New MRI muscle classification systems and associations with return to sport after acute hamstring injuries: a prospective study
- 874 Downloads
To determine agreement between modified Peetrons, Chan acute muscle strain injury classification and British Athletics Muscle Injury Classification (BAMIC) and to investigate their associations and ability to predict time to return to sport (RTS).
Male athletes (n=176) with acute hamstring injury and MRI (1.5T) ≤5 days were followed until RTS. MRIs were scored using standardised forms.
For MRI-positive injuries there was moderate agreement in severity grading (κ = 0.50–0.56). Substantial variance in RTS was demonstrated within and between MRI categories. Mean differences showed an overall main effect for severity grading (p < 0.001), but post hoc pairwise comparisons for BAMIC (grade 0a/b vs. 1, p = 0.312; 1 vs 2, p = 0.054; 0a/b vs 2, p < 0.001; 1 vs 3, p < 0.001) and mean differences for anatomical sites (BAMIC a–c, p < 0.001 [a vs b, p = 0.974; a vs c, p = 0.065; b vs c, p = 0.007]; Chan anatomical sites 1–5, p < 0.077; 2A–C, p = 0.373; 2a–e, p = 0.008; combined BAMIC, p < 0.001) varied. For MRI-positive injuries, total explained RTS variance was 7.6–11.9% for severity grading and BAMIC anatomical sites.
There was wide overlap between/variation within the grading/classification categories. Therefore, none of the classification systems could be used to predict RTS in our sample of MRI-positive hamstring injuries.
• Days to RTS varied greatly within the grading and classification categories.
• Days to RTS varied greatly between the grading and classification categories.
• Using MRI classification systems alone to predict RTS cannot be recommended.
• The specific MRI classification used should be reported to avoid miscommunication.
KeywordsHamstring injury Magnetic resonance imaging Radiological grading Classification Return to sport
The authors would like to thank the staff of the Qatar National Sports Medicine Program (NSMP), the Sports Medicine Physicians and the staff in the Outpatient Department, and the staff of the Radiology Department, the Rehabilitation Department and the Surgery Department at Aspetar for their contribution to the study. Our sincere thanks are directed to Aziz Farooq for assisting with the statistical analysis.
The authors state that this work has not received any funding.
Compliance with ethical standards
The scientific guarantor of this publication is Arnlaug Wangensteen
Conflict of interest
The following authors of this manuscript declare relationships with the following companies:
Outside the submitted work, AG is a consultant to Pfizer, AstraZeneca, Merck Serono, Sanofi-Aventis, GE Healthcare, TissueGene and OrthoTrophix. AG is also president and a shareholder of Boston Imaging Core Lab, LLC (BICL), which provides image assessment services. FWR is a shareholder of BICL. JLT’s institutes have received funding from Arthrex and Biomet for conducting RCTs on the value of PRP in hamstring and Achilles tendon injuries. JLT received no personal compensation.
Statistics and biometry
Abdulaziz Farooq kindly provided statistical advice for this manuscript.
Institutional Review Board approval was obtained.
Written informed consent was obtained from all subjects (patients) in this study.
Study subject or cohort overlap
Some study subjects have been previously reported in:
Wangensteen A, Tol JL, Roemer FW, Bahr R, Dijkstra HP, Crema MD, Farooq A, Guermazi A. Intra- and interrater reliability of three different MRI grading and classification systems after acute hamstring injuries. Eur J Radiol. 2017 Apr;89:182–190. doi: 10.1016/j.ejrad.2017.02.010. Epub 2017 Feb 11.
Wangensteen A, Almusa E, Boukarroum S, Farooq A, Hamilton B, Whiteley R, Bahr R, Tol JL. MRI does not add value over and above patient history and clinical examination in predicting time to return to sport after acute hamstring injuries: a prospective cohort of 180 male athletes. Br J Sports Med. 2015 Dec;49(24):1579–87. doi: 10.1136/bjsports-2015-094892. Epub 2015 Aug 24.
• observational, prognostic
• performed at one institution
- 2.Koulouris G, Connell D (2005) Hamstring muscle complex: an imaging review. Radiogr Rev Publ Radiol Soc N Am Inc 25:571–586Google Scholar
- 13.Pollock N, Patel A, Chakraverty J et al (2016) 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 50:305–310CrossRefPubMedGoogle Scholar
- 15.Wangensteen A, Tol JL, Roemer FW et al Intra- and interrater reliability of three different MRI grading and classification systems after acute hamstring injuries. Eur J Radiol. https://doi.org/10.1016/j.ejrad.2017.02.010
- 16.Patel A, Chakraverty J, Pollock N et al (2015) British athletics muscle injury classification: a reliability study for a new grading system. Clin Radiol. https://doi.org/10.1016/j.crad.2015.08.009
- 17.Tol JL, Hamilton B, Eirale C et al (2014) At return to play following hamstring injury the majority of professional football players have residual isokinetic deficits. Br J Sports Med. https://doi.org/10.1136/bjsports-2013-093016
- 19.Altman DG (1991) Practical Statistics for Medical Reasearch, 1st edn. Chapman & Hall, LondonGoogle Scholar
- 20.Tabachnick BG, Fidell LS (2013) Using Multivariate Statistics, 6th edn. Pearson Education, USAGoogle Scholar
- 22.Verrall GM, Slavotinek JP, Barnes PG, Fon GT (2003) Diagnostic and Prognostic Value of Clinical Findings in 83 Athletes with Posterior Thigh Injury Comparison of Clinical Findings with Magnetic Resonance Imaging Documentation of Hamstring Muscle Strain*. Am J Sports Med 31:969–973CrossRefPubMedGoogle Scholar
- 25.Silder A (2013) Clinical and Morphological Changes Following 2 Rehabilitation Programs for Acute Hamstring Strain Injuries: A Randomized Clinical Trial. J Orthop Sports Phys Ther. https://doi.org/10.2519/jospt.2013.4452
- 27.Askling CM, Tengvar M, Thorstensson A (2013) Acute hamstring injuries in Swedish elite football: a prospective randomised controlled clinical trial comparing two rehabilitation protocols. Br J Sports Med. https://doi.org/10.1136/bjsports-2013-092165
- 31.Moen MH, Reurink G, Weir A et al (2014) Predicting return to play after hamstring injuries. Br J Sports Med. https://doi.org/10.1136/bjsports-2014-093860
- 32.Cross TM, Gibbs N, Houang MT, Cameron M (2004) Acute quadriceps muscle strains: magnetic resonance imaging features and prognosis. Am J Sports Med 32:710–719.Google Scholar
- 34.Pedret C, Rodas G, Balius R, et al (2015) Return to Play After Soleus Muscle Injuries. Orthop J Sports Med 3. doi: https://doi.org/10.1177/2325967115595802
- 36.Valle X, Alentorn-Geli E, Tol JL et al (2016) Muscle Injuries in Sports: A New Evidence-Informed and Expert Consensus-Based Classification with Clinical Application. Sports Med Auckl NZ. https://doi.org/10.1007/s40279-016-0647-1