch or stop the lower
leg before reaching full knee extension by a hamstring contraction.’’
A
B
C
J Orthop Sports Phys Ther • Volume 34 • Number 3 • March 2004 121
RESEARCH REPORT
difference in rehabilitation days was not statistically
significant (P = .2461, Wilcoxon rank sum test).
In the STST group, 7 of 11 (64%) athletes had
initially suffered a first-degree strain, while the other
4 (36%) had suffered a second-degree strain. In the
PATS group, 5 of 13 athletes (38%) suffered a
first-degree strain, while the other 8 athletes (72%)
suffered a second-degree strain. Analysis of injury
severity showed no statistical significance between the
STST and PATS groups (P = .219, Chi-square test), (P
= .414, Fisher’s exact test), and (P = .2421, Wilcoxon
rank sum test).
Performance on the functional testing profile was
also compared between the 2 rehabilitation groups
(Table 9) and between the reinjured subjects and the
subjects without reinjury (Table 10). The comparison
included absolute values between the involved and
uninvolved lower extremities of the 2 groups, as well
as individual percent differences of involved and
uninvolved sides compared between groups. There
was no significant difference (P⬍.05) with these
comparisons.
DISCUSSION
The major finding in this study was that the rate of
reinjury was significantly higher in an age- and
gender-matched group of athletes performing ham-
string stretching and strengthening exercises, as com-
pared to a group performing progressive agility and
trunk stabilization exercises, at 2 weeks and 1 year
after return to sport. The progressive agility and
trunk stabilization program used in this study re-
quires neuromuscular control, while limiting end
range tension on the hamstring muscles. An animal
study of muscle laceration suggested that scar weak-
ness is the limiting factor until 10 days postinjury.
Thereafter, muscle atrophy is the most important
factor in injury recurrence.
15
Orchard and Best
20
suggest early loading of the muscle-tendon unit to
avoid secondary atrophy, and simultaneously being
careful to avoid overstressing the scar tissue. The
progressive agility and trunk stabilization program
used in this study controls the early range of motion
for dynamic activities by controlling the direction of
movement. Frontal plane movements will not in-
crease the length of the hamstring muscle-tendon
unit as much as sagittal plane movements. This
potentially allows early loading of the injured tissue
and return of quick movements without overstressing
the healing tissue. The early loading on the ham-
string muscles at a protected muscle-tendon length
may help to reduce muscle atrophy. The controlled
direction of movement permits early retraining of
quick changes in agonist and antagonist muscle
TABLE 9. Statistical analysis of functional testing between individuals in the stretching and strengthening (STST) group and the progres-
sive agility and trunk stabilization (PATS) group. P values based on Wilcoxon’s rank sum test. Hop tests are measured in cm and sprint-
ing tests are measured in seconds.
