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Hamstring Strain Injury in Athletes

February 2022
Journal of Orthopaedic and Sports Physical Therapy 52(3):CPG1-CPG44

February 2022
52(3):CPG1-CPG44

DOI:10.2519/jospt.2022.0301

Authors:

Robroy Martin

Duquesne University

Michael T Cibulka

Thomas Koc Jr

Kean University

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Hamstring strain injury (HSI) may result in considerable impairment, activity limitation, and participation restriction, including time lost from competitive sports. This CPG includes sports-related overloading and overstretching injuries to myofascial or musculotendinous structures in any combination of the 3 hamstring muscles (the semitendinosus, semimembranosus, and biceps femoris). J Orthop Sports Phys Ther, Epub 14 Feb 2022. doi:10.2519/jospt.2022.0301.

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Clinical Practice Guidelines

ROBROY L. MARTIN, PT, PhD • MICHAEL T. CIBULKA, PT, DPT, OCS • LORI A. BOLGLA, PT, PhD

THOMAS A. KOC, JR., PT, DPT, PhD, OCS • JANICE K. LOUDON, PT, PhD • ROBERT C. MANSKE, PT, DPT

LEIGH WEISS, PT, DPT, ATC, OCS, SCS • JOHN J. CHRISTOFORETTI, MD, FAAOS • BRYAN C. HEIDERSCHEIT, PT, PhD, FAPTA

Hamstring Strain

Injury in Athletes

Clinical Practice Guidelines Linked to the International Classiﬁcation

of Functioning, Disability and Health From the Academy of

Orthopaedic Physical Therapy and the American Academy of Sports

Physical Therapy of the American Physical Therapy Association

J Orthop Sports Phys Ther. 2022;52(3):CPG1-CPG44. doi:10.2519/jospt.2022.0301

Therapy, American Physical Therapy Association (APTA), Inc, and JOSPT®, Inc. The Academy of Orthopaedic Physical Therapy, American Academy of Sports Physical

Therapy, APTA, Inc, and JOSPT®, Inc consent to reproducing and distributing this guideline for educational purposes. Address correspondence to Clinical Practice

Guidelines Managing Editor, Academy of Orthopaedic Physical Therapy, APTA, Inc, 2920 East Avenue South, Suite 200, La Crosse, WI 54601. E-mail: cpg@orthopt.org

SUMMARY OF RECOMMENDATIONS ................................CPG2

INTRODUCTION .................................................................CPG3

METHODS ..........................................................................CPG4

CLINICAL PRACTICE GUIDELINES

Incidence/Prevalence ......................................................... CPG7

Pathoanatomical Features .................................................. CPG7

Risk Factors ......................................................................... CPG8

Clinical Course .................................................................... CPG9

Return to Play and Reinjury Risk .......................................CPG10

Diagnosis/Classiﬁcation .................................................... CPG11

Examination ........................................................................CPG13

Interventions .......................................................................CPG19

DECISION TREE ............................................................... CPG21

AFFILIATIONS AND CONTACTS ......................................CPG22

REFERENCES ................................................................... CPG23

APPENDICES (ONLINE) ...................................................CPG27

REVIEWERS: Mike Voight, PT, DHSc, OCS, SCS, ATC, FAPTA • John DeWitt, PT, DPT, AT • Brian Young, PT, DSc • Liran Lifshitz, PT, MSc

Douglas White, PT, DPT, OCS, RMSK • David Killoran, PhD • Sandra Kaplan, PT, DPT, PhD, FAPTA

Steve Paulseth, PT, DPT, SCS, ATC • James A. Dauber, DPT, DSc

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cpg2 | march 2022 | volume 52 | number 3 | journal of orthopaedic & sports physical therapy

Hamstring Strain Injury in Athletes: Clinical Practice GuidelinesHamstring Strain Injury in Athletes: Clinical Practice Guidelines

List of Abbreviations

AASPT: American Academy of Sports Physical Therapy

AKE: active knee extension

AOPT: Academy of Orthopaedic Physical Therapy

APTA: American Physical Therapy Association

CI: conﬁdence interval

CPG: clinical practice guideline

FASH : Functional Assessment Scale for Acute Hamstring

Injuries

FIFA: International Federation of Association Football

(Fédération Internationale de Football Association)

HaOS: hamstring outcome score

HHD: handheld dynamometer

Summary of Recommendations

REINJURY RISK AND RETURN TO PLAY

BClinicians should use the history of a hamstring strain in-

jury (HSI) in return-to-play (RTP) progression, as a previ-

ous HSI is a risk factor for a future reinjury.

BClinicians should use caution in RTP decisions for individ-

uals who did not complete an appropriately progressed,

comprehensive impairment-based functional exercise program

that speciﬁcally included eccentric training.

BClinicians should use hamstring strength, pain level at the

time of injury, number of days from injury to pain-free

walking, and area of tenderness measured on initial evaluation to

estimate time to RTP.

DIAGNOSIS/CLASSIFICATION

BClinicians should make a diagnosis of HSI when an indi-

vidual presents with a sudden onset of posterior thigh

pain during activity, with pain reproduced when the hamstring is

stretched and/or activated, muscle tenderness with palpation,

and loss of function.

EXAMINATION: PHYSICAL IMPAIRMENT MEASURES

AClinicians should quantify knee ﬂexor strength following

HSI by using either a handheld or isokinetic dynamometer.

AClinicians should assess hamstring length by measuring

the knee extension deﬁcit with the hip ﬂexed to 90°, using

an inclinometer.

CClinicians may use the length of muscle tenderness and

proximity to the ischial tuberosity to assist in predicting

timing of RTP.

FClinicians may assess for abnormal trunk and pelvic pos-

ture and control during functional movements.

