 
 
Rehabilitation Protocol for Proximal Hamstring Repair 
 
This protocol is intended to guide clinicians through the post-operative course for proximal hamstring repair. This 
protocol is time based (dependent on tissue healing) as well as criterion based. Specific intervention should be based on 
the needs of the individual and should consider exam findings and clinical decision making. The timeframes for expected 
outcomes contained within this guideline may vary based on surgeon’s preference, additional procedures performed, 
and/or complications. If a clinician requires assistance in the progression of a post-operative patient, they should consult 
with the referring surgeon. 
 
The interventions included within this protocol are not intended to be an inclusive list. Therapeutic interventions should 
be included and modified based on the progress of the patient and under the discretion of the clinician. 
 
Considerations for the Post-operative Proximal Hamstring 
Many different factors influence the post-operative proximal hamstring rehabilitation outcomes, including chronicity of 
injury prior to surgery, length of retraction, number of tendons involved, pre-surgical gluteal motor control/strength and 
presence of any concomitant sciatic neural tension. It is recommended that clinicians collaborate closely with the 
referring physician regarding the above. 
 
If you develop a fever, intense calf pain, uncontrolled pain, or any other symptoms you have concerns about you should 
call your doctor. 
 
PHASE I: IMMEDIATE POST-OP (0-2WEEKS AFTER SURGERY) 
Rehabilitation Goals 
• Allow healing of repaired tendon 
• Initiate early restricted and protected ROM 
• Prevent muscular atrophy 
• Decrease pain and inflammation 
Weight Bearing 
• TDWB with crutches 
Precautions 
• Post-op hip brace to limit hip flexion (45°) 
• Brace at all times (aside from exercise and bathing) 
• Avoid hip flexion with knee extension 
Range of Motion 
• Active assisted and passive hip and knee flexion 
• Hip flexion ROM limit 60° flexion 
Interventions 
Manual Therapy 
• Peri-incisional mobilization 
• STM along hamstring muscle group as needed 
• Myofascial (no lotion) release to posterolateral glute and lateral hamstring fascia/muscle 
(proximal 1/3 of lateral thigh) 
• Attain and maintain neutral iliac position ipsilateral and contralateral to injured side with 
manual posterior rotations to ilium 
 
Stretching 
• Nerve gliding (sciatic neural flossing): if neural tension exists – Do not stretch the 
hamstring 
• Hip flexors in Thomas test position (maintain neutral pelvis/spine throughout 
stretch) 
• Gastrocnemius/Soleus stretching 
 
Therapeutic Exercise 
 
 
• Ankle pumps  
• Quad sets 
• AA and PROM hip  flexion (60deg limit) and knee flexion 
• Upper body circuit training or upper body ergometer (UBE) 
Criteria to Progress 
• 2+ weeks post-operative 
 
PHASE II: INTERMEDIATE POST-OP (2-6 WEEKS AFTER SURGERY) 
Rehabilitation Goals 
• Reduce/resolve pain and edema 
• Good motor control and pain-free functional movements  
Weight Bearing 
• PWB 50% with crutches 
Precautions/Guidelines 
• Continue post-op hip brace Hip flexion limit to 60°  
• Increase brace hip flexion limit at week 4 gradually to 90° by week 6 
• Avoid hip flexion with knee extension 
• No active hamstrings yet  
• No active hip extension exercises 
Range of Motion 
• Active-assisted and passive hip and knee flexion 
Additional 
Interventions 
*Continue with Phase I 
interventions as indicated 
Manual Therapy 
• Scar mobilization 
• Gentle cross friction massage to proximal tendon including proximal to attachment on 
ischial tuberosity 
• Manual trigger point release as needed (common area is within distal 1/3 of biceps 
femoris) 
• Manual trigger point release as needed with ART (active release therapy) to piriformis, 
quadratus femoris 
• Anterior hip glides with and without external rotation at the hip (hip in neutral to slightly 
extended) 
• Posterior/inferior belted hip mobilizations as needed for full flexion (belted quadruped 
position with active movement into child’s pose) 
 
Stretching 
• Hip external rotation in flexion 
• Limit/avoid piriformis stretching (massage instead) 
  
Therapeutic Exercise 
• Gluteal setting in prone 
• Gluteal setting in supine 
*above must be mastered before progressing any gluteal or hamstring muscle strengthening* 
• Low Double Leg (DL) Bridge  
• Side-lying hip abduction  
• Standing calf raises 
• Strengthening of uninvolved limb ok 
Criteria to Progress 
• 6 weeks post-operative 
 
