Abstract
Background
Rehabilitation progression and return-to-play (RTP) decision making following hamstring strain injury (HSI) can be challenging for clinicians, owing to the competing demands of reducing both convalescence and the risk of re-injury. Despite an increased focus on the RTP process following HSI, little attention has been paid to rehabilitation progression and RTP criteria, and subsequent time taken to RTP and re-injury rates.
Objective
The aim of this systematic review is to identify rehabilitation progression and RTP criteria implemented following HSI and examine the subsequent time taken to RTP and rates of re-injury.
Methods
A systematic literature review of databases MEDLINE, CINAHL, SPORTDiscus, Cochrane Library, Web of Science and EMBASE was conducted to identify studies of participants with acute HSI reporting time taken to RTP and rates of re-injury after a minimum 6-month follow-up. General guidelines and specific criteria for rehabilitation progression were identified for each study. In addition, RTP criteria were identified and categorised as performance tests, clinical assessments, isokinetic dynamometry or the Askling H-test.
Results
Nine studies were included with a total of 601 acute HSI confirmed by clinical examination or magnetic resonance imaging within 10 days of initial injury. A feature across all nine studies was that the injured individual’s perception of pain was used to guide rehabilitation progression, whilst clinical assessments and performance tests were the most frequently implemented RTP criteria. Mean RTP times were lowest in studies implementing isokinetic dynamometry as part of RTP decision making (12–25 days), whilst those implementing the Askling H-test had the lowest rates of re-injury (1.3–3.6%).
Conclusions
This systematic review highlights the strong emphasis placed on the alleviation of pain to allow HSI rehabilitation progression, and the reliance on subjective clinical assessments and performance tests as RTP criteria. These results suggest a need for more objective and clinically practical criteria, allowing a more evidence-based approach to rehabilitation progression, and potentially reducing the ambiguity involved in the RTP decision-making process.
Similar content being viewed by others
References
Orchard JW, Seward H, Orchard JJ. Results of 2 decades of injury surveillance and public release of data in the Australian Football League. Am J Sports Med. 2013;41(4):734–41.
Ekstrand J, Hagglund M, Walden M. Injury incidence and injury patterns in professional football: the UEFA injury study. Br J Sports Med. 2011;45(7):553–8.
Opar D, Drezner J, Shield A, et al. Acute injuries in track and field athletes: a 3-year observational study at the Penn relays carnival with epidemiology and medical coverage implications. Am J Sports Med. 2015;43(4):816–22.
Elliott MC, Zarins B, Powell JW, et al. Hamstring muscle strains in professional football players: a 10-year review. Am J Sports Med. 2011;39(4):843–50.
Woods C. The Football Association Medical Research Programme: an audit of injuries in professional football: analysis of hamstring injuries. Br J Sports Med. 2004;38(1):36–41.
Timmins RG, Shield AJ, Williams MD, et al. Biceps femoris long head architecture: a reliability and retrospective injury study. Med Sci Sport Exerc. 2015;47(5):905–13.
Opar DA, Williams MD, Timmins RG, et al. Knee flexor strength and bicep femoris electromyographical activity is lower in previously strained hamstrings. J Electromyogr Kinesiol. 2013;23(3):696–703.
Opar DA, Williams MD, Timmins RG, et al. Rate of torque and electromyographic development during anticipated eccentric contraction is lower in previously strained hamstrings. Am J Sports Med. 2013;41(1):116–25.
Silder A, Heiderscheit BC, Thelen DG, et al. MR observations of long-term musculotendon remodeling following a hamstring strain injury. Skeletal Radiol. 2008;37(12):1101–9.
Opar DA, Piatkowski T, Williams MD, et al. A novel device using the Nordic hamstring exercise to assess eccentric knee flexor strength: a reliability and retrospective injury study. J Orthop Sport Phys. 2013;43(9):636–40.
Maniar N, Shield AJ, Williams MD, et al. Hamstring strength and flexibility after hamstring strain injury: a systematic review and meta-analysis. Br J Sports Med. 2016;50(15):909–20.
Opar DA, Williams MD, Shield AJ. Hamstring strain injuries: factors that lead to injury and re-injury. Sports Med. 2012;42(3):209–26.