EXAMINATION: ACTIVITY LIMITATION AND

PARTICIPATION RESTRICTION

BClinicians should include objective measures of an individ-

ual’s ability to walk, run, and sprint when documenting

changes in activity and participation over the course of treatment.

EXAMINATION: OUTCOME MEASURES

BClinicians should use the Functional Assessment Scale for

Acute Hamstring Injuries before and after interventions,

intended to alleviate the impairments of body function and struc-

ture, activity limitations, and participation restrictions in those

diagnosed with an acute HSI.

INTERVENTIONS: INJURY PREVENTION

AClinicians should include the Nordic hamstring exercise as

part of an HSI prevention program, along with other com-

ponents of warm-up, stretching, stability training, strengthening, and

functional movements (sport speciﬁc, agility, and high-speed running).

INTERVENTIONS: AFTER INJURY

BClinicians should use eccentric training to the patient’s

tolerance, added to stretching, strengthening, stabiliza-

tion, and progressive running programs, to improve RTP time af-

ter an individual sustains an HSI.

BClinicians should use progressive agility and trunk stabili-

zation, added to a comprehensive impairment-based

treatment program of stretching, strengthening, and functional ex-

ercises, to reduce reinjury rate after an individual sustains an HSI.

FClinicians may perform neural tissue mobilization after

injury to reduce adhesions to surrounding tissue and ther-

apeutic modalities to control pain and swelling early in the heal-

ing process.

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journal of orthopaedic & sports physical therapy | volume 52 | number 3 | march 2022 | cpg3

Hamstring Strain Injury in Athletes: Clinical Practice GuidelinesHamstring Strain Injury in Athletes: Clinical Practice Guidelines

H/Q: hamstring-quadriceps

HR: hazard ratio

HSI: hamstring strain injury

ICC: intraclass correlation coecient

ICF: International Classiﬁcation of Functioning, Disability

and Health

JOSPT: Journal of Orthopaedic & Sports Physical Therapy

MDC: minimal detectable change

MRI: magnetic resonance imaging

NHE: Nordic hamstring exercise

OR: odds ratio

RCT: randomized controlled trial

ROM: range of motion

RR: relative risk

RTP: return to play

SEM: standard error of measurement

SLR: straight leg raise

US: ultrasound

Introduction

AIM OF THE GUIDELINES

The Academy of Orthopaedic Physical Therapy (AOPT)

and the American Academy of Sports Physical Therapy

(AASPT) of the American Physical Therapy Association

(APTA) has an ongoing effort to create evidence-based

clinical practice guidelines (CPGs) for orthopaedic and

sports physical therapist management of patients with

musculoskeletal impairments described in the World

Health Organization’s International Classification of

Functioning, Disability and Health (ICF).108 The purposes

of these CPGs are as follows:

• Describe evidence-based physical therapist practice, in-

cluding diagnosis, prognosis, intervention, and assessment

of outcome, for musculoskeletal disorders commonly man-

aged by orthopaedic physical therapists

• Classify and deﬁne common musculoskeletal conditions

using the World Health Organization’s terminology relat-

ed to impairments of body function and structure, activity

limitations, and participation restrictions

• Identify interventions supported by current best evidence

to address impairments of body function and structure, ac-

tivity limitations, and participation restrictions associated

with common musculoskeletal conditions

• Identify appropriate outcome measures to assess chang-

es resulting from physical therapist interventions in body

function and structure, as well as in activity and participa-

tion of these individuals

• Provide a description to policy makers, using internation-

ally accepted terminology, of the practice of orthopaedic

physical therapists

• Provide information for payers and claims reviewers re-

garding the practice of orthopaedic physical therapy for

common musculoskeletal conditions

• Create a reference publication for orthopaedic physical

therapy clinicians, academic instructors, clinical instruc-

tors, students, interns, residents, and fellows regarding the

best current practice of orthopaedic physical therapy

STATEMENT OF INTENT

These guidelines are not intended to be construed or to serve

as a standard of medical care. Standards of care are based

on all clinical data available for an individual patient and

are subject to change, as scientiﬁc knowledge and technolo-

gy advance and patterns of care evolve. These parameters of

practice should be considered guidelines only. Adherence to

them will not ensure a successful outcome in every patient,

nor should they be construed as including all proper methods

of care or excluding other acceptable methods of care aimed

at the same results. The ultimate judgment regarding a par-

ticular clinical procedure or treatment plan must be made

based on clinician experience and expertise, considering the

clinical presentation of the patient, the available evidence,

available diagnostic and treatment options, and the patient’s

values, expectations, and preferences. However, we suggest

that signiﬁcant departures from accepted guidelines should

be documented in the patient’s medical records at the time

the relevant clinical decision is made.

SCOPE AND RATIONALE OF THE GUIDELINE

The hamstring muscle group consists of 3 muscles in the

posterior thigh: the semitendinosus, semimembranosus,

and biceps femoris. Hamstring strain injury (HSI) may

result in considerable impairment, activity limitation, and

participation restriction, including time lost from compet-

itive sports. In professional sports, HSIs may be associated

with signiﬁcant ﬁnancial costs.18 The high reinjury rate is

also an important issue.55 Typically, HSIs are classiﬁed by

the involved muscle, anatomical location, and severity of

damage.3,18 Classiﬁcations also may consider whether there

is myofascial, musculotendinous, and/or intratendinous

involvement.3,18 A variety of injury mechanisms for HSIs

have been described and typically involve some type of ec-

centric overloading and/or overstretching in a position of

hip ﬂexion and knee extension.4 Dierent mechanisms of

injury may be associated with unique injury locations and

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Hamstring Strain Injury in Athletes: Clinical Practice GuidelinesHamstring Strain Injury in Athletes: Clinical Practice Guidelines

