Skeletal Radiology

, Volume 47, Issue 8, pp 1087–1098 | Cite as

Adult thigh muscle injuries—from diagnosis to treatment: what the radiologist should know

  • João Cruz
  • Vasco Mascarenhas
Review Article


Muscle injuries are one of the major problems facing elite athletes, representing a significant source of time lost from competition, with substantial consequences for teams and athletes. There are considerable pressures for a rapid return, but players who return to competition too soon have an increased risk of recurrent muscle injuries, which are associated with longer lay-offs. Imaging plays a key role in achieving the correct diagnosis, and magnetic resonance imaging (MRI) has emerged as the method of choice for skeletal muscle imaging. Several authors have reported prognostic MRI features, but it is difficult to predict the exact length of time to return to full training afterwards due to considerable discrepancy and overlap between different injuries. Therefore, development of a universally applicable classification and grading system is challenging. This paper aims to: (a) review the contemporary role of imaging in the setting of muscle injuries, with special focus on thigh muscles; (b) list the most accepted terminology used to describe muscle injuries; (c) review the most recent classification and grading systems reported in the literature; and (d) illustrate muscular MRI findings and examine their prognostic value.


Athletic injuries Return to sport Muscle Sprains and strains Magnetic resonance imaging 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflicts of interest.


  1. 1.
    Hancock CR, Sanders TG, Zlatkin MB, et al. Flexor femoris muscle complex: grading systems used to describe the complete spectrum of injury. J Clin Imaging Elsevier Inc. 2009;33:130–5. Scholar
  2. 2.
    Crema MD, Jarraya M, Engebretsen L, et al. Imaging-detected acute muscle injuries in athletes participating in the Rio de Janeiro 2016 Summer Olympic Games. Br. J. Sports Med. 2017;0:1–6; Available from:
  3. 3.
    Ekstrand J, Hägglund M, Waldén M. Epidemiology of muscle injuries in professional football (soccer). Am J Sports Med. 2011;39:1226–32. Scholar
  4. 4.
    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. 2002;179(6):1621–8.CrossRefPubMedGoogle Scholar
  5. 5.
    Haensel L, Mithoefer K, Ekstrand J, et al. Terminology and classification of muscle injuries in sport: a consensus statement. Br J Sports Med 2012;0:1–9.
  6. 6.
    Kerkhoffs G, van Es N, Wieldraaijer T, et al. Diagnosis and prognosis of acute hamstring injuries in athletes. Knee Surg Sports Traumatol Arthrosc. 2013;21:500–9.CrossRefPubMedGoogle Scholar
  7. 7.
    Grassi A, Quaglia A, Canata G, et al. An update on the grading of muscle injuries: a narrative review from clinical to comprehensive systems. Joints. 2016;4:39–46.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Theodorou D, Theodorou S, Kakitsubata. Skeletal muscle disease: patterns of MRI appearances. Br J Radiol. 2012;85:1298–308.CrossRefGoogle Scholar
  9. 9.
    Crema MD, Guermazi A, Reurink G, et al. Can a clinical examination demonstrate intramuscular tendon involvement in acute hamstring injuries? Orthop J Sport Med. 2017;5:1–8.CrossRefGoogle Scholar
  10. 10.
    Guanche CA. Hamstring injuries. J Hip Preserv Surg. 2015;2:116–22. Scholar
  11. 11.
    Veryser J, Gielen J. Radiologic imaging of pelvis, groin, hip, and thigh injuries. In: Glaudemans A, Dierckx R, Gielen J, Zwerver J, editors. Nuclear medicine and radiologic imaging in sports injuries. 1st ed. Verlag Berlin Heidelberg: Springer; 2015. p. 563–97.Google Scholar
  12. 12.