PHASE III: LATE POST-OP (6-12 WEEKS AFTER SURGERY) 
Rehabilitation Goals 
• Normalized gait 
• Gradually progress to full ROM 
• Improve neuromuscular control 
• Increase strength 
• Enhance proprioception and kinesthesia 
Weight Bearing 
• Progressively wean crutches over the next 2 weeks to FWB 
Precautions/Guidelines 
• Discontinue brace at 6-8 weeks,  per MD 
Range of Motion 
• Progressive active hip and knee flexion  
• Active stretching all uninvolved muscle groups  
 
 
Additional Intervention 
*Continue with Phase I-II 
Interventions as indicated 
Therapeutic Exercise 
• DL Bridge with band around thighs 
• DL Bridge with ball squeeze 
• DL Bridge with Upper back on the bench  
• Plank with alternating leg lifts 
• Side plank with leg lift (on left knee until stronger) or oblique twists 
• Straight Leg Raise (SLR) 
• Hamstring (HS) curls antigravity  
• Hip extension antigravity  
• 10 weeks postop: 
- Single Leg (SL) bridge, back on floor, foot on bench 
- Progress to ankle weight for all leg lifts PRE 
- Wall slides  
- Clam shells  
- Partial squats 
- Step ups 
- Step downs 
 
Cardiovascular Exercise 
• Stationary bike 
• Progressive slow walking on level surfaces 
• No running 
Criteria to Progress 
• Normalized gait all surfaces 
• Good control with functional movements without antalgic movement patterns 
• Hamstring strength 5/5 in prone with knee at 90° flexion 
 
PHASE IV: TRANSITIONAL (13-16 WEEKS AFTER SURGERY) 
Rehabilitation Goals 
• Full ROM 
• Improve neuromuscular control 
• Improve strength/power/endurance 
• Enhance dynamic stability 
Precautions/Guidelines 
• Neoprene support as needed 
• No pain during strength training 
Additional 
Interventions 
*Continue with Phase I-III 
interventions as indicated 
Therapeutic Exercise: 
• Gentle hamstring stretching 
• Cautious use of weight training machines  
• Single leg closed chain exercises 
• Resisted step ups using sports cord around waist from behind 
• Double Leg Hamstring ball roll out (eccentric portion only) --> DL eccentric and 
concentric --> SL eccentric portion only --> SL eccentric and concentric 
• Double Leg deadlift, short range --> progressing to Single Leg no rotation 
• Double Leg deadlift – wide abducted leg stance with band around forefeet – pushing into 
abduction during eccentric phase of deadlift  
• Progress to single leg with spine rotation deadlift  
• Bridge on ball – eccentric portion only double leg 
 progressing to single leg 
 
Cardiovascular Exercise 
• Walk progression on level surface with gradual increase in speed and distance 
• Preparing to run 
 
 
 
Criteria to Progress 
• Good neuromuscular control in all planes without pain 
• HHD testing: To initiate plyometrics: 
- LSI hamstring strength >70/80% 
- LSI glute med strength >80% 
- LSI quad strength >80%  
• To initiate running: 
- LSI hamstring strength >80/90% 
- LSI glute med strength >90% 
- LSI quad strength >90%  
- Single leg hop cluster (distance, triple, cross over, 6 meter timed) >85% 
 
PHASE V: EARLY RETURN TO SPORT (16-20 WEEKS AFTER SURGERY) 
Rehabilitation Goals 
• Emphasis on gradual return to recreational activities 
Precautions/Guidelines 
• Neoprene support as needed 
Additional 
Interventions 
*Continue with Phase II-IV 
interventions as indicated 
Therapeutic Exercise: 
• Progressive strengthening avoiding overload to HS 
• Progress speed of resisted steps and add forward lean 
• SL dead lift with band under stance leg: hold for resistance 
• Reverse Lunge on Slider: Progress load bearing and add concentric/eccentric phase: 
- Part 1: Eccentric hamstring with core strength exercise:  
- Part 2: in full lunge position:  
• Short range Nordic HS to physio ball height 
 progress range to ground depth 
• Kettle bell swing 
• Retro lunge slide 
 
Cardiovascular Exercise 
• Walk-to jog progression 
• No sprinting 
• No speed work 
Criteria to Progress 
• Full ROM 
• No pain/tenderness 
• Satisfactory clinical exam including isokinetic testing 
• Walk to jog progression 
 
PHASE VI: UNRESTRICTED RETURN TO SPORT (20-24 WEEKS AFTER SURGERY) 
Rehabilitation Goals 
• Progressively increase activities to prepare for unrestricted functional return  
Additional 
Interventions 
*Continue with Phase II-V 
interventions as indicated 
Therapeutic Exercise 
• Continued isotonic strengthening exercises above 
• Continue ROM exercises 
• Progressive running/speed and agility 
• Jump training after 22 weeks 
 