Group Test Mean SD Minimum Maximum P Value
STST Hop for height, uninvolved 37.0 11.5 20.3 55.9 .7276
PATS Hop for height, uninvolved 38.0 9.2 19.1 52.1
STST Hop for height, involved 35.6 11.9 17.8 58.4 .4165
PATS Hop for height, involved 39.0 7.9 25.4 49.5
STST Hop for height, involved to
uninvolved (%)
96.1 13.5 83.3 131.8 .0637
PATS Hop for height, involved to
uninvolved (%)
104.9 16.4 77.8 134.5
STST Hop for distance, uninvolved 160.8 43.6 71.1 215.9 .5239
PATS Hop for distance, uninvolved 169.2 31.0 111.8 205.7
STST Hop for distance, involved 159.7 45.5 71.1 238.8 .5238
PATS Hop for distance, involved 166.8 29.3 114.3 205.7
STST Hop for distance, involved to
uninvolved (%)
99.4 6.7 87.2 111.0 .7943
PATS Hop for distance, involved to
uninvolved (%)
98.9 6.2 85.5 109.0
STST 4-hop crossover test, uninvolved 609.9 224.9 154.9 975.4 1.000
PATS 4-hop crossover test, uninvolved 644.2 132.7 442.0 825.5
STST 4-hop crossover test, involved 609.9 223.8 177.8 1038.9 .7281
PATS 4-hop crossover test, involved 633.1 140.4 401.3 833.1
STST Crossover hop, involved to
uninvolved (%)
99.6 9.3 78.5 114.8 .4513
PATS Crossover hop, involved to
uninvolved (%)
98.0 4.6 86.8 104.0
STST 40-yd sprint, first trial 6.0 1.8 4.9 11.1 .9020
PATS 40-yd sprint, first trial 5.5 0.7 4.5 7.1
STST 40-yd sprint, second trial 5.9 1.6 4.9 10.4 .5181
PATS 40-yd sprint, second trial 5.7 0.7 4.9 7.4
122 J Orthop Sports Phys Ther • Volume 34 • Number 3 • March 2004
FIGURE 3. Side bridge: performed by using abdominal and hip
muscles to hold the body in a side-lying plank position with the
lower elbow and feet being the only points of contact.
FIGURE 4. Single-leg stand windmill touches: performed by stand-
ing on 1 leg, then rotating the trunk and flexing the hips to bring the
hand down in front of the lower leg.
contractions of the muscles that control hip and
pelvis movement. This also allows the lower-extremity
muscles to function at a higher velocity while main-
taining a protected range of motion. Other authors
have hypothesized that the ability to control the
lumbopelvic region during higher-speed skilled move-
ments may prevent hamstring injury.
11,14,24,25
Our
study supports that this type of program is effective in
preventing reinjury after an acute hamstring strain,
but because no measurements related to the assess-
ment of trunk stabilization and neuromuscular con-
trol were made, it is not possible to conclude that the
results were due to changes in trunk stability, coordi-
nation, or other aspects of motor control. More
research is needed to quantify changes in muscle
activation and response times of the trunk and pelvis
that may occur from these types of rehabilitation
programs.
The difference in reinjury rates between these
groups could not be attributed to degree of initial
injury. In the STST group, 7 athletes (64%) suffered
a first-degree strain, while the other 4 (36%) suffered
a second-degree strain. In the PATS group, 5 athletes
(38%) suffered a first-degree strain, while the other 8
athletes (62%) suffered a second-degree strain. The
difference between the percentages of first-degree
injuries for the 2 groups is 25% and the 95%
confidence interval is –14% and 64%, showing no
difference in injury severity between groups.
The average time required to return to sports for
athletes in the STST group was 37.4 days (SD, 27.6
days), while the average for athletes in the PATS
group was 22.2 days (SD, 8.3 days). This was not a
statistically significant difference (P = .2455). There-
fore, the difference in reinjury rate between groups
could not be attributed to a longer rehabilitation
time either.
It was also shown that the difference in reinjury
rate at 2 weeks after return to sport could not be
attributed to time to return to sport (P = .789). The
average time required to return to sports for athletes
from both groups who subsequently reinjured (n = 6)
was 35.2 days (SD, 26.7 days), while the average for
athletes who did not reinjure (n = 18) was 25.4 days
(SD, 19.5 days). Therefore, successful return to sports
without reinjury was not due to a longer rehabilita-
tion time.
Statistical analysis of the functional testing profile
data did not show any difference between the 2
rehabilitation groups or between the reinjury and
nonreinjury groups. These results also suggest that
these particular functional tests have a limited ability
to predict which athletes with a hamstring injury are
ready to safely return to sports. More research is
needed to identify clinical tests that can predict when
athletes can return to sports with minimal risk of
reinjury after sustaining a hamstring strain.
At the current time, we are unaware of any
prospective randomized studies comparing acute
hamstring strain rehabilitation programs. This pre-
vents us from directly comparing our results with
those of others. However, our findings are similar to
the results demonstrated by Holmich and col-
leagues.
