Askling Protocol

Original Editor - Shreya Pavaskar

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Description[edit | edit source]

Hamstring strains are caused by a rapid extensive contraction or a violent stretch of the hamstring muscle group which causes high mechanical stress. This results in varying degrees of rupture within the fibres of the musculotendinous unit.[1] Hamstring strains are common in sports with a dynamic character like sprinting, jumping, contact sports such as Australian Rules football (AFL), American football and soccer where quick eccentric contractions are regular. They also have the highest incidence rate of re injury over any other injury, with up to 1/3rdof hamstring injuries reoccurring, and typically in the first 2 weeks (Brukner and Khan, 2017)[2]. Hamstring injuries can also occur in recreational sports such as water-skiing and bull riding, where the knee is forcefully fully extended during injury.

There are two main types of Hamstring injury:

Type 1 - Occurs due to high speed running, typically affecting the long head of bicep femoris, with pain reported further down from the ischial tuberosity. Tend to initially cause a marked decline in function but have a quicker rehabilitation rate than type 2

Type 2 - Occurs due to excessive lengthening, typically affects the proximal free tendon of semimembranosus, with pain reported closer to the ischial tuberosity and up into the buttock. Rehabilitation time has been said to take slightly longer

Askling Protocol [3] - In their paper of 2003, Carl Askling and colleagues used 75 elite Swedish football players to compare two different hamstring rehabilitation protocols called the C-Protocol and L-Protocol. They then assessed outcomes of return to play and re-injury. The L-Protocol focused on eccentric loading of the hamstrings while the C-protocol consisted of conventional hamstring rehabilitation exercises. Participants in the L-protocol were able to return to sport significantly faster than those in the conventional group (mean 28 days vs 52 days). Their research into which protocol was best for chronic injuries was inconclusive, but the researchers were able to surmise that rehabilitation protocols consisting of eccentric exercises are more effective in returning athletes to their sports following hamstring injury.

The time from the date of injury (total ruptures were excluded) to the date of RP initiation in these two studies was 5 days for both protocols, and no pain provocation and/or analgesic treatments were allowed at any time during the rehabilitation process. Each RP consisted of three different exercises, all performed in the sagittal plane. In both protocols, exercise 1 was aimed mainly at increasing flexibility, exercise 2 was a combined exercise for strength and lumbopelvic control, and exercise 3 was a specific strength training exercise. [4]

Additionally, it is recommended that hamstring injury rehabilitation protocols should be preferentially based on strength and flexibility exercises that primarily involve exercises with high loads at long muscle–tendon lengths

Indication[edit | edit source]

Hamstring Strain

L-Protocol[edit | edit source]

  1. THE EXTENDER (Flexibility)
    • Starting position - The athlete is lying supine, holding and stabilize the thigh of the injured leg with the hip flexed approximately 90°.
    • Instructions - The athlete is instructed to perform slow knee extensions to a point just before pain is felt. (3sets x 12 reps x twice per day)
    • Progression: Increase speed.
  2. THE DIVER (Hamstring Strength and Trunk Stabilisation)
    • Starting position - The athlete is standing with full weight on his injured leg and the opposite knee slightly flexed backwards.
    • Instructions -The athlete is asked to perform the exercise as a simulated dive (hip flexion from an upright trunk position) of the injured, standing leg and simultaneous stretching arms forward and attempting maximal hip extension (3 sets X 6 reps X once per day)1
    • Good quality, ASIS/pelvis horizontally throughout the whole movement
    • Maintain 10–20° knee flexion in the standing leg.
  3. THE GLIDER (Specific Eccentric Strength Exercise)
    • Starting position - The exercise is started with the patient positioned with upright trunk, one hand holding on to a support and legs slightly split. All the body weight should be on the heel of the injured leg with approximately 10–20° knee flexion. Stand on a non friction surface.
    • Instructions - The athlete is instructed to perform a gliding backward movement on the other leg and stop the movement before pain is reached. The movement back to the starting position should be performed by the help of both arms, not using the injured leg (3 sets X 6 reps X once every third day)
    • Progression is achieved by increasing the gliding distance and performing the exercise faster.


Resources[edit | edit source]

Aspetar Hamstring protocol

Rehabilitation of Hamstring Injuries

References[edit | edit source]

  1. Sutton G. Hamstrung by hamstring strains: a review of the literature*.J Orthop Sports Phys Ther. 1984; 5(4):184-95. ↑
  2. Landry M. Brukner & Khan's Clinical Sports Medicine. Physiotherapy Canada. 2014;66(1):109.
  3. Askling CM, Koulouris G, Saartok T, Werner S, Best TM. Total proximal hamstring ruptures: clinical and MRI aspects including guidelines for postoperative rehabilitation. Knee Surgery, Sports Traumatology, Arthroscopy. 2013 Mar;21(3):515-33.
  4. Wangensteen A, Askling C, Hickey J, Purdam C, Made AD, Thorborg K. Rehabilitation of hamstring injuries. InPrevention and Rehabilitation of Hamstring Injuries 2020 (pp. 225-270). Springer, Cham.
  5. Physiotutors. Askling Protocol | Hamstring Strain Rehabilitation. Available from:[last accessed 4/9/2022]