Download PDF
Semin Musculoskelet Radiol 2024; 28(02): 119-129
DOI: 10.1055/s-0043-1778027
Review Article

Hamstring Injuries: A Paradigm for Return to Play

Michael K. Hoy
1   Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
,
Stephen Stache Jr.
2   Departments of Orthopaedics and Family and Community Medicine, Rothman Orthopaedic Institute, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
,
Johannes B. Roedl
1   Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
› Author Affiliations
› Further Information
Also available at
    Permissions and Reprints

Abstract

Muscle injuries are the most common sports-related injuries, with hamstring involvement most common in professional athletes. These injuries can lead to significant time lost from play and have a high risk of reinjury. We review the anatomy, mechanisms of injury, diagnostic imaging modalities, and treatment techniques for hamstring injuries. We also present the latest evidence related to return to play (RTP) after hamstring injuries, including a review of articles targeted to RTP in European soccer (Union of European Football Associations), American football (National Football League), and other professional sports. Review of imaging findings in hamstring injury, grading systems for injuries, considerations for RTP, as well as advances in injury prevention, are discussed.

Keywords

return to play - hamstring strain - injuries - soccer - football


Publication History

Article published online:
14 March 2024

© 2024. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Ahmad CS, Redler LH, Ciccotti MG, Maffulli N, Longo UG, Bradley J. Evaluation and management of hamstring injuries. Am J Sports Med 2013; 41 (12) 2933-2947
    CrossrefPubMedGoogle Scholar
  • 2 van der Horst N, Smits DW, Petersen J, Goedhart EA, Backx FJG. The preventive effect of the Nordic hamstring exercise on hamstring injuries in amateur soccer players: a randomized controlled trial. Am J Sports Med 2015; 43 (06) 1316-1323
    CrossrefPubMedGoogle Scholar
  • 3 Miller SL, Gill J, Webb GR. The proximal origin of the hamstrings and surrounding anatomy encountered during repair. A cadaveric study. J Bone Joint Surg Am 2007; 89 (01) 44-48
    CrossrefPubMedGoogle Scholar
  • 4 Yu B, Li L. Research in prevention and rehabilitation of hamstring muscle strain injury. J Sport Health Sci 2017; 6 (03) 253-254
    CrossrefPubMedGoogle Scholar
  • 5 Trunz LM, Landy JE, Dodson CC, Cohen SB, Zoga AC, Roedl JB. Effectiveness of hematoma aspiration and platelet-rich plasma muscle injections for the treatment of hamstring strains in athletes. Med Sci Sports Exerc 2022; 54 (01) 12-17
    CrossrefPubMedGoogle Scholar
  • 6 Lemire J. Orreco data collective's algorithms identify risk of hamstring injuries. Available at: https://www.sportsbusinessjournal.com/Journal/Issues/2022/10/24/Upfront/Injury-tech.aspx Accessed October 30, 2023
    PubMedGoogle Scholar
  • 7 Eliakim E, Morgulev E, Lidor R, Meckel Y. Estimation of injury costs: financial damage of English Premier League teams' underachievement due to injuries. BMJ Open Sport Exerc Med 2020; 6 (01) e000675
    CrossrefPubMedGoogle Scholar
  • 8 Stępień K, Śmigielski R, Mouton C, Ciszek B, Engelhardt M, Seil R. Anatomy of proximal attachment, course, and innervation of hamstring muscles: a pictorial essay. Knee Surg Sports Traumatol Arthrosc 2019; 27 (03) 673-684
    CrossrefPubMedGoogle Scholar
  • 9 Azzopardi C, Almeer G, Kho J, Beale D, James SL, Botchu R. Hamstring origin-anatomy, angle of origin and its possible clinical implications. J Clin Orthop Trauma 2020; 13: 50-52
    CrossrefPubMedGoogle Scholar
  • 10 Vieira RL, Rosenberg ZS, Kiprovski K. MRI of the distal biceps femoris muscle: normal anatomy, variants, and association with common peroneal entrapment neuropathy. AJR Am J Roentgenol 2007; 189 (03) 549-555
