Muscle Injury Classification and Grading Systems



The process of injury classification theoretically allows for the detailed taxonomic description of muscle injuries. Accurate classification has the potential to allow the implementation of specific anatomical treatment approaches, to allow for a meaningful re-injury risk assessment and to allow for effective comparison between treatment approaches. Effective grading of muscle injuries has the purpose of allowing practitioners to provide athletes and coaches with an effective prognosis for a return to play. As a result of renewed interest in recent years, significant progress has been made in both the classification and grading of muscle injury, but still, there remains little consensus and many questions. This chapter addresses recent developments in both the classification and grading of muscle injury.


Classification Grading Severity 


  1. 1.
    Hamilton B, Valle X, Rodas G, Til L, Grive RP, Rincon JA, et al. Classification and grading of muscle injuries: a narrative review. Br J Sports Med. 2015;49(5):306.CrossRefGoogle Scholar
  2. 2.
    Rachun A. Standard nomenclature of athletic injuries. 1st ed. Chicago, IL: American Medical Association; 1966. 157p.Google Scholar
  3. 3.
    Peetrons P. Ultrasound of muscles. Eur Radiol. 2002;12(1):35–43.CrossRefGoogle Scholar
  4. 4.
    Peetrons P, Creteur P. Echographies et traumatismes musculaires aigus. In: Chevrot A, Kahn M, Morvan G, editors. Imagerie des parties molles de l’appareil locomoteur. Montpellier: Sauramps Medical; 1993. p. 229–35.Google Scholar
  5. 5.
    Pomeranz SJ, Heidt RS Jr. MR imaging in the prognostication of hamstring injury. Work in progress. Radiology. 1993;189(3):897–900.CrossRefGoogle Scholar
  6. 6.
    Takebayashi S, Takasawa H, Banzai Y, Miki H, Sasaki R, Itoh Y, et al. Sonographic findings in muscle strain injury: clinical and MR imaging correlation. J Ultrasound Med. 1995;14(12):899–905.CrossRefGoogle Scholar
  7. 7.
    Fleckenstein JL, Weatherall PT, Parkey RW, Payne JA, Peshock RM. Sports-related muscle injuries: evaluation with MR imaging. Radiology. 1989;172(3):793–8.CrossRefGoogle Scholar
  8. 8.
    Ekstrand J, Healy JC, Walden M, Lee J, English B, Hagglund M. Hamstring muscle injuries in professional football: the correlation of MRI findings with return to play. Br J Sports Med. 2012;46:112–7.CrossRefGoogle Scholar
  9. 9.
    Hallen A, Ekstrand J. Return to play following muscle injuries in professional footballers. J Sports Sci. 2014;32(13):1229–36.CrossRefGoogle Scholar
  10. 10.
    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.CrossRefGoogle Scholar
  11. 11.
    Connell DA, Schneider-Kolsky ME, Hoving JL, Malara F, Buchbinder R, Koulouris G, et al. Longitudinal study comparing sonographic and MRI assessments of acute and healing hamstring injuries. AJR Am J Roentgenol. 2004;183(4):975–84.CrossRefGoogle Scholar
  12. 12.
    Gibbs NJ, Cross TM, Cameron M, Houang MT. 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(2):248–58.CrossRefGoogle Scholar
  13. 13.
    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. Am J Radiol. 2002;179:1621–8.Google Scholar
  14. 14.
    Verrall GM, Slavotinek JP, Barnes PG, Fon GT. 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(6):969–73.CrossRefGoogle Scholar
  15. 15.
    Verrall GM, Slavotinek JP, Barnes PG, Fon GT, Spriggins AJ. Clinical risk factors for hamstring muscle strain injury: a prospective study with correlation of injury by magnetic resonance imaging. Br J Sports Med. 2001;35(6):435–9.CrossRefGoogle Scholar
  16. 16.
    Reurink G, Whiteley R, Tol JL. Hamstring injuries and predicting return to play: ‘bye-bye MRI?’. Br J Sports Med. 2015;49(18):1162–3.CrossRefGoogle Scholar
  17. 17.
    Schneider-Kolsky ME, Hoving JL, Warren P, Connell DA. Comparison between clinical assessment and magnetic resonance imaging of acute hamstring injuries. Am J Sports Med. 2006;34(6):1008–15.CrossRefGoogle Scholar
  18. 18.
    Verrall GM, Slavotinek JP, Barnes PG, Fon GT, Esterman A. Assessment of physical examination and magnetic resonance imaging findings of hamstring injury as predictors for recurrent injury. J Orthop Sports Phys Ther. 2006;36(4):215–24.CrossRefGoogle Scholar
  19. 19.
    Reurink G, Brilman EG, de Vos RJ, Maas M, Moen MH, Weir A, et al. Magnetic resonance imaging in acute hamstring injury: can we provide a return to play prognosis? Sports Med. 2015;45(1):133–46.CrossRefGoogle Scholar