speciﬁc structural impairments. For example, overloading

injuries typically occur in a lengthened position, as in high-

speed running, when the hamstring is eccentrically con-

tracting across the hip and knee, and late in swing phase/

early heel strike.11 This overload injury usually involves the

biceps femoris and surrounding tissue. In contrast, over-

stretching injuries occur with combined hip ﬂexion and

knee extension movements, as in kicking or reaching to

pick up and lift something o the ground with the knee

extended. This overstretching injury typically involves the

proximal semimembranosus.6 This CPG includes sports-re-

lated overloading and overstretching injuries to myofascial

or musculotendinous structures in any combination of the

3 hamstring muscles. Injuries exclusive to the proximal or

distal hamstring tendons with primarily intratendinous

involvement are dierent from HSIs that involve the my-

ofascial and musculotendinous structures with respect to

incidence, mechanism of injury, pathoanatomical features,

clinical course, and treatment strategies.3 Given these dif-

ferences, this CPG will exclude isolated tendon injuries.

While the eect of interventions for those with an HSI can

be measured in a variety of ways, including but not limited

to strength, range of motion (ROM), and pain levels, the

ultimate success of the rehabilitation process is determined

by the individual’s ability to return to sports participation

while preventing reinjury. Therefore, only studies that di-

rectly assessed time to return to play (RTP) and reinjury

rates were included when discussing interventions for HSIs.

Methods

The AOPT and AASPT appointed content experts to con-

duct a review of the literature and develop an HSI CPG. The

aims of this review were to provide a concise summary of the

contemporary evidence and to develop recommendations to

support evidence-based practice. The authors of this guide-

line worked with the CPG editors and medical librarians for

methodological guidance. The research librarians were cho-

sen for their expertise in systematic review and rehabilita-

tion literature searching and to perform systematic searches

for concepts associated with classiﬁcation, examination, and

intervention strategies for HSI. Brieﬂy, the following data-

bases were searched from database inception to June 2021:

PubMed, Embase, CINAHL, Cochrane Library, Ovid, and

SPORTDiscus (see APPENDIX A for full search strategies, dates,

and results, available at www.jospt.org).

The authors declared relationships and developed a con-

ﬂict management plan, which included submitting a con-

ﬂict-of-interest form to the AOPT. Articles authored by a

reviewer were assigned to an alternate reviewer. The CPG

authors did not draft recommendations when their research

was included in that topic area. The AOPT and AASPT

funded the CPG development team for travel and CPG de-

velopment training. The CPG development team maintained

editorial independence.

Articles used to support recommendations were reviewed

based on prespeciﬁed inclusion and exclusion criteria, with

the goal of identifying evidence relevant to clinical decision

making for managing adults with HSI. Two members of the

CPG development team independently reviewed the title and

abstract of each article for inclusion (see APPENDIX B for inclu-

sion and exclusion criteria, available at www.jospt.org). Full-

text review was then similarly conducted to obtain the ﬁnal

set of articles used to make the recommendations. The team

leader (R.L.M.) provided the ﬁnal decision for discrepancies

that were not resolved by the review team (see APPENDIX C for

ﬂow charts of articles, available at www.jospt.org). Articles

for selected relevant topics that were not sucient for devel-

oping recommendations (eg, incidence and imaging) were

not subject to the systematic review process and were not

included in the ﬂow chart. Evidence tables for this CPG are

available on the CPG page of the AOPT and AASPT of the

APTA websites (www.orthopt.org and www.aaspt.org).

This guideline was issued in 2022, based on the published

literature through June 2021, and will be considered for

review in 2026, or sooner if important evidence becomes

available. Any updates to the guideline in the interim period

will be noted on the AOPT and AASPT of the APTA web-

sites (www.orthopt.org and www.aaspt.org).

LEVELS OF EVIDENCE

Individual clinical research articles were graded according to

criteria adapted from the Centre for Evidence-Based Med-

icine (Oxford, UK) for diagnostic, prospective, and thera-

peutic studies. In teams of 2, each reviewer independently

assigned a level of evidence and evaluated the quality of each

article using a critical appraisal tool (see APPENDICES D and

E for the levels-of-evidence table and details on procedures

used for assigning levels of evidence, available at www.jospt.

org). The evidence update was organized from the highest

level of evidence to the lowest level of evidence. An abbre-

viated version of the grading system is provided in TABLE 1.

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Hamstring Strain Injury in Athletes: Clinical Practice GuidelinesHamstring Strain Injury in Athletes: Clinical Practice Guidelines

STRENGTH OF EVIDENCE AND GRADES OF RECOMMENDATION

The strength of the evidence supporting the recommendations

was graded according to the established methods provided be-

low (TABLE 2). Each team developed recommendations based

on the strength of evidence, including how directly the studies

addressed the question relating to HSIs. In developing their

recommendations, the authors considered the strengths and

limitations of the body of evidence and the health beneﬁts, side

eects, and risks of tests and interventions.

GUIDELINE REVIEW PROCESS AND VALIDATION

Identiﬁed reviewers who are experts in HSI management

and rehabilitation reviewed the CPG draft for integrity and

accuracy, and to ensure that it fully represented the current

evidence for the condition. The guideline draft was also

posted for open review on www.orthopt.org, and a notiﬁca-

tion of this posting was sent to the members of the AOPT.

In addition, reviewers were invited from a panel including

consumer/patient representatives and external stakeholders,

claims reviewers, medical coding experts, academic educa-

tors, clinical educators, physician specialists, researchers,

and CPG methodologists. All comments, suggestions, and

feedback from the reviews were provided to the authors and

editors for consideration and revision. The AOPT Clinical

Practice Guideline Advisory Panel reviews guideline devel-

opment methods, policies, and implementation processes on

a yearly basis.