    CrossrefPubMedGoogle Scholar
  • 11 De Smet AA, Best TM. MR imaging of the distribution and location of acute hamstring injuries in athletes. AJR Am J Roentgenol 2000; 174 (02) 393-399
    CrossrefPubMedGoogle Scholar
  • 12 Martin RL, Cibulka MT, Bolgla LA. et al. Hamstring strain injury in athletes. J Orthop Sports Phys Ther 2022; 52 (03) CPG1-CPG44
    CrossrefPubMedGoogle Scholar
  • 13 Sonnery-Cottet B, Daggett M, Gardon R, Pupim B, Clechet J, Thaunat M. Surgical management of recurrent musculotendinous hamstring injury in professional athletes. Orthop J Sports Med 2015; 3 (10) 2325967115606393
    CrossrefPubMedGoogle Scholar
  • 14 Askling C, Tengvar M, Saartok T, Thorstensson A. Acute first-time hamstring strains during slow-speed stretching: clinical, magnetic resonance imaging, and recovery characteristics. Available at: https://journals.sagepub.com/doi/full/10.1177/0363546507303563 Accessed August 30, 2023
    PubMedGoogle Scholar
  • 15 Linklater JM, Hamilton B, Carmichael J, Orchard J, Wood DG. Hamstring injuries: anatomy, imaging, and intervention. Semin Musculoskelet Radiol 2010; 14 (02) 131-161
    Article in Thieme ConnectPubMedGoogle Scholar
  • 16 Grassi A, Quaglia A, Canata GL, Zaffagnini S. An update on the grading of muscle injuries: a narrative review from clinical to comprehensive systems. Joints 2016; 4 (01) 39-46
    Article in Thieme ConnectPubMedGoogle Scholar
  • 17 Pollock N, James SLJ, Lee JC, Chakraverty R. British Athletics Muscle Injury Classification: a new grading system. Br J Sports Med 2014; 48 (18) 1347-1351
    CrossrefPubMedGoogle Scholar
  • 18 Cohen SB, Towers JD, Zoga A. et al. Hamstring injuries in professional football players: magnetic resonance imaging correlation with return to play. Sports Health 2011; 3 (05) 423-430
    CrossrefPubMedGoogle Scholar
  • 19 Shelly MJ, Hodnett PA, MacMahon PJ, Moynagh MR, Kavanagh EC, Eustace SJ. MR imaging of muscle injury. Magn Reson Imaging Clin N Am 2009; 17 (04) 757-773 , vii
    CrossrefPubMedGoogle Scholar
  • 20 Carmichael J, Packham I, Trikha SP, Wood DG. Avulsion of the proximal hamstring origin. Surgical technique. J Bone Joint Surg Am 2009; 91 (Suppl 2): 249-256
    CrossrefPubMedGoogle Scholar
  • 21 Chang JS, Kayani B, Plastow R, Singh S, Magan A, Haddad FS. Management of hamstring injuries: current concepts review. Bone Joint J 2020; 102-B (10) 1281-1288
    CrossrefPubMedGoogle Scholar
  • 22 Qiao Y, Zhang L, Zhang B. Rehabilitation treatment of muscle strain in athlete training under intelligent intervention. Comput Math Methods Med 2022; 2022: 5403681
    CrossrefPubMedGoogle Scholar
  • 23 Valle X, Alentorn-Geli E, Tol JL. et al. Muscle injuries in sports: a new evidence-informed and expert consensus-based classification with clinical application. Sports Med 2017; 47 (07) 1241-1253
    CrossrefPubMedGoogle Scholar
  • 24 Mueller-Wohlfahrt HW, Haensel L, Mithoefer K. et al. Terminology and classification of muscle injuries in sport: the Munich consensus statement. Br J Sports Med 2013; 47 (06) 342-350
    CrossrefPubMedGoogle Scholar
  • 25 Danielsson A, Horvath A, Senorski C. et al. The mechanism of hamstring injuries - a systematic review. BMC Musculoskelet Disord 2020; 21 (01) 641
    CrossrefPubMedGoogle Scholar
  • 26 Burkett LN. Investigation into hamstring strains: the case of the hybrid muscle. J Sports Med 1975; 3 (05) 228-231
    CrossrefPubMedGoogle Scholar
  • 27 Opar DA, Williams MD, Shield AJ. Hamstring strain injuries: factors that lead to injury and re-injury. Sports Med 2012; 42 (03) 209-226
    CrossrefPubMedGoogle Scholar
  • 28 Colosimo AJ, Wyatt HM, Frank KA, Mangine RE. Hamstring avulsion injuries. Oper Tech Sports Med 2005; 13 (01) 80-88
    CrossrefPubMedGoogle Scholar