12
Both studies indicate that exercises that
aim to improve neuromuscular control are more
effective for rehabilitating pelvic muscle injuries than
stretching exercises. Holmich et al
12
demonstrated
that individuals with longstanding adductor pain had
less pain and improved sports performance after
undergoing an active rehabilitation program that
aimed at improving strength and coordination of the
muscles acting on the pelvis, as compared to individu-
als who completed a rehabilitation program consist-
ing of modalities and stretching. Croiser et al
7
showed that correction of concentric and eccentric
muscle strength deficits and muscle imbalances be-
tween the hamstrings and quadriceps allowed subjects
with acute and recurrent hamstring strains to return
A
B
A
B
J Orthop Sports Phys Ther • Volume 34 • Number 3 • March 2004 123
RESEARCH REPORT
TABLE 10. Statistical analysis of functional testing between individuals who were reinjured within 2 weeks of return to sports group (n
= 6) and those who were not (n = 18). P values based on Wilcoxon’s rank sum test. Hop tests are measured in cm and sprinting tests
are measured in seconds.
Group Test Mean SD Minimum Maximum P Value
No reinjury Hop for height, uninvolved 38.3 9.3 19.1 52.1 .4424
Reinjured Hop for height, uninvolved 35.4 12.8 20.3 57.2
No reinjury Hop for height, involved 37.9 8.6 19.1 49.5 .5258
Reinjured Hop for height, involved 36.0 13.7 17.8 58.4
No reinjury Hop for height, involved to
uninvolved (%)
100.6 15.8 77.8 134.5 1.0000
Reinjured Hop for height, involved to
uninvolved (%)
101.6 15.8 87.5 131.8
No reinjury Hop for distance,
uninvolved
165.5 36.1 71.1 207.0 .9734
Reinjured Hop for distance,
uninvolved
165.0 41.8 96.5 216.7
No reinjury Hop for distance, involved 161.0 33.5 73.2 205.7 .7138
Reinjured Hop for distance, involved 171.1 48.3 96.5 240.5
No reinjury Hop for distance, involved
to uninvolved (%)
97.9 6.3 85.5 109.0 .0718
Reinjured Hop for distance, involved
to uninvolved (%)
103.1 4.9 97.3 111.0
No reinjury 4-hop crossover test,
uninvolved
621.8 167.2 154.9 826.8 .6648
Reinjured 4-hop crossover test,
uninvolved
668.5 216.9 349.8 977.1
No reinjury 4-hop crossover test,
involved
602.6 160.9 177.8 833.1 .4047
Reinjured 4-hop crossover test,
involved
682.2 233.2 360.7 1038.9
No reinjury Crossover hop, involved to
uninvolved (%)
97.7 7.6 78.5 114.75 .1336
Reinjured Crossover hop, involved to
uninvolved (%)
101.8 4.0 97.6 106.3
No reinjury 40-yd sprint, first trial 5.9 1.5 4.5 11.1 .6489
Reinjured 40-yd sprint, first trial 5.5 0.7 4.9 6.9
No reinjury 40-yd sprint, second trial 6.0 1.4 4.9 10.4 .2479
Reinjured 40-yd sprint, second trial 5.5 0.8 4.9 6.9
to sports at preinjury levels with subjective reduction
in pain.
7
Progressive agility and trunk stabilization
drills do involve a combination of concentric, eccen-
tric, and isometric contractions of the hamstring
muscles in various length-tension positions. Although
isokinetic testing was not carried out in our study, it
is possible that early initiation (phase 1) of concen-
tric, eccentric, and isometric contractions in the PATS
group helped to prevent reduction in strength or
muscle imbalances without adversely affecting the
scar tissue. The STST group did not start eccentric
contractions (non–weight-bearing foot catches) until
phase 2.