DISSEMINATION AND IMPLEMENTATION TOOLS

In addition to publishing this CPG in the Journal of Ortho-

paedic & Sports Physical Therapy (JOSPT), it will be posted

on the CPG pages of the JOSPT, AASPT, and AOPT websites,

which are free-access website areas, and submitted for free

access on the ECRI Guidelines Trust (guidelines.ecri.org)

and the Physiotherapy Evidence Database (www.PEDro.org.

au). The planned implementation tools for patients, clini-

cians, educators, payers, policy makers, and researchers, and

the associated implementation strategies, are listed in TABLE 3.

ORGANIZATION OF THE GUIDELINE

When systematic reviews were conducted to support specif-

ic recommendations, summaries of studies with the corre-

sponding evidence levels are followed by a synthesis of the

literature and rationale for the recommendation(s), discus-

sion of gaps in the literature when appropriate, and the rec-

ommendation(s). Topics for which a systematic review was

conducted and recommendations provided include RTP and

reinjury risk, examination, injury prevention, and interven-

tions. For other topics where a systematic review was outside

the scope of this CPG, a summary of the literature is pro-

vided. This includes incidence/prevalence, pathoanatomical

features, risk factors, clinical course, dierential diagnosis,

and imaging.

CLASSIFICATION

The primary International Classiﬁcation of Diseases-10th

Revision codes associated with an HSI are as follows:

1. S76.01 Strain of muscle, fascia and tendon of hip

TABLE 1 Levels of Evidence

IEvidence obtained from high-quality diagnostic studies, prospective

studies, systematic reviews, or randomized controlled trials

II Evidence obtained from lesser-quality diagnostic studies, systematic

reviews, prospective studies, or randomized controlled trials (eg, weaker

diagnostic criteria and reference standards, improper randomization,

no blinding, less than 80% follow-up)

III Case-control studies or retrospective studies

IV Case series

VExpert opinion

TABLE 2 Grades of Recommendation

Grades of

Recommendation Strength of Evidence

Level of

Obligation

AStrong evidence A preponderance of level I and/or level

II studies support the recommen-

dation. This must include at least 1

level I study

Must or

should

BModerate

evidence

A single high-quality randomized

controlled trial or a preponderance

of level II studies support the

recommendation

Should

CWeak evidence A single level II study or a prepon-

derance of level III and IV studies,

including statements of consensus

by content experts, support the

recommendation

May

DConﬂicting

evidence

Higher-quality studies conducted on

this topic disagree with respect to

their conclusions. The recommen-

dation is based on these conﬂicting

study results

ETheoretical/

foundational

evidence

A preponderance of evidence from

animal or cadaver studies, from

conceptual models/principles, or

from basic sciences/bench research

support this conclusion

May

FExpert opinion Best practice based on the clinical

experience of the guidelines

development team supports this

conclusion

May

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Hamstring Strain Injury in Athletes: Clinical Practice GuidelinesHamstring Strain Injury in Athletes: Clinical Practice Guidelines

2. S76.302A Unspeciﬁed injury of muscle, fascia and ten-

don of the posterior muscle group at thigh level, left thigh,

initial encounter

a. S76.312 Strain of muscle, fascia and tendon of the

posterior muscle group at thigh level, left thigh

b. S76.311 Strain of muscle, fascia and tendon of the

posterior muscle group at thigh level, right thigh

3. S76.319D Strain of muscle, fascia and tendon of the pos-

terior muscle group at thigh level, unspeciﬁed thigh, sub-

sequent encounter

The primary ICF body function codes associated with HSI

are b28015 Pain in lower limb and b7301 Power of muscles

of one limb.

The primary ICF body structure code associated with HSI is

S75002 Muscles of thigh.

The primary ICF activities and participation codes associ-

ated with HSI are d4105 Bending, d4153 Maintaining a

sitting position, d4351 Kicking, d4509 Walking, unspeci-

ﬁed, d4551 Climbing, d4552 Running, d4553 Jumping, and

d9201 Sports.

TABLE 3 Planned Strategies and Tools to Support the

Dissemination and Implementation of This CPG

Tool Strategy

JOSPT’s “Perspectives for Patients” and “Perspectives for Practice” articles Patient- and clinician-oriented guideline summaries available at www.jospt.org

Mobile app of guideline-based exercises for patients/clients and health care

practitioners

Marketing and distribution of app via www.orthopt.org and www.aaspt.org

Clinician’s Quick-Reference Guide Summary of guideline recommendations available at www.orthopt.org and www.aaspt.org

JOSPT’s Read for CreditSM continuing education units Continuing education units available for physical therapists and athletic trainers at

www.jospt.org

Webinars and educational oerings for health care practitioners Guideline-based instruction available for practitioners at www.orthopt.org

Mobile and web-based app of guideline for training of health care practitioners Marketing and distribution of app via www.orthopt.org

Non-English versions of the guidelines and guideline implementation tools Development and distribution of translated guidelines and tools to JOSPT’s international

partners and global audience via www.jospt.org

APTA CPG+ Dissemination and implementation aids

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Hamstring Strain Injury in Athletes: Clinical Practice GuidelinesHamstring Strain Injury in Athletes: Clinical Practice Guidelines

