Physical Therapy Order for Acute Hamstring Strain
A physical therapy order for acute hamstring strain should specify: diagnosis with injury location and severity, progressive eccentric strengthening exercises with trunk stabilization and agility training, pain-guided progression, functional testing criteria including hop tests, and specific return-to-sport benchmarks rather than time-based clearance.
Essential Components to Include
1. Diagnostic Information
- Specific injury location: Proximal tendon, muscle belly, or myotendinous junction (location predicts recovery duration) 1
- Severity grading: Grade I, II, or III strain
- Mechanism of injury: Sprint-related vs. extensive lengthening
- Imaging findings if available: MRI is the gold standard for classification of location, extent, and degree (partial vs. complete) 1
2. Exercise Prescription Specifics
Primary intervention - Progressive eccentric loading:
- Loading exercises during extensive lengthening facilitate faster return to play 2
- Begin as soon as pain allows (typically within first week)
- Progress from isometric → concentric → eccentric strengthening 3, 4
Secondary intervention - Trunk stabilization and agility:
- Strengthening combined with trunk stabilization and agility exercises significantly reduces reinjury rates (though doesn't accelerate initial recovery) 2
- This combination is critical for preventing the 30% recurrence rate within first year 4, 5
Frequency and dosing:
- Minimum 2 days per week for strengthening 6
- Moderate to vigorous intensity (60-80% of one repetition maximum) 6
- 8-12 repetitions per set 6
3. Progression Criteria
Pain-guided advancement (universal across all evidence):
- Pain is the primary guide for rehabilitation progression 7
- Avoid activities causing pain during healing phase 8
- Progress loading to injury site safely and systematically 3
Specific progression phases:
- Acute phase: Pain management, gentle range of motion
- Subacute phase: Progressive strengthening (eccentric emphasis), flexibility work 9
- Functional phase: Running progression, agility protocols, sport-specific movements 9
4. Return-to-Sport Criteria
Functional testing requirements:
- Hop testing should be included as one factor in return-to-sport decision 10
- Clinical assessments and performance tests are most frequently used 7
- Objective measures to assess musculotendon recovery 5
Avoid premature return:
- Do not use time-based criteria alone 4, 5
- Traditional criteria may be insensitive to persistent deficits 5
- Ensure resolution of muscular weakness, reduced tissue extensibility, and altered movement patterns 5
5. Specific Order Language
Include these exact elements:
- "Progressive eccentric strengthening with emphasis on exercises during extensive lengthening"
- "Trunk stabilization exercises integrated throughout rehabilitation"
- "Agility training in functional phase"
- "Pain-guided progression - advance only when pain-free at current level"
- "Functional hop testing prior to return-to-sport clearance"
- "No time-based return criteria - clearance based on objective functional measures"
6. Precautions and Red Flags
Refer back if:
- Proximal hamstring tendon avulsion suspected (may require surgical reinsertion) 1, 11
- Pain worsens or persists beyond expected timeline
- Inability to progress through rehabilitation phases
Common pitfall to avoid:
- Premature return to sport based solely on pain resolution leads to 30% reinjury rate 4, 5
- Inadequate eccentric strengthening and trunk stabilization increases reinjury risk 2
Key Evidence Distinctions
The research clearly differentiates two rehabilitation goals with distinct interventions 2:
- Faster return to play: Achieved through loading exercises during extensive lengthening
- Reduced reinjury: Achieved through strengthening with trunk stabilization and agility work
Both components must be included in the order to optimize outcomes and minimize the high recurrence rate characteristic of hamstring injuries.