Our study has recognized limitations. One major
limitation is that we do not have direct evidence that
the PATS group had less reinjuries because of im-
proved neuromuscular control or trunk stabilization.
We did not measure the changes that were hypoth-
esized to occur as a result of our interventions. We
are currently investigating how hip and trunk muscle
activation, timing, and sequencing is affected in
healthy subjects who undergo a 6-week training
program consisting of the exercises in the PATS
program. Another limitation was that patients were
required to self-report their exercise compliance,
abstinence from other treatment modalities, and
injury recurrences at the 1-year follow-up call. We
tried to minimize self-reporting bias by informing
subjects during the initial evaluation that there would
not be any personal consequence of the reports. Two
subjects who reported less than 70% compliance with
the exercise program were eliminated from the study,
but chose to continue receiving free treatment. An-
other limitation of our study is that 1 of the authors
was responsible for supervising subjects’ rehabilitation
program and performing evaluative testing. Although
this provided consistency for instruction and testing,
it prevented blinding during the rehabilitation and
testing.
There was also a large range in the number of days
(10-95) needed for return to sports by the individual
subjects. By using the Wilcoxon rank sum test, and
thus treating these data as nonparametric data, we
have decreased the chance that differences occurred
due to large variations within the variables.
124 J Orthop Sports Phys Ther • Volume 34 • Number 3 • March 2004
We did not randomize subjects based on grade of
injury. Classification systems categorize muscle inju-
ries that produce pain, while muscle output remains
at near full strength, as first-degree strains, muscles
injuries that produce weakness and pain as second-
degree strains, and injuries that result in pronounced
weakness and a palpable defect as third-degree
strains.
6
The severity of hamstring strains ranges on a
continuum from very mild to very severe. Research
has not demonstrated a clear relationship between
classification of injury and incidence of reinjury or
time needed to return to sport. For this reason, the
subjects were not stratified by the muscle strain
classification system shown in Table 3. Subjects were
given a grade using the strain classification, but this
was only used for postrehabilitation comparisons.
CONCLUSION
A rehabilitation program consisting of progressive
agility and trunk stabilization exercises is effective in
promoting return to sports and in preventing injury
recurrence in athletes who have sustained an acute
hamstring strain. This program allows athletes to
return to sports at less risk for acute reinjury than
those who complete a more traditional isolated
stretching and strengthening exercise program.
ACKNOWLEDGEMENTS
We thank Glen Leverson, PhD for his consultation
and computation of the statistical analysis. We thank
the University of Wisconsin Health Sports Medicine
staff for their help in recruiting subjects.
REFERENCES
1. Agre JC. Hamstring injuries. Proposed aetiological fac-
tors, prevention, and treatment. Sports Med. 1985;2:21-
33.
2. Bennell K, Tully E, Harvey N. Does the toe-touch test
predict hamstring injury in Australian Rules footballers?
Aust J Physiother. 1999;45:103-109.
3. Canale ST, Cantler ED, Jr., Sisk TD, Freeman BL, 3rd. A
chronicle of injuries of an American intercollegiate
football team. Am J Sports Med. 1981;9:384-389.
4. Clanton TO, Coupe KJ. Hamstring strains in athletes:
diagnosis and treatment. J Am Acad Orthop Surg.
1998;6:237-248.
5. Coole WG, Gieck JH. An analysis of hamstring strains
and their rehabilitation. J Orthop Sports Phys Ther.
1987;9:77-85.
6. Craig TT. Comments in Sports Medicine. Chicago, IL:
American Medical Association; 1973.
7. Croisier JL, Forthomme B, Namurois MH, Vanderthom-
men M, Crielaard JM. Hamstring muscle strain recur-
rence and strength performance disorders. Am J Sports
Med. 2002;30:199-203.
8. Ekstrand J, Gillquist J. Soccer injuries and their mecha-
nisms: a prospective study. Med Sci Sports Exerc.
1983;15:267-270.