Pathoanatomical Features

Skeletal muscle consists of slow (type I) and fast (type II) mus-

cle ﬁbers. It is believed that the hamstring muscle group has

a higher percentage of type II ﬁbers than other thigh muscles,

making the muscle more susceptible to injury.30,64 However, the

actual percentage of type II ﬁbers may vary, depending on age

and other individual anatomical variations.64 The long head

of the biceps femoris muscle is the most commonly involved

hamstring muscle in both ﬁrst-time and recurrent injuries, be-

ing involved in 79% to 84% of HSIs.23,86,103,106 Anatomically, an

increased anterior pelvic tilt may place the hamstring muscle

group in a more lengthened position and potentially increase

the likelihood of an HSI.49,64 Timmins et al90 studied 20 rec-

reationally active athletes with no history of HSI and 16 elite

athletes with a history of a unilateral HSI and compared ul-

trasound (US) imaging measures of the biceps femoris muscle

architecture (eg, muscle thickness, pennation angle, and fas-

cicle length) during graded isometric contractions at 0°, 30°,

and 60° of knee ﬂexion. The researchers found (1) signiﬁcantly

shorter fascicle length and fascicle length relative to muscle

thickness on the injured side compared to the uninjured side

at all contraction intensities, and (2) signiﬁcantly greater pen-

nation angle on the injured biceps femoris compared to the

uninjured side at all contraction intensities.90

SUMMARY

Most HSIs occur in the long head of the biceps femoris. Evi-

dence suggests that muscle architecture (eg, higher pennation

angle and shorter fascicle length) may contribute to an HSI.

CLINICAL PRACTICE GUIDELINES

Incidence/Prevalence

Hamstring strain injuries are common in activities that involve

high-speed running, jumping, kicking, and/or explosive lower

extremity movements with rapid changes in direction, includ-

ing lifting objects from the ground. Therefore, sports such as

track and ﬁeld, soccer, Australian rules football, American

football, and rugby have the highest frequency of reported in-

juries.8,50,89,93 The estimated incidence of HSIs per 1000 hours

of exposure is 0.87 in noncontact sports and 0.92 to 0.96 in

contact sports.50 Incidence rate estimates are 3 to 4.1 per 1000

competition hours and 0.4 to 0.5 per 1000 training hours for

professional male European soccer players.29 Some groups

have reported an increasing incidence of HSIs. For example,

in professional male European soccer players between 2001

and 2014, there was an increase in HSIs per year of 2.3% (95%

conﬁdence interval [CI]: 0.6%, 4.1%) during competition and

4.0% (95% CI: 1.1%, 7.0%) during training.25 Dalton et al17

reported that 68.2% of HSIs occurred during practice in men’s

football, men’s soccer, and women’s soccer. A professional soc-

cer team of 25 players can expect about 7 HSIs per season.50

Australian rules football players have a 1.3-fold higher risk

of HSI with each additional year of age, while soccer players

have a 1.9-fold higher risk with each increasing year of age.64

Hamstring strain injuries frequently cause a signiﬁcant loss of

time from competition, generally ranging from 3 to 28 days or

more, depending on injury severity.50 Reinjury rates are high

and range between 13.9% and 63.3% across Australian rules

football and track and ﬁeld athletes.21,50 Furthermore, those

with a history of HSI have a 3.6-times higher risk of sustaining

a future HSI.55 The high incidence of recurrent HSIs may be

attributable to inadequate rehabilitation or premature RTP.17

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Hamstring Strain Injury in Athletes: Clinical Practice GuidelinesHamstring Strain Injury in Athletes: Clinical Practice Guidelines

Risk Factors

Risk factors for acute HSI are categorized as being non-

modifiable or modifiable. Nonmodifiable factors describe

characteristics of an individual that cannot be changed,

such as history of previous HSI and age. Modifiable

factors are factors that can be altered, such as muscle

characteristics, muscle performance, and performance

characteristics.38,98,100

NONMODIFIABLE RISK FACTORS

Previous Injury

Systematic reviews have consistently identiﬁed previous inju-

ry as a risk factor for a subsequent HSI.34,38,73 Studies within

these reviews reported a 2- to 6-times higher rate of recur-

rence following a previous HSI.27,35 A prospective study not

included in these reviews found that male sprinters with a

prior HSI had a signiﬁcantly higher injury rate than those

who had never sustained an HSI (odds ratio [OR] = 2.85,

P<.05).91 A recent HSI (within 8 weeks) was found to place

individuals at greater risk for injury when compared to those

with a nonrecent injury (OR = 13.1; 95% CI: 11.5, 14.9 versus

OR = 3.5; 95% CI: 3.2, 3.9).69 Also, Green et al38 reported the

risk of recurrent HSI to be greatest during the same season

(relative risk [RR] = 4.8; 95% CI: 3.5, 6.6). Green et al38 also

reported a history of anterior cruciate ligament injury (RR

= 1.7; 95% CI: 1.2, 2.4) and calf strain (RR = 1.5; 95% CI:

1.3, 1.7), as well as other knee injuries and ankle ligament

sprains, to be risk factors for an HSI. A history of a quadri-

ceps strain and chronic groin pathology were not identiﬁed

as risk factors.38

Physical Characteristics

Systematic reviews have identiﬁed increasing age to be a

signiﬁcant risk factor for HSI.34,38,73 One study included in

these reviews found that athletes older than 23 years of age

were at greater risk than those 23 years of age or young-

er (RR = 1.34; 95% CI: 1.14, 1.57).68 Another study found

that Australian rules football athletes older than 25 years

of age were at greater risk than those 25 years of age or

younger (RR = 4.43; 95% CI: 1.57, 12.52).35 While systemat-

ic reviews have found height34,73 and preferred kicking leg34

not to be risk factors, ethnicity represented a risk factor in

African-American athletes and Aboriginal Australian rules

footballers.73

MODIFIABLE RISK FACTORS

Weight and Body Mass Index

Findings from systematic reviews do not support weight or

body mass index as risk factors for HSIs.34,73

Muscle Characteristics

Findings from systematic reviews and meta-analyses found

no relationship between hamstring ﬂexibility and HSI.34,38,73

In addition, Green et al38 found no relationship between

HSIs and passive knee extension ROM, active knee exten-

sion (AKE) ROM, passive straight leg raise (SLR), and slump

tests. While ﬂexibility does not play a role, lower-level stud-

ies suggest that biceps femoris fascicle length and hamstring

muscle-tendon unit stiness are related to HSIs.38 Green et

al38 also found conﬂicting evidence regarding the eect of hip

ﬂexor tightness and limited ankle dorsiﬂexion ROM on HSIs.