Freckleton G, Pizzari T. Risk factors for hamstring muscle strain injury in sport: a systematic review and meta-analysis. Br J Sports Med. 2013;47(6):351–8.
Bourne MN, Opar DA, Williams MD, et al. Eccentric knee flexor strength and risk of hamstring injuries in rugby union: a prospective study. Am J Sports Med. 2015;43(11):2663–70.
Hickey J, Shield AJ, Williams MD, et al. The financial cost of hamstring strain injuries in the Australian Football League. Br J Sports Med. 2014;48(8):729–30.
Hagglund M, Walden M, Magnusson H, et al. Injuries affect team performance negatively in professional football: an 11-year follow-up of the UEFA Champions League injury study. Br J Sports Med. 2013;47(12):738–42.
Creighton DW, Shrier I, Shultz R, et al. Return-to-play in sport: a decision-based model. Clin J Sport Med. 2010;20(5):379–85.
Orchard J, Best TM. The management of muscle strain injuries: an early return versus the risk of recurrence. Clin J Sport Med. 2002;12(1):3–5.
Shrier I. Strategic Assessment of Risk and Risk Tolerance (StAART) framework for return-to-play decision-making. Br J Sports Med. 2015;49(20):1311–5.
Jarvinen TA, Jarvinen TL, Kaariainen M, et al. Muscle injuries: biology and treatment. Am J Sports Med. 2005;33(5):745–64.
Maffulli N, Oliva F, Frizziero A, et al. ISMuLT guidelines for muscle injuries. Muscles Ligaments Tendons J. 2013;3(4):241–9.
Page P. Pathophysiology of acute exercise-induced muscular injury: clinical implications. J Athl Train. 1995;30(1):29–34.
Fernandes TL, Pedrinelli A, Hernandez AJ. Muscle injury: physiopathology, diagnosis, treatment and clinical presentation. Rev Bras Ortop. 2011;46(3):247–55.
Jarvinen TA, Jarvinen M, Kalimo H. Regeneration of injured skeletal muscle after the injury. Muscles Ligaments Tendons J. 2013;3(4):337–45.
Jarvinen MJ, Lehto MU. The effects of early mobilisation and immobilisation on the healing process following muscle injuries. Sports Med. 1993;15(2):78–89.
Kujala UM, Orava S, Järvinen M. Hamstring injuries: current trends in treatment and prevention. Sports Med. 1997;23(6):397–404.
Jarvinen TA, Jarvinen TL, Kaariainen M, et al. Muscle injuries: optimising recovery. Best Pract Res Clin Rheumatol. 2007;21(2):317–31.
Drezner JA. Practical management: hamstring muscle injuries. Clin J Sport Med. 2003;13(1):48–52.
Tol JL, Hamilton B, Eirale C, et al. At return to play following hamstring injury the majority of professional football players have residual isokinetic deficits. Br J Sports Med. 2014;48(18):1364–9.
Mendiguchia J, Brughelli M. A return-to-sport algorithm for acute hamstring injuries. Phys Ther Sport. 2011;12(1):2–14.
Schmitt B, Tim T, McHugh M. Hamstring injury rehabilitation and prevention of reinjury using lengthened state eccentric training: a new concept. Int J Sports Phys Ther. 2012;7(3):333–41.
DeWitt J, Vidale T. Recurrent hamstring injury: consideration following operative and non-operative management. Int J Sports Phys Ther. 2014;9(6):798–812.
Sherry MA, Johnston TS, Heiderscheit BC. Rehabilitation of acute hamstring strain injuries. Clin Sport Med. 2015;34(2):263–84.
Valle X, Tol JL, Hamilton B, et al. Hamstring muscle injuries, a rehabilitation protocol purpose. Asian J Sports Med. 2015;6(4):e25411.
Heiderscheit BC, Sherry MA, Silder A, et al. Hamstring strain injuries: recommendations for diagnosis, rehabilitation, and injury prevention. J Orthop Sport Phys. 2010;40(2):67–81.
Garrett WE Jr, Safran MR, Seaber AV, et al. Biomechanical comparison of stimulated and nonstimulated skeletal muscle pulled to failure. Am J Sports Med. 1987;15(5):448–54.