    Lee J, Mitchell A, Healy J. Imaging of muscle injury in the elite athlete. Br J Radiol. 2012;85:1173–85.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Ekstrand J, Askling C, Magnusson H, et al. Return to play after thigh muscle injury in elite football players: implementation and validation of the Munich muscle injury classification. Br J Sports Med. 2013;47:769–74.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Muscle Injuries Clinical Guide 3.0. FC Barcelona. January 2015; Muscle Injuries Clinical Guide 3.0. FC Barcelona. January 2015; Available from:
  15. 15.
    Takebayashi S, Takasawa H, Banzai Y, et al. Sonographic findings in muscle strain injury: clinical and MR imaging correlation. J Ultrasound Med. 1995;14(12):899–905.CrossRefPubMedGoogle Scholar
  16. 16.
    Ekstrand J, Healy JC, Waldén M, et al. Hamstring muscle injuries in professional football: the correlation of MRI findings with return to play. Br J Sports Med. 2012;46:112–7.CrossRefPubMedGoogle Scholar
  17. 17.
    Shelly MJ, Hodnett PA, Macmahon PJ, et al. MR imaging of muscle injury. Magn Reson Imaging Clin N Am. 2009;17(4):757–73.CrossRefPubMedGoogle Scholar
  18. 18.
    Elsayes KM, Lammle M, Shariff A, et al. Value of magnetic resonance imaging in muscle trauma. Curr Probl Diagn Radiol. 2006;35(5):206–12.CrossRefPubMedGoogle Scholar
  19. 19.
    Chan O, Del A, Thomas B, et al. Acute muscle strain injuries: a proposed new classification system. Knee Surg Sports Traumatol Arthrosc. 2012;20:2356–62.CrossRefPubMedGoogle Scholar
  20. 20.
    Pollock N, James SLJ, Lee JC, et al. British athletics muscle injury classification: a new grading system. Br J Sports Med. 2014;48:1347–51. Scholar
  21. 21.
    Hamilton B, Valle X, Rodas G, et al. Classification and grading of muscle injuries: a narrative review. Br J Sports Med. 2015;49(5):306.CrossRefPubMedGoogle Scholar
  22. 22.
    Pomeranz S, Heidt R. MR imaging in the prognostication of hamstring injury. Musculoskeletal injury. Radiology. 1993;189:897–900.CrossRefPubMedGoogle Scholar
  23. 23.
    Gibbs NJ, Cross TM, Cameron M, et al. The accuracy of MRI in predicting recovery and recurrence of acute grade one hamstring muscle strains within the same season in Australian rules football players. J Sci Med Sport. 2004;7:248–58.CrossRefPubMedGoogle Scholar
  24. 24.
    Askling CM, Tengvar M, Saartok T, et al. Acute first-time hamstring strains during high-speed running. Am J Sports Med. 2007;35:197–206. Scholar
  25. 25.
    Askling CM, Tengvar M, Saartok T, Thorstensson A. Acute first-time hamstring strains during slow-speed stretching clinical, magnetic resonance imaging, and recovery characteristics. Am J Sports Med. 2007;35(10):1716–24. Scholar
  26. 26.
    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;3:423–30.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Hamilton B, Whiteley R, Almusa E, et al. Excellent reliability for MRI grading and prognostic parameters in acute hamstring injuries. Br J Sports Med. 2014;48(18):1385–7. Scholar
  28. 28.
    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.CrossRefPubMedGoogle Scholar
  29. 29.
    Connell D, Schneider-Kolsky M, Hoving J, et al. Sonographic and MRI assessments of acute and healing hamstring injuries. AJR. 2004;183:975–84.CrossRefPubMedGoogle Scholar
  30. 30.
    Verrall GM, Slavotinek JP, Barnes PG, et al. 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. 2003;31:969–73.CrossRefPubMedGoogle Scholar
  31. 31.
    Hamstrings - Guidelines for MR Imaging of Sports Injuries. European Society of Skeletal Radiology Sports Sub-committee 2016. Available from:;
  32. 32.
    Rubin D. Imaging diagnosis and prognostication of hamstring injuries. AJR. 2012;199:525–33.CrossRefPubMedGoogle Scholar
  33. 33.