  20. 20.
    Comin J, Malliaras P, Baquie P, Barbour T, Connell D. Return to competitive play after hamstring injuries involving disruption of the central tendon. Am J Sports Med. 2013;41(1):111–5.CrossRefGoogle Scholar
  21. 21.
    Pollock N, Patel A, Chakraverty J, Suokas A, James SL, Chakraverty R. 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.CrossRefGoogle Scholar
  22. 22.
    van der Made AD, Almusa E, Reurink G, Whiteley R, Weir A, Hamilton B, et al. Intramuscular tendon injury is not associated with an increased hamstring reinjury rate within 12 months after return to play. Br J Sports Med. 2018;52(19):1261–6.CrossRefGoogle Scholar
  23. 23.
    van der Made AD, Almusa E, Whiteley R, Hamilton B, Eirale C, van Hellemondt F, 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. 2018;52(2):83–8.CrossRefGoogle Scholar
  24. 24.
    Chan O, Del Buono A, Best T, Maffulli N. Acute muscle strain injuries: a proposed new classification system. Knee Surg Sports Traumatol Arthrosc. 2012;20:2356–62.CrossRefGoogle Scholar
  25. 25.
    Cohen SB, Towers JD, Zoga A, Irrgang JJ, Makda J, Deluca PF, et al. Hamstring injuries in professional football players: magnetic resonance imaging correlation with return to play. Sports Health. 2011;3(5):423–30.CrossRefGoogle Scholar
  26. 26.
    Mueller-Wohlfahrt H-W, Haensel L, Mithoefer K, Ekstrand J, English B, McNally S, et al. Terminology and classification of muscle injuries in sport: the Munich consensus statement. Br J Sports Med. 2013;47(6):342–50.CrossRefGoogle Scholar
  27. 27.
    Pollock N, James SL, Lee JC, Chakraverty R. British athletics muscle injury classification: a new grading system. Br J Sports Med. 2014;48(18):1347–51.CrossRefGoogle Scholar
  28. 28.
    Valle X, Alentorn-Geli E, Tol JL, Hamilton B, Garrett WE Jr, Pruna R, et al. Muscle injuries in sports: a new evidence-informed and expert consensus-based classification with clinical application. Sports Med. 2017;47(7):1241–53.CrossRefGoogle Scholar
  29. 29.
    Hamilton B, Wangensteen A, Whiteley R, Almusa E, Geertsema L, Targett S, et al. Cohen’s MRI scoring system has limited value in predicting return to play. Knee Surg Sports Traumatol Arthrosc. 2018;26(4):1288–94.PubMedGoogle Scholar
  30. 30.
    Ekstrand J, Askling C, Magnusson H, Mithoefer K. 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(12):769–74.CrossRefGoogle Scholar
  31. 31.
    Tol JL, Hamilton B, Best TM. Palpating muscles, massaging the evidence? An editorial relating to ‘Terminology and classification of muscle injuries in sport: the Munich consensus statement’. Br J Sports Med. 2013;47(6):340–1.CrossRefGoogle Scholar
  32. 32.
    Orchard JW, Farhart P, Leopold C. Lumbar spine region pathology and hamstring and calf injuries in athletes: is there a connection? Br J Sports Med. 2004;38(4):502–4.CrossRefGoogle Scholar
  33. 33.
    Patel A, Chakraverty J, Pollock N, Chakraverty R, Suokas AK, James SL. British athletics muscle injury classification: a reliability study for a new grading system. Clin Radiol. 2015;70(12):1414–20.CrossRefGoogle Scholar
  34. 34.
    Prakash A, Entwisle T, Schneider M, Brukner P, Connell D. Connective tissue injury in calf muscle tears and return to play: MRI correlation. Br J Sports Med. 2018;52:929–33.CrossRefGoogle Scholar
  35. 35.
    Jacobsen P, Witvrouw E, Muxart P, Tol JL, Whiteley R. 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.CrossRefGoogle Scholar
  36. 36.
    Wangensteen A, Almusa E, Boukarroum S, Farooq A, Hamilton B, Whiteley R, et al. MRI does not add value over and above patient history and clinical examination in predicting time to return to sport (RTS) after acute hamstring injuries: a prospective cohort of 180 male athletes. Br J Sports Med. 2015;49(24):1579–87.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.High Performance Sport NZMillennium Institute of Sport and HealthAucklandNew Zealand
  2. 2.Institute of Sport, Exercise and HealthLondonUK
  3. 3.Academic Centre of Evidence Based Sports MedicineAmsterdam University Medical CenterAmsterdamThe Netherlands
  4. 4.Department of Orthopaedics and Sports MedicineErasmus MC University Medical CentreRotterdamThe Netherlands
  5. 5.Physiotherapy DepartmentUniversity of CanberraBruceAustralia
  6. 6.Department of Orthopedic Surgery, Sports Orthopedic Research Center—Copenhagen (SORC-C)Amager-Hvidovre Hospital, Copenhagen UniversityCopenhagenDenmark

Personalised recommendations