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Return to Play Following Hamstring Injuries

‘Pulling a hammy’ is the most common of all muscle injuries in sport. Even what seems like a minor injury can cause a delay in returning to sport or even cause a change in the type of sport you are able to do. Not all hamstring injuries are the same and the prognosis following hamstring injuries can vary from injury to injury and from person to person. The variable healing times of differing tissues and the range of tissues involved make it difficult to accurately predict an individual’s healing time.

Good assessment and treatment is key to returning to play. The focus should be on a criteria-based progression rather than a time-based progression. Good rehabilitation programmes include a progressive strengthening protocol which should involve eccentric strengthening such as the Nordic Hamstring Exercises. It should also include a progressive running protocol. (See below for link).

A key priority following hamstring injury is reducing the risk of injury recurrence. We know that previous injury is a well-established risk factor for future injury and that recurrent injuries require more extensive rehabilitation than the initial injury. Of all the hamstring injury recurrences, almost half occur within the first month following return to play. It is hypothesized that injury recurrence may be due to inadequate rehabilitation or premature return to play (RTP).

A large number of factors contribute to the time to return to play (TTRTP) and this combination can make determining the right moment to RTP difficult. In 2017 a consensus statement was released from the British Journal of Sports Medicine regarding RTP following hamstring injuries in football. The consensus statement was formed using responses from 58 experts in hamstring injury worldwide.

They defined return to play as:

‘The moment a player has received criteria-based medical clearance and is mentally ready for full availability for match selection and/or full training.’

It was felt that the RTP decision should be based on a multidisciplinary consultation involving several people involved with the athlete and the team including the athlete, the physiotherapist, the sports physician and the coach.

They advised that the following medical criteria should determine the return to play decision:

  1. Absence of pain on palpation
  2. Pain can indicate incomplete healing and players with pain on palpation just after RTP were four times more likely to reinjure.
  3. Absence of pain during strength and flexibility testing
  4. The absence of pain during functional performance
  5. The absence of pain after functional testing
  6. Similar hamstring flexibility (0-10% difference compared to pre-injury date or uninjured side) Testing of both passive and active straight leg raise should be done.
  7. Psychological readiness and the athlete’s confidence
  8. Medical staff clearance
  9. Performance on-field testing
  10. Repeated sprint ability test
  11. Deceleration drills
  12. Single leg bridge
  13. Position specific targeted match specific rehabilitation

It was also advised that an MRI should not play a role in the RTP decision making as this did not add any prognostic value in terms of TTRTP or does it help predict reinjury. The same is also true of ultrasound findings.

In summary, not at all hamstring injuries are the same with certain injuries needing prolonged rehabilitation and delayed RTP. The above definition of RTP and medical criteria can be used to help the multidisciplinary team reach a decision on when is the right time to RTP.

Aspetar Hamstring Protocol
Brukner, P.(2014). Hamstring injuries: prevention and treatment – an update. Br J Sports Med. 49:1241-1244
Hamilton, B., Valle, X., Rodas, G., Til, Luis, Grive, R.P., Rincon, A.G. & Tol, J.L. (2014). Classificatino and grading of muscle injuries: a narrative review. Br. J.Sports Med. 49:306
Reurink, G., Whiteley, R & Tol, J.L. (2015). Hamstring injuries and predicting return to play: ‘bye-bye MRI?’. Br J Sports Med. Vol 49 No 18
Van der Horst, N., Backx, F., Goedhart, E.A., & Huisstede, B. (2017). Return to play after hamstring injuries in football (soccer): a worldwide Delphi procedure regarding definition, medical criteria and decision making. Br J Sports Med. 51:1583-1591
Van Dyk, N. & Whiteley, R. (2015). Hamstring rehabilitation: criteria based progression protocol and clinical predictors for return to play. Br J Sports Med Blog.