  • 29 Folsom GJ, Larson CM. Surgical treatment of acute versus chronic complete proximal hamstring ruptures: results of a new allograft technique for chronic reconstructions. Am J Sports Med 2008; 36 (01) 104-109
    CrossrefPubMedGoogle Scholar
  • 30 Hamilton B, Whiteley R, Almusa E, Roger B, Geertsema C, Tol JL. Excellent reliability for MRI grading and prognostic parameters in acute hamstring injuries. Br J Sports Med 2014; 48 (18) 1385-1387
    CrossrefPubMedGoogle Scholar
  • 31 Kruse RC, Whipple MT, Schmidt E, Wilz L. Role of ultrasound in managing hamstring muscle injuries. Curr Phys Med Rehabil Rep 2021; 9 (04) 237-242
    CrossrefPubMedGoogle Scholar
  • 32 Connell D. Longitudinal study comparing sonographic and MRI assessments of acute and healing hamstring injuries. Available at: https://www.ajronline.org/doi/full/10.2214/ajr.183.4.1830975 Accessed October 8, 2023
    PubMedGoogle Scholar
  • 33 Liu H, Garrett WE, Moorman CT, Yu B. Injury rate, mechanism, and risk factors of hamstring strain injuries in sports: a review of the literature. J Sport Health Sci 2012; 1 (02) 92-101
    CrossrefPubMedGoogle Scholar
  • 34 Zarins B, Ciullo JV. Acute muscle and tendon injuries in athletes. Clin Sports Med 1983; 2 (01) 167-182
    CrossrefPubMedGoogle Scholar
  • 35 Reurink G, Goudswaard GJ, Tol JL. et al. MRI observations at return to play of clinically recovered hamstring injuries. Br J Sports Med 2014; 48 (18) 1370-1376
    CrossrefPubMedGoogle Scholar
  • 36 Matsuda DK. Editorial commentary: Proximal hamstring syndrome: another pain in the buttock. Arthroscopy 2018; 34 (01) 122-125
    CrossrefPubMedGoogle Scholar
  • 37 Kantrowitz DE, Padaki AS, Ahmad CS, Lynch TS. Defining platelet-rich plasma usage by team physicians in elite athletes. Orthop J Sports Med 2018; 6 (04) 2325967118767077
    CrossrefPubMedGoogle Scholar
  • 38 Ekstrand J, Waldén M, Hägglund M. Hamstring injuries have increased by 4% annually in men's professional football, since 2001: a 13-year longitudinal analysis of the UEFA Elite Club injury study. Br J Sports Med 2016; 50 (12) 731-737
    CrossrefPubMedGoogle Scholar
  • 39 Ekstrand J, Lee JC, Healy JC. MRI findings and return to play in football: a prospective analysis of 255 hamstring injuries in the UEFA Elite Club Injury Study. Br J Sports Med 2016; 50 (12) 738-743
    CrossrefPubMedGoogle Scholar
  • 40 Ekstrand J, Bengtsson H, Waldén M, Davison M, Khan KM, Hägglund M. Hamstring injury rates have increased during recent seasons and now constitute 24% of all injuries in men's professional football: the UEFA Elite Club Injury Study from 2001/02 to 2021/22. Br J Sports Med 2022; 57 (05) 292-298
    CrossrefPubMedGoogle Scholar
  • 41 Shamji R, James SLJ, Botchu R, Khurniawan KA, Bhogal G, Rushton A. Association of the British Athletic Muscle Injury Classification and anatomic location with return to full training and reinjury following hamstring injury in elite football. BMJ Open Sport Exerc Med 2021; 7 (02) e001010
    CrossrefPubMedGoogle Scholar
  • 42 McAuley S, Dobbin N, Morgan C, Goodwin PC. Predictors of time to return to play and re-injury following hamstring injury with and without intramuscular tendon involvement in adult professional footballers: a retrospective cohort study. J Sci Med Sport 2022; 25 (03) 216-221
    CrossrefPubMedGoogle Scholar
  • 43 McAleer S. Time to return to full training and recurrence of rectus femoris injuries in elite track and field athletes 2010–2019; a 9-year study using the British Athletics Muscle Injury Classification. Scandinavian Journal of Medicine & Science in Sports. Available at: https://onlinelibrary.wiley.com/doi/full/10.1111/sms.14160 Accessed November 26, 2023
    PubMedGoogle Scholar