Jarvinen MJ, Einola SA, Virtanen EO. Effect of the position of immobilization upon the tensile properties of the rat gastrocnemius muscle. Arch Phys Med Rehab. 1992;73(3):253–7.
Askling CM, Nilsson J, Thorstensson A. A new hamstring test to complement the common clinical examination before return to sport after injury. Knee Surg Sports Traumatol Arthrosc. 2010;18(12):1798–803.
Ardern CL, Glasgow P, Schneiders A, et al. 2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern. Br J Sports Med. 2016;50(14):853–64.
Orchard J, Best TM, Verrall GM. Return to play following muscle strains. Clin J Sport Med. 2005;15(6):436–41.
Fournier-Farley C, Lamontagne M, Gendron P, et al. Determinants of return to play after the nonoperative management of hamstring injuries in athletes: a systematic review. Am J Sports Med. 2016;44(8):2166–72.
Delvaux F, Rochcongar P, Bruyere O, et al. Return-to-play criteria after hamstring injury: actual medicine practice in professional soccer teams. J Sport Sci Med. 2014;13(3):721–3.
Clanton TO, Coupe KJ. Hamstring strains in athletes: diagnosis and treatment. J Am Acad Orthop Sur. 1998;6(4):237–48.
van der Horst N, van de Hoef S, Reurink G, et al. Return to play after hamstring injuries: a qualitative systematic review of definitions and criteria. Sports Med. 2016;46(6):899–912.
Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med. 2009;151(4):264–9.
Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Commun Health. 1998;52(6):377–84.
Team RC. R: a language and environment for statistical computing. Vienna: R Foundation for Statistical Computing; 2016.
Wickham H. ggplot2: elegant graphics for data analysis. New York: Springer; 2009.
De Vos RJ, Reurink G, Goudswaard GJ, et al. Clinical findings just after return to play predict hamstring re-injury, but baseline MRI findings do not. Br J Sports Med. 2014;48(18):1377–84.
Reurink G, Goudswaard GJ, Moen MH, et al. Rationale, secondary outcome scores and 1-year follow-up of a randomised trial of platelet-rich plasma injections in acute hamstring muscle injury: the Dutch Hamstring Injection Therapy study. Br J Sports Med. 2015;49(18):1206–12.
Kilcoyne KG, Dickens JF, Keblish D, et al. Outcome of grade I and II hamstring injuries in intercollegiate athletes: a novel rehabilitation protocol. Sports Health. 2011;3(6):528–33.
Hamilton B, Tol JL, Almusa E, et al. Platelet-rich plasma does not enhance return to play in hamstring injuries: a randomised controlled trial. Br J Sports Med. 2015;49(14):943–50.
Askling CM, Tengvar M, Thorstensson A. Acute hamstring injuries in Swedish elite football: a prospective randomised controlled clinical trial comparing two rehabilitation protocols. Br J Sports Med. 2013;47(15):953–9.
Askling CM, Tengvar M, Tarassova O, et al. Acute hamstring injuries in Swedish elite sprinters and jumpers: a prospective randomised controlled clinical trial comparing two rehabilitation protocols. Br J Sports Med. 2014;48(7):532–9.
Verrall GM, Slavotinek JP, Barnes PC, et al. Assessment of physical examination and magnetic resonance imaging findings of hamstring injury as predictors for recurrent injury. J Orthop Sport Phys. 2006;36(4):215–24.
Malliaropoulos N, Papacostas E, Kiritsi O, et al. Posterior thigh muscle injuries in elite track and field athletes. Am J Sports Med. 2010;38(9):1813–9.
Sherry MA, Best TM. A comparison of 2 rehabilitation programs in the treatment of acute hamstring strains. J Orthop Sport Phys. 2004;34(3):116–25.
Silder A, Sherry MA, Sanfilippo J, et al. Clinical and morphological changes following 2 rehabilitation programs for acute hamstring strain injuries: a randomized clinical trial. J Orthop Sport Phys. 2013;43(5):284–99.
Askling C, Karlsson J, Thorstensson A. Hamstring injury occurrence in elite soccer players after preseason strength training with eccentric overload. Scand J Med Sci Sports. 2003;13(4):244–50.
van der Horst N, Smits D-W, Petersen J, et al. 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(6):1316–23.
