What should you tell your students to do if they have an injured upper hamstring tendon? The recovery program below is based on the physiology of healing and the principles of yoga. It has three stages, corresponding to the three phases of the healing process: 1. Rest during the inflammation phase (72 hours). 2. Align during the repair phase (6 weeks). 3. Strengthen and lengthen during the remodeling phase (up to a year or more).
Stage 1: Rest. For 72 hours after the initial injury, the student should rest the area completely. This gives the body time to remove damaged tissue and bring in cells that will produce new capillaries and collagen. The student should not attempt any stretching or strengthening activities and should not apply heat. To prevent excessive inflammation and swelling, apply ice (20 minutes on, 20 minutes off) as often as is practical, compress the upper thigh just below the sitting bone (using an elastic sleeve), and elevate the pelvis above the heart.
Stage 2: Align. Over the next six weeks, very gently align the newly forming connective tissue fibers. Do this by gradually introducing modified asanas (see Asanas for Hamstring Recovery below) that provide micro-strengthening actions with the hamstring muscles in the neutral, slightly shortened, and slightly lengthened positions. These asanas should apply just enough tension at just the right angle to induce the healing tendon to grow strong and flexible in the desired direction. Practice with subtlety. Do not perform the asanas too vigorously or stretch too far, because this can damage the delicate molecular/cellular matrix that is being created. If pain increases during this stage, back off and start over with Stage 1.
Stage 3: Strengthen and Lengthen. Over the next year or more, very gradually strengthen, then stretch, the injured hamstring tendon. As in Stage 2, practice asanas that contract the hamstrings against resistance in the neutral, shortened, and lengthened positions (see Asanas for Hamstring Recovery). Start out where Stage 2 left off, then gradually increase the load and length demands on the muscles and tendons. Done properly, this systematically adds high-quality, correctly aligned collagen fibers to the injured area. Back off if pain increases. One of the key benefits of this program is that it strengthens the hamstrings not only while short, but also while in progressively longer positions, for several months before introducing full stretching postures.
Stage 1: First 72 Hours
Purpose: To Elevate the pelvis and rest the hamstrings.
Supported Setu Bandha Sarvangasana (supported Bound Bridge Pose)
Place two bolsters (or long folded blankets) end to end. To enter the pose, first sit in the middle of one bolster, then turn your body to align your legs over the other bolster and lie back so your upper back drapes over the end of the first bolster. Lengthen your lower back, place your shoulders and head on the floor, and extend your legs straight. Do not enter the pose starting with your pelvis on the floor, because lifting it up onto the bolster would require a strong hamstring contraction. Also, take care not to stress the hamstrings while adjusting position or exiting the pose. Hold the posture for 10 minutes or more (but exit sooner if it causes discomfort). Do this pose during the first 72 hours after an injury. It’s OK to repeat it several times a day, and to continue to practice it in Stages 2 and 3.
Stage 2: Next Six Weeks
Purpose: To gently pull the delicate, new collagen fibers of the healing tendon into alignment without tearing them.
The first time you try each asana in this sequence, do it just once, with the mildest possible muscle contraction, and hold it only briefly. If it does not cause pain, build up over several days to three repetitions, holding the pose for 30 seconds each time. Start with extremely mild muscle contractions, and build force gradually until you achieve moderate contraction strength at the end of six weeks. Never contract or stretch with great force in Stage 2. It may also be helpful to apply ice after your asana session.
To maintain standard alignment, point your knees straight ahead (no internal or external rotation of thighs) and align your feet with your knees (no internal or external rotation of shins at knee joint). You may also wish to try variations in some cases to focus strength and stretch on particular parts of the hamstring tendons.
Partial Salabhasana (Partial Locust Pose)
Effect: Alignment and micro-strengthening in the neutral position.
Lie prone. Keep your knees straight. Keep your forehead and hands on the floor. Contract your hamstrings very gently as if to lift your legs without bending your knees, but do not lift your feet or legs off the floor for the first few weeks. Instead, use just enough effort to lighten the weight of the legs on the floor by a small amount. Gradually increase the strength of the lift until, after a few weeks, you lift your legs slightly off the floor. At the end of six weeks, your legs should lift a few inches only.
Dhanurasana Preparation (Bow Pose preparation, without hands)
Effect: Alignment and micro-strengthening in the partially contracted position.
Lie prone. Support your ankles on a bolster with your knees bent. Keep your forehead and hands on the floor throughout this practice. Contract your hamstrings very gently as if to bend your knees and lift your feet off the bolster, but do not lift the feet for the first week or two. Instead, use just enough effort to lighten the weight of the feet on the bolster by a small amount. Gradually increase the strength of lift until, after a week or two, you lift your feet slightly off the bolster. After holding your feet off the bolster for 30 seconds, bend your knees to 90 degrees and then slowly lower your feet back to the bolster. Over the next four or five weeks, support your ankles on a progressively lower and lower prop (such as folded blankets) as you perform the same sequence (30 second hold slightly off prop followed by 90 degree bend, then lower to prop again). By the end of six weeks, practice without any prop (start and end with feet on the floor).