  • 44 Hollabaugh WL, Sin A, Lane Walden R. et al. Outcomes of activity-related lower extremity muscle tears after application of the British Athletics Muscle Injury Classification. A systematic review. Available at: https://journals.sagepub.com/doi/full/10.1177/19417381231195529 Accessed November 26, 2023
    PubMedGoogle Scholar
  • 45 Volner D. NFL regular-season ratings increase 10% over last season. Available at: https://www.espn.com/nfl/story/_/id/33050695/nfl-regular-season-ratings-increase-10-percent-last-season Accessed October 30, 2023
    PubMedGoogle Scholar
  • 46 Luxenburg D, Wasserman NA, Geller JS, Perez JR, Burke J, Kaplan LD. Hamstring injuries in the national football league: an epidemiological study. J Orthop 2022; 35: 111-114
    CrossrefPubMedGoogle Scholar
  • 47 Slavotinek JP, Verrall GM, Fon GT. Hamstring injury in athletes: using MR imaging measurements to compare extent of muscle injury with amount of time lost from competition. AJR Am J Roentgenol 2002; 179 (06) 1621-1628
    CrossrefPubMedGoogle Scholar
  • 48 Erickson LN, Sherry MA. Rehabilitation and return to sport after hamstring strain injury. J Sport Health Sci 2017; 6 (03) 262-270
    CrossrefPubMedGoogle Scholar
  • 49 De Vos RJ, Reurink G, Goudswaard GJ, Moen MH, Weir A, Tol JL. Clinical findings just after return to play predict hamstring re-injury, but baseline MRI findings do not. Br J Sports Med 2014; 48 (18) 1377-1384
    CrossrefPubMedGoogle Scholar
  • 50 Ekstrand J, Bengtsson H, Walden M, Davison M, Hagglund M. Still poorly adopted in male professional football: but teams that used the Nordic Hamstring Exercise in team training had fewer hamstring injuries - a retrospective survey of 17 teams of the UEFA Elite Club Injury Study during the 2020–2021 season. BMJ Open Sport Exerc Med 2022; 8 (03) e001368
    CrossrefPubMedGoogle Scholar
  • 51 Augustsson J, Augustsson SR. Development of a novel Nordic Hamstring Exercise performance test device: a reliability and intervention study. Sports (Basel) 2022; 10 (02) 26
    CrossrefPubMedGoogle Scholar
  • 52 Al Attar WSA, Soomro N, Sinclair PJ, Pappas E, Sanders RH. Effect of injury prevention programs that include the Nordic Hamstring Exercise on hamstring injury rates in soccer players: a systematic review and meta-analysis. Sports Med 2017; 47 (05) 907-916
    CrossrefPubMedGoogle Scholar
  • 53 Bahr R, Thorborg K, Ekstrand J. Evidence-based hamstring injury prevention is not adopted by the majority of Champions League or Norwegian Premier League football teams: the Nordic Hamstring survey. Br J Sports Med 2015; 49 (22) 1466-1471
    CrossrefPubMedGoogle Scholar
  • 54 The effect of Nordic Hamstring Exercise intervention volume on eccentric strength and muscle architecture adaptations.. A systematic review and meta-analyses. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6942028/ Accessed October 30, 2023
    PubMedGoogle Scholar
  • 55 van Dyk N, Witvrouw E, Bahr R. Interseason variability in isokinetic strength and poor correlation with Nordic hamstring eccentric strength in football players. Scand J Med Sci Sports 2018; 28 (08) 1878-1887
    CrossrefPubMedGoogle Scholar
  • 56 Ayala F, López-Valenciano A, Gámez Martín JA. et al. A preventive model for hamstring injuries in professional soccer: learning algorithms. Int J Sports Med 2019; 40 (05) 344-353
    Article in Thieme ConnectPubMedGoogle Scholar
  • 57 Mandorino M, Figueiredo AJ, Cima G, Tessitore A. A data mining approach to predict non-contact injuries in young soccer players. Int J Comput Sci Sport 2021; 20 (02) 147-163
    CrossrefPubMedGoogle Scholar
  • 58 Valle X, Mechó S, Alentorn-Geli E. et al. Return to play prediction accuracy of the MLG-R classification system for hamstring injuries in football players: a machine learning approach. Sports Med 2022; 52 (09) 2271-2282
    CrossrefPubMedGoogle Scholar