Muscle Performance

Green et al38 reported limited evidence for hamstring weak-

ness as a risk factor for HSI, a ﬁnding potentially inﬂuenced

by the method and timing of measurement. They includ-

ed a summary of previously published meta-analyses and

noted no association between HSI and reduced knee ﬂexor

strength measured during the Nordic hamstring exercise

(NHE) or with isokinetic testing.38 Similar ﬁndings were

noted by Opar et al63 in their meta-analysis. The meta-anal-

ysis by Freckleton and Pizzari34 identiﬁed increased peak

quadriceps torque as a risk factor for HSIs. Conﬂicting re-

sults from systematic reviews existed when examining ham-

string-to-quadriceps strength imbalances as a risk factor for

HSI.34,73 Study ﬁndings did not seem to be related to mea-

surement, speed, or type of muscle contraction.34,73 Based

on lower-level studies, Green et al38 found altered trunk and

gluteus muscle activity and abnormal motor control to be

potential risk factors for HSI.38

Performance Characteristics

The meta-analysis by Green et al38 found that increased po-

sitional high-speed running demands were a risk factor for

HSIs, with moderate to strong evidence in soccer, American

football, and rugby and lower levels of evidence in Gaelic foot-

ball and cricket. Athletes with rapid increases in high-speed

running exposure may be especially at risk. Findings from low-

er-level studies showed that sprinting characteristics, with in-

creased anterior pelvic tilting and thoracic spine sidebending

during the backswing, were also associated with HSIs. Within

this meta-analysis, 1 study found a higher proportion (68%,

P<.001) of HSIs sustained during running activities and more

severe injuries during kicking.8 Systematic reviews have in-

cluded lower levels of evidence for predicting HSI using per-

formance measures, such as the single-leg hop for distance and

the jumping percentage dierence between noncountermove-

ment and countermovement jumping.34,38 Freckleton and Piz-

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journal of orthopaedic & sports physical therapy | volume 52 | number 3 | march 2022 | cpg9

Hamstring Strain Injury in Athletes: Clinical Practice GuidelinesHamstring Strain Injury in Athletes: Clinical Practice Guidelines

zari34 examined a variety of sports and found that workload,

with time spent in games versus practice, as well as frequency

of o-season running were not risk factors for HSI.

SUMMARY

Previous HSI, age greater than 23 years, anterior cruciate

ligament injuries, calf strains, and other knee and ankle lig-

ament injuries represent nonmodiﬁable risk factors for HSI.

Hamstring fascicle length and stiness, but not ﬂexibility,

are modiﬁable risk factors. High-speed running demands

with abnormal trunk and pelvic posture and motor control

may be risk factors for HSI. However, further research is

needed to better deﬁne performance characteristics, such

as hamstring weakness, that might be risk factors.

Clinical Course

An HSI can occur anywhere along the length of the muscle,

but occurs most frequently in the proximal biceps femoris at

the musculotendinous junction.14 At the time of injury, an

individual experiences a sudden, sharp pain in the posterior

thigh. Additionally, an audible or palpable popping sensa-

tion39 often occurs during an activity that overloads and/or

overstretches the hamstring muscle.2,4 The individual may

stop the event or activity due to the pain and limited func-

tion. The recurrence rate of HSI ranges between 13.9% and

63.3% when followed over the same and subsequent sea-

sons.21 Also, injuries with more extensive myofascial damage

extending into the tendon are more prone to reinjury and

delayed RTP.72

The clinical course of an HSI depends on the extent and na-

ture of the muscle damage. In mild injuries, only the myoﬁ-

brils are damaged.2 With greater injury severity, the extreme

tensile and shear forces result in additional fascia, basal lam-

ina, and blood vessel tearing.49 Release of muscle enzymes,

creatine kinase, and collagen, with proteoglycan degradation

and inﬂammation, occurs following the injury. Blood vessel

damage results in bleeding and clotting.49 The most common

type of HSI occurs within the biceps femoris, where the my-

oﬁbers attach to the intramuscular fascia.13,53,102

The healing process includes 3 phases: inﬂammation, pro-

liferation, and remodeling.49 The inﬂammation phase occurs

immediately after HSI and lasts approximately 3 to 5 days.53

Vasodilation and increased capillary permeability during this

phase cause ﬂuid stasis, resulting in an ischemic local envi-

ronment, causing further muscle damage and edema. Two

to 4 days after injury, phagocytic cells enter the damaged

area to activate local undierentiated (“stem”) cells that be-

gin rebuilding the collagen and vascular infrastructure (eg,

ﬁbroblasts and endothelial cells).53 Clinically, pain, swelling,

bleeding, and loss of ROM typically characterize this phase.

The proliferation phase may overlap to varying degrees with

the inﬂammation phase and last up to several weeks. During

this phase, satellite cells contribute to repair damaged myo-

ﬁbers61 as collagen and vascular infrastructures are rebuilt.