    Crema MD, Yamada AF, Guermazi A, et al. Imaging techniques for muscle injury in sports medicine and clinical relevance. Curr Rev Musculoskelet Med. 2015;8(2):154–61.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Rehabilitation Guidelines Following Proximal Hamstring Primary Repair. University of Wisconsin Sports Medicine 2010;3–8.Google Scholar
  35. 35.
    Stoller D, Sampson T, Bredella M. The hip. In: Stoller D, McAllister L, Barrett K, editors. Magnetic resonance imaging in orthopaedics & sports medicine. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2007. p. 41–304.Google Scholar
  36. 36.
    Schneider-Kolsky M, Hoving J, Warren P, et al. A comparison between clinical assessment and magnetic resonance imaging of acute hamstring injuries. Am J Sports Med. 2006;34:1008–15. Available from CrossRefPubMedGoogle Scholar
  37. 37.
    Reurink G, Brilman E, Maas M, et al. Magnetic resonance imaging in acute hamstring injury: can we provide a return to play prognosis? Sports Med. 2015;45:133–46. Scholar
  38. 38.
    Comin J, Malliaras P, Baquie P, et al. Return to competitive play after hamstring injuries involving disruption of the central tendon. Am J Sports Med. 2013;41(1):111–5. Scholar
  39. 39.
    Silder A, Sherry M, Sanfilippo J, et al. Clinical and morphological changes following 2 rehabilitation programs for acute hamstring strain injuries: a randomized clinical trial. J Orthop Sports Phys Ther. 2013;43:284–99. Available from: CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Crema M, Godoy I, Abdalla R, Aquino J, Ingham S, Skaf A. Hamstring injuries in professional soccer players: extent of MRI-detected edema and the time to return to play. Sports Health SAGE Publications. 2017;10:75–9. Scholar
  41. 41.
    van der Made A, Almusa E, Whiteley R, et al. Intramuscular tendon involvement on MRI has limited value for predicting time to return to play following acute hamstring injury. Br. J. Sports Med. 2017;0:1 Available from:
  42. 42.
    Brukner P, Nealon A, Morgan C, et al. Recurrent hamstring muscle injury: applying the limited evidence in the professional football setting with a seven-point programme. Br J Sports Med 2013;0:1–12.
  43. 43.
    Guermazi A, Roemer F, Robinson P, Tol J, Regatte R, Crema M. Imaging of muscle injuries in sports medicine: sports imaging series. Radiology. 2017;282:646–63. Scholar
  44. 44.
    Moen M, Reurink G, Weir A, Tol J, Maas M, Goudswaard G. Predicting return to play after hamstring injuries. Br J Sports Med. 2014;48:1358–63. Available from: CrossRefPubMedGoogle Scholar
  45. 45.
    Wangensteen A, Almusa E, Boukarroum S, et al. 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;49:1579–87. Available from: CrossRefPubMedGoogle Scholar
  46. 46.
    Engebretsen L, Steffen K, Alsousou J, et al. IOC consensus paper on the use of platelet-rich plasma in sports medicine. Br J Sports Med. 2010;44:1072–81. Scholar
  47. 47.
    Hamid M, Ali M, Yusof A, et al. Platelet-rich plasma injections for the treatment of hamstring injuries a randomized controlled trial. Am J Sports Med. 2014;42(10):2410–8. Scholar
  48. 48.
    Rettig AC, Meyer S, Bhadra AK. Platelet-rich plasma in addition to rehabilitation for acute hamstring injuries in NFL players clinical effects and time to return to play. The Orthopaedic Journal of Sports Medicine. 2006;1:1–5. Scholar
  49. 49.
    Zanon G, Combi F, Combi A. Platelet-rich plasma in the treatment of acute hamstring injuries. Joints. 2016;4:17–23.CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    Ramos L, Carvalho R, Abdalla R, et al. Surgical treatment for muscle injuries. Curr Rev Musculoskelet Med. 2015;8:188–92. Scholar

Copyright information

© ISS 2018

Authors and Affiliations

  1. 1.Radiology DepartmentHospital Garcia de Orta EPEAlmadaPortugal
  2. 2.Hospital da LuzLisbonPortugal

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