9. Gleim GW, McHugh MP. Flexibility and its effects on
sports injury and performance. Sports Med.
1997;24:289-299.
10. Heiser TM, Weber J, Sullivan G, Clare P, Jacobs RR.
Prophylaxis and management of hamstring muscle inju-
ries in intercollegiate football players. Am J Sports Med.
1984;12:368-370.
11. Hodges PW, Richardson CA. Inefficient muscular stabi-
lization of the lumbar spine associated with low back
pain. A motor control evaluation of transversus
abdominis. Spine. 1996;21:2640-2650.
12. Holmich P, Uhrskou P, Ulnits L, et al. Effectiveness of
active physical training as treatment for long-standing
adductor-related groin pain in athletes: randomised trial.
Lancet. 1999;353:439-443.
13. Jonhagen S, Nemeth G, Eriksson E. Hamstring injuries
in sprinters. The role of concentric and eccentric
hamstring muscle strength and flexibility. Am J Sports
Med. 1994;22:262-266.
14. Jull GA, Richardson CA. Rehabilitation of active stabili-
zation of the lumbar spine. In: Twomey L. T.Taylor J. R.
eds. Physical Therapy of the Low Back. Clinician
Physical Therapy. 2nd ed. London, UK: Churchill
Livingston; 1994:251-271.
15. Kaariainen M, Kaariainen J, Jarvinen TL, Sievanen H,
Kalimo H, Jarvinen M. Correlation between
biomechanical and structural changes during the regen-
eration of skeletal muscle after laceration injury. J
Orthop Res. 1998;16:197-206.
16. Knapik JJ, Bauman CL, Jones BH, Harris JM, Vaughan L.
Preseason strength and flexibility imbalances associated
with athletic injuries in female collegiate athletes. Am J
Sports Med. 1991;19:76-81.
17. Kujala UM, Orava S, Jarvinen M. Hamstring injuries.
Current trends in treatment and prevention. Sports Med.
1997;23:397-404.
18. Levine WN, Bergfeld JA, Tessendorf W, Moorman CT,
3rd. Intramuscular corticosteroid injection for hamstring
injuries. A 13-year experience in the National Football
League. Am J Sports Med. 2000;28:297-300.
19. Meeuwisse WH, Hagel BE, Mohtadi NG, Butterwick DJ,
Fick GH. The distribution of injuries in men’s Canada
West university football. A 5-year analysis. Am J Sports
Med. 2000;28:516-523.
20. Orchard JW, Best TM. The management of muscle
strain injuries: an early return versus the risk of recur-
rence. Clin J Sport Med. 2002;12:3-5.
21. Orchard JW. Intrinsic and extrinsic risk factors for
muscle strains in Australian football. Am J Sports Med.
2001;29:300-303.
22. Orchard JW, Marsden J, Lord S, Garlick D. Preseason
hamstring muscle weakness associated with hamstring
muscle injury in Australian footballers. Am J Sports
Med. 1997;25:81-85.
23. Orchard JW, Seward H. Epidemiology of injuries in the
Australian Football League, seasons 1997-2000. Br J
Sports Med. 2002;36:39-44.
24. Richardson C, Bullock MI. Changes in muscle activity
during fast, alternating flexion-extension movements of
the knee. Scand J Rehabil Med. 1986;18:51-58.
25. Wohlfahrt DA, Jull GA, Richardson CA. The relationship
between the dynamic and static function of abdominal
muscles. Aust J Physiother. 1993;39:9-13.
26. Worrell TW. Factors associated with hamstring injuries.
An approach to treatment and preventative measures.
Sports Med. 1994;17:338-345.
27. Worrell TW. Factors associated with hamstring injuries.
An approach to treatment and preventative measures.
Sports Med. 1994;17:338-345.
J Orthop Sports Phys Ther • Volume 34 • Number 3 • March 2004 125
RESEARCH REPORT