At this time, individuals often experience muscle weakness,

stiness, swelling, and limited function.109 Suboptimal out-

comes occur when these symptoms and signs continue for an

extended period.53

Depending on the extent of the HSI, the remodeling phase

can continue for up to 2 years. This phase is characterized by

ﬁnal collagen formation, allowing for support to the injury

site. A properly aligned extracellular matrix is required to

maintain optimal myoﬁbril orientation. With an intact or

repaired basal lamina acting as a scaold, myoﬁbrils can re-

generate. Early ROM and soft tissue mobilization after injury

may help promote more organized scar formation, with fewer

adhesions to surrounding tissue. As the remodeling phase

progresses, the individual will have minimal complaints and

can tolerate greater stress to the muscle.53

SUMMARY

The normal healing process of an HSI is similar to other bio-

logical tissues and progresses through stages of inﬂammation,

proliferation, and remodeling. The remodeling phase can last

up to 2 years. Early hip and knee ROM may contribute to less

disorganized scar formation and a lower reinjury rate.

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cpg10 | march 2022 | volume 52 | number 3 | journal of orthopaedic & sports physical therapy

Hamstring Strain Injury in Athletes: Clinical Practice GuidelinesHamstring Strain Injury in Athletes: Clinical Practice Guidelines

Return to Play and Reinjury Risk

OVERVIEW

The high rates of recurrent HSIs are associated with substan-

tial losses of time in training and competition for athletes and

large costs to professional sports organizations. Optimizing

reinjury risk assessment and RTP decision making is a high

priority for all stakeholders. The importance of determining

when the athlete can safely RTP while minimizing risk of

reinjury remains high, especially following severe HSI that

usually requires a longer recovery.

In a meta-analysis that included 71 324 athletes, a

previous HSI was a risk factor for future injury (RR

= 2.7; 95% CI: 2.4, 3.1).38 Multiple systematic re-

views31,34,95 and additional studies not included in these re-

views supported this ﬁnding.12,66 In Australian rules football

players (n = 1932), those with a recent HSI (within 8 weeks)

were at higher risk (OR = 13.1; 95% CI: 11.5, 14.9) for reinjury

compared to those with a nonrecent injury (greater than 8

weeks) (OR = 3.5; 95% CI: 3.2, 3.9).69 Green et al38 noted that

the risk of recurrent HSI was greatest during the same season

(RR = 4.8; 95% CI: 3.5, 6.6).

The systematic review by de Visser et al21 noted a

lower risk of hamstring strain reinjury when indi-

viduals performed agility and stabilization exercis-

es after injury, compared to only stretching and strengthening

exercises (7.7% versus 70%, respectively). In 48 semiprofes-

sional soccer players, Mendiguchia et al60 found that a com-

prehensive impairment-based treatment program reduced

the risk of reinjury compared to a standard NHE program

(RR = 6; 90% CI: 1, 35).

A systematic review by Hickey et al45 recommended

a combination of clinical assessment (manual mus-

cle testing, ROM, palpation), performance (sprint-

ing, agility, hopping, sport-speciﬁc movements), and

isokinetic dynamometry tests to inform RTP decision mak-

ing. Four studies included in the Hickey et al45 review used

RTP criteria, based on a combination of clinical assessment

and performance tests, and reported mean RTP times of 23

to 45 days and reinjury rates between 9.1% and 63.3%.45 Tw o

studies that implemented the Askling H-test as part of the

decision-making criteria reported mean RTP times of 36 and

63 days, with reinjury rates of 1.3% and 3.6%.45 The most

practical ﬁndings were noted in 3 studies that used isokinetic

dynamometry, in addition to clinical assessment and perfor-

mance tests, with reported mean RTP times of 12 to 25 days

and reinjury rates between 6.25% and 13.9%.45 In their sys-

tematic review, Schut et al84 found limited evidence for initial

ﬁndings of visible bruising, muscle pain during everyday ac-

tivities, a popping sound at injury, being forced to stop play

within 5 minutes, width of palpation pain, pain on trunk

ﬂexion, and pain on active knee ﬂexion in predicting RTP

times. They also found limited evidence to support an asso-

ciation between RTP times and an individual’s height and

weight.84

At the time of physical therapist initial evaluation,

a combination of 3 demographic and 6 clinical vari-

ables explained 50% of the variance (±19 days) in

predicting the time to RTP after grade I or II HSI.48 However,

a combination of clinical and demographic variables, ob-

tained on physical therapy assessment 7 days after the initial

evaluation, explained 97% of the variance (±5 days) in pre-

dicting time to RTP. In order of importance, the following

variables were most predictive for RTP: (1) change in

strength during the ﬁrst week for the “mid-range” test, (2)

peak isokinetic knee ﬂexion torque of the uninjured leg at day

1, (3) pain level at the time of injury, (4) days to walk pain

free, (5) playing soccer, (6) “inner-range” hamstring strength

at day 1, (7) the presence or absence of pain on a single-leg

bridge at day 7, (8) delay in starting physical therapy, and (9)

percentage of strength in the “outer-range” test compared to

the healthy leg.48

Cross et al15 found no between-sex dierences in the

RTP time for ﬁrst-time (median: men, 7.0 days;

women, 6.0 days; P = .07) or recurrent (median:

men, 11 days; women, 5.5 days; P = .06) HSIs. However, they

reported that male soccer players had higher rates of reinjury

compared to female players (men, 22%; women, 12%; P =

.003).15 Similarly, Schut et al84 noted no association between

RTP times and sex or previous HSI sustained within the last

12 months. Related to characteristics of sport and time to

RTP, moderate evidence showed no association between the

level of sport activity or the intensity of sport activity per-

formed (3 or fewer times per week or more than 3 times per

week).84 Conﬂicting evidence existed for type of sport and

time to RTP from injury.84

Two lesser-quality randomized controlled trials

(RCTs) identiﬁed in a meta-analysis found a signif-

icant reduction in time to RTP (hazard ratio [HR]

= 3.22; 95% CI: 2.17, 4.77) when eccentric exercises were

added to a conventional stretching, strengthening, and sta-

bilization program after HSI.70

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journal of orthopaedic & sports physical therapy | volume 52 | number 3 | march 2022 | cpg11