Petersen J, Thorborg K, Nielsen MB, et al. Preventive effect of eccentric training on acute hamstring injuries in men’s soccer: a cluster-randomized controlled trial. Am J Sports Med. 2011;39(11):2296–303.
Arnason A, Andersen TE, Holme I, et al. Prevention of hamstring strains in elite soccer: an intervention study. Scand J Med Sci Sports. 2008;18(1):40–8.
Opar DA, Williams MD, Timmins RG, et al. Eccentric hamstring strength and hamstring injury risk in Australian footballers. Med Sci Sport Exerc. 2015;47(4):857–65.
Croisier JL, Ganteaume S, Binet J, et al. Strength imbalances and prevention of hamstring injury in professional soccer players: a prospective study. Am J Sports Med. 2008;36(8):1469–75.
Timmins RG, Bourne MN, Shield AJ, et al. Short biceps femoris fascicles and eccentric knee flexor weakness increase the risk of hamstring injury in elite football (soccer): a prospective cohort study. Br J Sports Med. 2016;15(24):1524–35.
Timmins RG, Ruddy JD, Presland J, et al. Architectural changes of the biceps femoris long head after concentric or eccentric training. Med Sci Sport Exerc. 2016;48(3):499–508.
Hegedus EJ, Cook CE. Return to play and physical performance tests: evidence-based, rough guess or charade? Br J Sports Med. 2015;49(20):1288–9.
Askling C, Saartok T, Thorstensson A. Type of acute hamstring strain affects flexibility, strength, and time to return to pre-injury level. Br J Sports Med. 2006;40(1):40–4.
Jacobsen P, Witvrouw E, Muxart P, et al. A combination of initial and follow-up physiotherapist examination predicts physician-determined time to return to play after hamstring injury, with no added value of MRI. Br J Sports Med. 2016;50(7):431–9.
Bohannon RW. Manual muscle testing: does it meet the standards of an adequate screening test? Clin Rehabil. 2005;19(6):662–7.
Wadsworth CT, Krishnan R, Sear M, et al. Intrarater reliability of manual muscle testing and hand-held dynametric muscle testing. Phys Ther. 1987;67(9):1342–7.
van Dyk N, Bahr R, Whiteley R, et al. Hamstring and quadriceps isokinetic strength deficits are weak risk factors for hamstring strain injuries: a 4-year cohort study. Am J Sports Med. 2016;44(7):1789–95.
Brukner P, Connell D. ‘Serious thigh muscle strains’: beware the intramuscular tendon which plays an important role in difficult hamstring and quadriceps muscle strains. Br J Sports Med. 2016;50(4):205–8.
Pollock N, Patel A, Chakraverty J, et al. Time to return to full training is delayed and recurrence rate is higher in intratendinous (‘c’) acute hamstring injury in elite track and field athletes: clinical application of the British Athletics Muscle Injury Classification. Br J Sports Med. 2016;50(5):305–10.
Pas HI, Reurink G, Tol JL, et al. Efficacy of rehabilitation (lengthening) exercises, platelet-rich plasma injections, and other conservative interventions in acute hamstring injuries: an updated systematic review and meta-analysis. Br J Sports Med. 2015;49(18):1197–205.
Verrall GM, Brukner PD, Seward HG. 6. Doctor on the sidelines. Med J Aust. 2006;184(5):244–8.
Khan KM, Scott A. Mechanotherapy: how physical therapists’ prescription of exercise promotes tissue repair. Br J Sports Med. 2009;43(4):247–52.
Acknowledgements
The authors thank Mr. Nicol van Dyk and Dr. Peter Hickey for reviewing this manuscript prior to submission.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Funding
No sources of funding were required in the preparation of this article.
Conflict of interest
Jack Hickey, Ryan Timmins, Nirav Maniar, Morgan Williams and David Opar declare that they have no conflicts of interest relevant to the content of this review.
Rights and permissions
About this article
Cite this article
Hickey, J.T., Timmins, R.G., Maniar, N. et al. Criteria for Progressing Rehabilitation and Determining Return-to-Play Clearance Following Hamstring Strain Injury: A Systematic Review. Sports Med 47, 1375–1387 (2017). https://doi.org/10.1007/s40279-016-0667-x
Published:
Issue Date:
DOI: https://doi.org/10.1007/s40279-016-0667-x