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Effectiveness of Conservative Interventions After Acute Hamstrings Injuries in Athletes: A Living Systematic Review

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Abstract

Background

Hamstrings injuries are common in sports and the reinjury risk is high. Despite the extensive literature on hamstrings injuries, the effectiveness of the different conservative (i.e., non-surgical) interventions (i.e., modalities and doses) for the rehabilitation of athletes with acute hamstrings injuries is unclear.

Objective

We aimed to compare the effects of different conservative interventions in time to return to sport (TRTS) and/or time to return to full training (TRFT) and reinjury-related outcomes after acute hamstrings injuries in athletes.

Data Sources

We searched CINAHL, Cochrane Library, EMBASE, PubMed, Scopus, SPORTDiscus, and Web of Science databases up to 1 January, 2022, complemented with manual searches, prospective citation tracking, and consultation of external experts.

Eligibility Criteria

The eligibility criteria were multi-arm studies (randomized and non-randomized) that compared conservative treatments of acute hamstrings injuries in athletes.

Data Analysis

We summarized the characteristics of included studies and conservative interventions and analyzed data for main outcomes (TRTS, TRFT, and rate of reinjuries). The risk of bias was judged using the Cochrane tools. Quality and completeness of reporting of therapeutic exercise programs were appraised with the i-CONTENT tool and the certainty of evidence was judged using the GRADE framework. TRTS and TRFT were analyzed using mean differences and the risk of reinjury with relative risks.

Results

Fourteen studies (12 randomized and two non-randomized) comprising 730 athletes (mostly men with ages between 14 and 49 years) from different sports were included. Nine randomized studies were judged at high risk and three at low risk of bias, and the two non-randomized studies were judged at critical risk of bias. Seven randomized studies compared exercise-based interventions (e.g., L-protocol vs C-protocol), one randomized study compared the use of low-level laser therapy, and three randomized and two non-randomized studies compared injections of platelet-rich plasma to placebo or no injection. These low-level laser therapy and platelet-rich plasma studies complemented their interventions with an exercise program. Only three studies were judged at low overall risk of ineffectiveness (i-CONTENT). No single intervention or combination of interventions proved superior in achieving a faster TRTS/TRFT or reducing the risk of reinjury. Only eccentric lengthening exercises showed limited evidence in allowing a shorter TRFT. The platelet-rich plasma treatment did not consistently reduce the TRFT or have any effect on the risk of new hamstrings injuries. The certainty of evidence was very low for all outcomes and comparisons.

Conclusions

Available evidence precludes the prioritization of a particular exercise-based intervention for athletes with acute hamstrings injuries, as different exercise-based interventions showed comparable effects on TRTS/TRFT and the risk of reinjuries. Available evidence also does not support the use of platelet-rich plasma or low-level laser therapy in clinical practice. The currently available literature is limited because of the risk of bias, risk of ineffectiveness of exercise protocols (as assessed with the i-CONTENT), and the lack of comparability across existing studies.

Clinical Trial Registration

PROSPERO CRD42021268499 and OSF (https://osf.io/3k4u2/).

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Acknowledgements

José Afonso, Jesús Olivares-Jabalera, Ricardo Fernandes, Filipe Manuel Clemente, Sílvia Rocha-Rodrigues, João Gustavo Claudino, Rodrigo Ramirez-Campillo, Cristina Valente, Renato Andrade, and João Espregueira-Mendes thank Professors Gustaaf Reurink, Jack Hickey, and Noel Pollock for their role as external experts: they verified our eligibility criteria and the list of included studies, providing additional suggestions of potentially relevant studies.