Supported Partial Supta Padangusthasana (Supported Partial Reclining Big Toe Pose)
Effect: Alignment and micro-strengthening in partially stretched position.
Lie supine. Support the heel of your injured leg on a block. Keep both knees straight. Press your heel gently straight down into the block. Over six weeks, gradually increase the height of the heel support (for example, with folded blankets, a bolster, chair seat, door jamb, etc.), but do not lift your leg beyond 45 degrees from the floor (if a 45 degree lift causes the sensation of stretch in the hamstrings, use less lift). Gradually increase from a mild to a moderate push on the heel. Hold for 30 seconds, repeat three times.
Stage 3: Subsequent Year (or longer)
Pupose: To systematically strengthen the healing tendon by adding high-quality, well-aligned collagen fibers to it, and to build long, strong, flexible hamstring muscles to prevent re-injury. Stage 3 normally lasts about one year, but it can continue for a lifetime.
This stage starts out where Stage 2 left off and includes some of the same asanas, practiced at a slightly higher level of difficulty. It then proceeds to asanas that demand muscle contraction against greater and greater resistance, in neutral, shortened, and increasingly stretched positions. When practicing, align the poses carefully, as in Stage 2, and practice both sides of one-sided poses, so both the left and right hamstrings benefit.
Assuming an asana does not cause pain, perform three repetitions, holding for 30 to 60 seconds each time and resting for a minute between repetitions. Contract the hamstrings moderately at the beginning, and build gradually to a strong contraction over several months. However, never apply strong force to stretching the hamstrings; rely instead on conscious release during a sustained, modest stretch.
When the student can practice all of the Stage 3 postures deeply, strongly, and without pain, he can return to the practice of conventional, full hamstring-stretching postures. However, the Stage 3 practice remains valuable indefinitely.
Effect: Alignment and strengthening in neutral position.
At the beginning of Stage 3, continue to increase the lift of your legs from where it left off at the end of Stage 2. Work gradually up to a full lift of the legs, then to a full lift of the upper body.
Effect: Alignment and strengthening in shortened position.
This pose replaces Dhanurasana preparation from Stage 2. Lie supine with bent knees. Lift your pelvis off the floor, emphasizing a contraction in the hamstrings near your sitting bones. Lift the pelvis only a few inches at first. Gradually work up to the full pose, over weeks or months. After several months, when strong in the pose, you may elevate your feet on blocks (milder), then on a chair seat (stronger) to put greater strength demands on the hamstrings. Finally, for the greatest challenge, you may introduce Eka Pada Setu Bandha Sarvangasana, which is the same pose with one leg lifted straight up.
Supta Padangusthasana against Resistance (Reclining Big Toe Pose against Resistance)
Effect: Alignment and strengthening in stretched position.
At the beginning of Stage 3, continue to increase the height of the leg prop from where it left off at the end of Stage 2. Work gradually up to a 90 degree elevation of the leg supported by a door jamb. Then work past 90 degrees, holding the leg in place with a strap around the ball of the foot. At all angles of the leg lift, remember that your goal is to push the straight leg away from your body against the resistance of a support prop in order to contract and strengthen hamstrings, not to pull the foot toward the body and stretch the hamstrings.
Purvottanasana (Upward Plane Pose)
Effect: Higher-resistance strengthening in neutral position.
Introduce this pose only if full Salabhasana is achieved without difficulty. Sit in Dandasana (Staff Pose) with your hands about six inches behind your hips. Keeping your legs straight, press your hands and heels down firmly to lift your hips and chest as high as possible. When your hips are maximally lifted, slowly drop your head backward.
Parsvottanasana against Resistance (Side Stretch Pose against Resistance)
Effect: Higher resistance strengthening in stretched position.
Stand facing a wall. Place both of your palms on the wall at shoulder height. Step one foot forward so your toes are six to 12 inches from the wall. Step the other foot back about three and one half to four feet from your front foot. Face your front foot directly toward the wall and turn your back foot out one third of the way (60 degrees to the wall). Center both feet on a line perpendicular to the wall. Bend forward at the hip joint of your front leg, keeping your spine in a neutral position (not flexing). Bend only enough to apply a mild stretch to the hamstring of the front leg. Adjust your foot and hip distances from the wall and from one another, and adjust your thigh rotation to maintain a mild stretch while strictly keeping the front knee squarely over the front foot, and the two hips square (equidistant from the wall and the floor). Keep both knees straight.
Simultaneously press the bottom of your front foot into the floor and pull it backward toward the back foot, using the friction of the floor to keep the feet from sliding toward one another. This will isometrically contract the hamstrings of the front leg. After 30 seconds, keep this same alignment but place your hands on your pelvic rim and slowly stand upright. This will isotonically contract the hamstrings of the front leg against the resistance of gravity. If you don’t experience any pain, repeat the same sequence with both feet slightly farther from the wall, so the pose creates a deeper forward bend at the hip joint. Remember, however, that the purpose of the practice is to contract and strengthen the hamstrings, not to maximally stretch them.