Cardiovascular Exercise 
• Progress step ups to resisted jump onto steps 
• Plyometric progression  
- Double leg up/down 
- Double leg forward/back 
- Alternating lateral bounding 
- Single leg jump 
- Progress plyometrics to resisted plyometrics using sports cord around waist 
• Ladder drills 
• Falling start runs- see below for details 
• Mini hurdle runs 
 
 
• Sprint progressions (5 times each) 
 
10 yard 
 20 yd 
 assisted deceleration with band around waist 
 deceleration lean 
• 40 yard sprints at 90% 
 
Criteria to Progress 
• To Return to Play: 
- LSI Hamstring strength > 95%  
- LSI Glute strength >95% 
- LSI quad strength >95% 
- Single leg hop cluster (distance, triple, cross over, 6 meter timed) >95% 
- Good acceleration, deceleration, change of direction control 
- 60 second timed step-down test 80 bpm, with excellent control 
- 60 second timed Lateral leap 60 bpm, with excellent control 
   Revised 10/2021 
 
Contact 
Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this 
protocol 
References: 
1. 
Brockett CL, Morgan DL, Proske U. Predicting hamstring strain injury in elite athletes. Med Sci Sports Exerc. 2004;36(3):379-387.  
2. 
Chakravarthy J, Ramisetty N, Pimpalnerkar A, Mohtadi N. Surgical repair of complete proximal hamstring tendon ruptures in water skiers and bull 
riders: a report of four cases and review of the literature. British journal of sports medicine. 2005;39(8):569-572.  
3. 
Chu SK, Rho ME. Hamtring injuries in the athlete: Diagnosis, treatment and return to play. Curr Sports Med Rep. 2016; 15(3): 184-190.  
4. 
Elliot MC, et al. Hamstring muscle strains in professional football players: a 10-year review. Am J Sports Medicine. 2011;39(4):843-850.  
5. 
Feeley BT, et al. Epidemiology of national football league training camp injuries from 1998 to 2007. Am J Sports med. 2008;36(8):1597-1603 
6. 
Henderson G, Barnes CA, Portas MD. Factors associated with increased propensity for hamstring injury in English Premier league soccer players. J 
Sci Med Sport. 2010;13(4):397-402 
7. 
Glazer DD. Development and preliminary validation of the injury-psychological readiness to return to sport (I-PRRS) scale. Journal of athletic 
training. 2009;44(2):185-218.  
8. 
Kijowski R, Wilson JJ, Liu F. Bicomponent ultrashort echo time T2 analysis for assessment of patients with patellar tendinopathy. J Magn Reason 
Imaging. 2017;46(5):1441-1447.  
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Klingele KE, Sallay PI. Surgical repair of complete proximal hamstring tendon rupture. AM J Sports Med. 2002;30(5):742-747.  
10. Liu F, et al. Articular cartilage of the human knee joint: in vivo multicomponent T2 analysis at 3.0T. Radiology. 2015;277(2):477-488.  
11. Liu F, et al. Rapid in vivo multicomponent T2 mapping of human knee menisci. J Magn Reason Imaging. 2015;42(5):1321-1328.  
12. Liu F, et al. Rapid multicomponent T2 analysis of the articular cartilage of the human knee joint at 3.0T. J Magn Reason Imaging. 2014;39(5):1191-
1197. 
13. Loegering IF, et al. Ultrashort echo time (UTE), imaging reveals a shift in bound water that is sensitive to sub-clinical tendinopathy in older adults. 
Skeletal Radiology. 2021;50(1):107-113. 
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16. Orchard J, Best TM, Verral GM. Return to play follow muscle strains. Clinical journal Sport Med. 2005;15(6):436-441.  
17. Orchard J, Best TM. The management of muscle strain injuries: an early return versus the risk of recurrence. Clin J Sport Med. 2002; 12(1):3-5.  
18. Prior M, Guerin M, Grimmer K. An evidence-based approach to hamstring strain injury: a systematic review of the literature. Sports Health. 
2009;1(2):154-164.  
19. Proske U, et al. Identifying athletes at risk of hamstring strains and how to protect them. Clin Exp Pharmacol Physiol. 2004;31(8):546-550.  
20. Reiman MP, Loudon JK, Goode AP. Diagnostic accuracy of clinical tests for assessment of hamstring injury: a systematic review. Journal of orthopedic 
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reinjuries. Am J Sports Med. 206;44(8):2112-2121.   
 
 
 
Return to Running Program 
 
This program is designed as a guide for clinicians and patients through a progressive return-to-run program. Patients 
should demonstrate > 80% on the Functional Assessment prior to initiating this program (after a knee ligament or 
meniscus repair). Specific recommendations should be based on the needs of the individual and should consider clinical 
decision making. If you have questions, contact the referring physician.  
 