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Authors and Affiliations

  1. Centre of Research, Education, Innovation, and Intervention in Sport (CIFI2D), Faculty of Sport, University of Porto, R. Dr. Plácido da Costa 91, 4200-450, Porto, Portugal

    José Afonso & Ricardo J. Fernandes

  2. Sport Research Lab, Football Science Institute, Granada, Spain

    Jesús Olivares-Jabalera

  3. Department of Physical and Sports Education, Sport and Health University Research Institute (iMUDS), University of Granada, Granada, Spain

    Jesús Olivares-Jabalera

  4. Porto Biomechanics Laboratory (LABIOMEP), University of Porto, Porto, Portugal

    Ricardo J. Fernandes & Renato Andrade

  5. Escola Superior de Desporto e Lazer, Instituto Politécnico de Viana do Castelo, Viana do Castelo, Portugal

    Filipe Manuel Clemente & Sílvia Rocha-Rodrigues

  6. Delegação da Covilhã, Instituto de Telecomunicações, Covilhã, Portugal

    Filipe Manuel Clemente

  7. Tumor & Microenvironment Interactions Group, INEB-Institute of Biomedical Engineering, i3S-Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal

    Sílvia Rocha-Rodrigues

  8. Group of Research, Innovation and Technology Applied to Sport (GSporTech), Multi-user Laboratory of the Department of Physical Education (MultiLab of the DPE), Department of Physical Education, Center for Health Sciences, Federal University of Piauí, Teresina, Piauí, Brazil

    João Gustavo Claudino

  9. Department of Physical Education, Center for Health Sciences, Federal University of Piauí, Teresina, Piauí, Brazil

    João Gustavo Claudino

  10. Exercise and Rehabilitation Sciences Laboratory, School of Physical Therapy, Faculty of Rehabilitation Sciences, Universidad Andres Bello, Santiago, Chile

    Rodrigo Ramirez-Campillo

  11. Clínica Espregueira - FIFA Medical Centre of Excellence, Porto, Portugal

    Cristina Valente, Renato Andrade & João Espregueira-Mendes

  12. Dom Henrique Research Centre, Porto, Portugal

    Cristina Valente, Renato Andrade & João Espregueira-Mendes

  13. School of Medicine, University of Minho, Braga, Portugal

    João Espregueira-Mendes

  14. ICVS/3B’s-PT Government Associate Laboratory, Braga/Guimarães, Portugal

    João Espregueira-Mendes

  15. 3B’s Research Group Biomaterials, Biodegradables and Biomimetics, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, University of Minho, AvePark, Parque de Ciência e Tecnologia, Zona Industrial da Gandra, Barco, 4805 017, Guimarães, Portugal

    João Espregueira-Mendes

  16. Research Center in Sports Performance, Recreation, Innovation and Technology (SPRINT), Melgaço, Portugal

    Sílvia Rocha-Rodrigues

Authors
  1. José Afonso
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  2. Jesús Olivares-Jabalera
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  3. Ricardo J. Fernandes
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  4. Filipe Manuel Clemente
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  6. João Gustavo Claudino
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  8. Cristina Valente
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  9. Renato Andrade
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  10. João Espregueira-Mendes
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Corresponding authors

Correspondence to José Afonso or Renato Andrade.

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There was no financial or non-financial support for this review. There were no funders or sponsors in the review.

Conflicts of Interest/Competing Interests

José Afonso, Jesús Olivares‑Jabalera, Ricardo Fernandes, Filipe Manuel Clemente, Sílvia Rocha‑Rodrigues, João Gustavo Claudino, Rodrigo Ramirez‑Campillo, Cristina Valente, Renato Andrade and João Espregueira‑Mendes have no competing interests.

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The data used to inform this review are fully disclosed either in the manuscript or in its Electronic Supplementary Material.

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Authors’ Contributions

JA and RA were responsible for the initial drafting of the article, which was reviewed and edited by all authors. All authors were involved in the conception, design, and interpretation of data. All authors read and reviewed the manuscript critically for important intellectual content and approved the final version to be submitted. Specific contributions pertaining data selection, extraction, and analysis are detailed in the methods section. All authors read and approved the final manuscript.

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Afonso, J., Olivares-Jabalera, J., Fernandes, R.J. et al. Effectiveness of Conservative Interventions After Acute Hamstrings Injuries in Athletes: A Living Systematic Review. Sports Med 53, 615–635 (2023). https://doi.org/10.1007/s40279-022-01783-z

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