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J Orthop Sports Phys Ther. 2019 Jun 28:1-35. doi: 10.2519/jospt.2019.8895. [Epub ahead of print]

Pain-Free Versus Pain-Threshold Rehabilitation Following Acute Hamstring Strain Injury: A Randomized Controlled Trial.

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School of Behavioural and Health Sciences, Australian Catholic University, Melbourne, Australia.
La Trobe Centre for Sports and Exercise Medicine Research, Melbourne, Australia.
Epigenetics and Development Division, Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia.
School of Health, Sport and Professional Practice, University of South Wales, Pontypridd, Wales, UK.



Randomized controlled trial.


Conventional guidelines recommend hamstring strain injury (HSI) rehabilitation should only be performed and progressed in complete absence of pain, despite lack of comparison to alternative approaches.


The primary aim of this study was to compare the number of days from acute HSI to return to play (RTP) clearance following a standardised rehabilitation protocol performed within either pain-free or pain-threshold limits. The secondary aims were to compare isometric knee flexor strength, biceps femoris long head (BFlh) fascicle length, fear of movement and re-injury during a six-month follow-up between pain-free and pain-threshold groups.


Forty-three men with acute HSIs were randomly allocated to either a pain-free (n=22) or pain-threshold (n=21) rehabilitation group. Days from HSI to RTP clearance, isometric knee flexor strength, BFlh fascicle length, fear of movement and re-injuries within six-month follow-up were reported.


The median time from HSI to RTP clearance was 15 days (95% CI = 13 to 17) in the pain-free group and 17 days (95% CI = 11 to 24) in the pain-threshold group, which was not significantly different (p = 0.37). Recovery of isometric knee flexor strength at 90/90 degrees of hip/knee flexion was greater in the pain-threshold group at RTP clearance by 15% (95% CI = 1 to 28) and by 15% (95% CI = 1 to 29) at two-month follow-up. BFlh fascicles were 0.91cm (95% CI = 0.34 to 1.48) longer at two-month follow-up in the pain-threshold group. Two re-injuries occurred in both the pain-free and pain-threshold group during six-month follow-up.


Pain-threshold rehabilitation did not accelerate RTP clearance but did result in greater recovery of isometric knee flexor strength and better maintenance of BFlh fascicle length improvements compared to pain-free rehabilitation. J Orthop Sports Phys Ther, Epub 28 Jun 2019. doi:10.2519/jospt.2019.8895.


hamstring strain injury; muscle; pain; rehabilitation; return to play


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