Exercise-based rehabilitation for hamstring strain injuries should consider the multifactorial nature (modifiable and non-modifiable) of the risk factors that lead to injury and address modifiable risk factors (high-speed running loads, residual hamstring strength deficits and decreased fascicle lengths) accordingly. Hamstring strain injuries and associated injury recurrences have a significant impact on individual athletes and teams by reducing player availability for training and competition, increasing financial strain as well as return to play performance deficits. By reviewing the literature, including a total of five randomised controlled trials, the primary aim of this review was to determine the current best practice exercise-based rehabilitation of acute hamstring strain injuries. The secondary aim of the current review was to provide direction for the practical application of the current evidence surrounding exercise-based rehabilitation to guide physical rehabilitation of hamstring strain injuries. The findings from the present paper highlighted that while there may not be a significant difference in terms of return to play times, exercise-based programs involving eccentric strengthening and lengthening exercises at longer hamstring muscles lengths may be superior in decreasing the risk of future hamstring strain injuries by addressing some of the modifiable physical risk factors for hamstring strain injury recurrence. Additionally, the results of this review suggest that while conventional hamstring strain rehabilitation is conducted with pain-free exercises, the use of pain-threshold exercise-based rehabilitation may allow athletes to return to play with less functional deficits which would otherwise contribute to a greater risk of future hamstring strain recurrence. Given that a history of previous hamstring muscle strains increases the risk of future hamstring strains as well as evidence to support the ongoing muscle strength and length deficits at return to play following hamstring muscle strains, it is recommended that coaches adopt a rehabilitation protocol that addresses these deficits. Therefore, the present paper recommends that exercise-based rehabilitation protocols adopted by coaches emphasise early eccentric exercises at greater muscle lengths.
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