PHASE I: WARM UP WALK 15 MINUTES, COOL DOWN WALK 10 MINUTES 
Day 
1 
2 
3 
4 
5 
6 
7 
Week 1 
W5/J1x5 
 
W5/J1x5 
 
W4/J2x5 
 
W4/J2x5 
Week 2 
 
W3/J3x5 
 
W3/J3x5 
 
W2/J4x5 
 
Week 3 
W2/J4x5 
 
W1/J5x5 
 
W1/J5x5 
 
Return 
to Run  
Key: W=walk, J=jog 
**Only progress if there is no pain or swelling during or after the run 
 
PHASE II: WARM UP WALK 15 MINUTES, COOL DOWN WALK 10 MINUTES 
Week 
Sunday 
Monday 
Tuesday 
Wednesday 
Thursday 
Friday 
Saturday 
1 
20 min 
 
20 min 
 
20 min 
 
25 min 
2 
 
25 min 
 
25 min 
 
30 min 
 
3 
30 min 
 
30 min 
 
35 min 
 
35 min 
4 
 
35 min 
 
40 min 
 
40 min 
 
5 
40 min 
 
45 min 
 
45 min 
 
45 min 
6 
 
50 min 
 
50 min 
 
50 min 
 
7 
55 min 
 
55 min 
 
55 min 
 
60 min 
8 
 
60 min 
 
60 min 
 
 
 
Recommendations 
• Runs should occur on softer surfaces during Phase I 
• Non-impact activity on off days 
• Goal is to increase mileage and then increase pace; avoid increasing two variables at once 
• 10% rule:  no more than 10% increase in mileage per week 
 
 
 
 
Agility and Plyometric Program 
 
This program is designed as a guide for clinicians and patients through a progressive series of agility and plyometric 
exercises to promote successful return to sport and reduce injury risk. Patients should demonstrate > 80% on the 
Functional Assessment prior to initiating this program. Specific intervention should be based on the needs of the 
individual and should consider clinical decision making. If you have questions, contact the referring physician.  
 
PHASE I: ANTERIOR PROGRESSION 
Rehabilitation 
Goals 
• Safely recondition the knee 
• Provide a logical sequence of progressive drills for pre-sports conditioning 
Agility 
• Forward run 
• Backward run 
• Forward lean in to a run 
• Forward run with 3-step deceleration 
• Figure 8 run 
• Circle run 
• Ladder  
Plyometrics 
• Shuttle press: Double leg
alternating leg
single leg jumps 
• Double leg:  
- Jumps on to a box
 jump off of a box
 jumps on/off box 
- Forward jumps, forward jump to broad jump 
- Tuck jumps 
- Backward/forward hops over line/cone 
• Single leg (these exercises are challenging and should be considered for more advanced 
athletes): 
- Progressive single leg jump tasks 
- Bounding run 
- Scissor jumps 
- Backward/forward hops over line/cone 
Criteria to 
Progress 
• No increase in pain or swelling 
• Pain-free during loading activities 
• Demonstrates proper movement patterns 
 
PHASE II: LATERAL PROGRESSION 
Rehabilitation 
Goals 
• Safely recondition the knee 
• Provide a logical sequence of progressive drills for the Level 1 sport athlete 
Agility 
*Continue with 
Phase I 
interventions 
 
• Side shuffle 
• Carioca 
• Crossover steps 
• Shuttle run 
• Zig-zag run 
• Ladder 
Plyometrics 
*Continue with 
Phase I 
interventions 
• Double leg:  
- Lateral jumps over line/cone 
- Lateral tuck jumps over cone 
• Single leg(these exercises are challenging and should be considered for more advanced 
athletes): 
- Lateral jumps over line/cone 
- Lateral jumps with sport cord 
Criteria to 
Progress 
• No increase in pain or swelling 
• Pain-free during loading activities 
• Demonstrates proper movement patterns 
 
 
 
 
PHASE III: MULTI-PLANAR PROGRESSION 
Rehabilitation 
Goals 
• Challenge the Level 1 sport athlete in preparation for final clearance for return to sport 
Agility  
*Continue with 
Phase I-II 
interventions 
• Box drill 
• Star drill 
• Side shuffle with hurdles 
Plyometrics 
*Continue with 
Phase I-II 
interventions 
• Box jumps with quick change of direction 
• 90 and 180 degree jumps  
Criteria to 
Progress 
• Clearance from MD 
• Functional Assessment 
- ≥90% contralateral side 
• Psych Readiness to Return to Sport (PRRS) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