Hamstring Strain Injury in Athletes: Clinical Practice GuidelinesHamstring Strain Injury in Athletes: Clinical Practice Guidelines

Hamstring strain injuries categorized by deﬁcits in

AKE ROM with the hip ﬂexed demonstrated longer

bouts of rehabilitation as the ROM deﬁcit in-

creased. Grade I injuries had less than a 15° ROM deﬁcit and

required 25.9 days of rehabilitation. Grade II injuries had a

16° to 25° ROM deﬁcit and required 30.7 days of rehabilita-

tion, while grade III injuries had a 26° to 35° ROM deﬁcit

and required 75.0 days of rehabilitation.86 Normalization of

isokinetic strength was not required to successfully complete

a soccer-speciﬁc rehabilitation program.92

The length of the area of tenderness measured on

initial evaluation (R2 = 0.58, P<.001), area of ten-

derness (R2 = 0.36, P = .006), and age (R2 = 0.27, P

= .024) were signiﬁcant predictors for RTP, while width of

tenderness (R2 = 0.006, P = .75) and location of injury were

not (proximal/distal P = .62, medial/lateral P = .64).82 Com-

bining the individual’s age with length of injury into a multi-

ple regression analysis improved the prediction of RTP (R2 =

0.73, P<.001).82

A systematic review by Fournier-Farley et al32 iden-

tiﬁed lower levels of evidence for the following risk

factors: (1) stretching-type injuries, (2) recreation-

al-level sport participant, (3) structural injuries (macroscopic

muscle ﬁber damage), (4) a greater than 20° to 25° deﬁcit of

AKE, (5) a greater than 1-week time to ﬁrst treatment consul-

tation, (6) higher maximal pain score on a 0-to-10 visual ana-

log scale, and (7) greater than 1 day to walk pain free after HSI.

When speciﬁcally looking at criteria for RTP decisions, a sys-

tematic review by van der Horst et al97 found a wide variety of

function-related criteria, none of which have been validated.

GAPS IN KNOWLEDGE

Despite some evidence, additional studies are needed to ac-

curately predict the clinical course as well as identify factors

that predict time to RTP and risk for reinjury. An important

limitation in this area is lack of consistency, reliability, and

validity in deﬁning RTP.

EVIDENCE SYNTHESIS AND RATIONALE

The CPG teams found the best evidence of a risk factor

for reinjury to be the history of HSI, with those having

sustained a more recent injury being at higher risk. There-

fore, RTP decisions should consider a previous HSI. Mod-

erate evidence supports the absence of an appropriately

progressed, comprehensive impairment-based functional

exercise program as a risk factor for reinjury. Moderate ev-

idence also identifies rehabilitation programs that do not

specifically include eccentric training as a risk factor for

reinjury and delayed RTP. An objective assessment with

a criterion-based functional exercise progression may al-

low injured athletes to effectively RTP in a time-sensitive

manner, while minimizing the risk of reinjury. Allowing

athletes to RTP before they are ready increases the risk

of reinjury.

RECOMMENDATIONS

Clinicians should use the history of an HSI when

implementing RTP progression, as a previous HSI

is a risk factor for a future reinjury.

Clinicians should use caution in RTP decisions for

individuals who did not complete an appropriately

progressed, comprehensive impairment-based

functional exercise program that speciﬁcally included eccen-

tric training.

Clinicians should use hamstring strength, pain level

at the time of injury, number of days from injury to

pain-free walking, and area of tenderness mea-

sured at initial evaluation to estimate time to RTP.

Diagnosis/Classiﬁcation

OVERVIEW

Early and accurate clinical diagnosis of an HSI is important

for providing appropriate treatment, deciding on RTP, and

preventing reinjury. Because HSIs are typically diagnosed and

graded based on physical ﬁndings, clinicians should recognize

both the clinical features and signs and symptoms associated

with the dierent injury grades of HSI. It should be noted that

detailed classiﬁcation systems using diagnostic imaging have

been described but are outside the scope of this CPG.

In 83 Australian rules football athletes with poste-

rior thigh pain, Verrall et al103 found the clinical

features of an HSI (n = 68) to be a sudden onset of

pain, an injury associated with running/acceleration, poste-

rior thigh tenderness, and pain on resisted hamstring muscle

contraction. The report of a sudden onset of pain (91%) was

the most useful ﬁnding.103

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cpg12 | march 2022 | volume 52 | number 3 | journal of orthopaedic & sports physical therapy

Hamstring Strain Injury in Athletes: Clinical Practice GuidelinesHamstring Strain Injury in Athletes: Clinical Practice Guidelines

In a prospective cohort of 180 male athletes,

Schneider-Kolsky et al83 found that clinical exam-

ination (r = 0.69, P<.001) and magnetic resonance

imaging (MRI) (r = 0.58, P<.001) were associated with time

to RTP in 58 Australian rules football athletes. Wangensteen

et al104,105 found that the addition of MRI to clinical examina-

tion alone explained only an additional 2.8% of the variance

in time to RTP.

Zeren and Oztekin111 deﬁned the taking-o-the-

shoe test for grade I and II biceps femoris injuries

(n = 140) and found it to be 100% accurate com-

pared to US diagnosis.

GAPS IN KNOWLEDGE

Although a clinical examination represents the gold standard

for diagnosing an HSI, evidence to deﬁne the accuracy of this

examination is limited. A clinical examination traditionally

describes an HSI as grade I, II, or III, representing severity

ranging from mild muscle damage without loss of structural

integrity to complete muscle tearing with ﬁber disruption.

The following criteria are used to identify each grade of

injury.1,86,110

Grade I (Mild Strain)

1. Microtearing of a few muscle ﬁbers

2. Local pain of smaller dimensions

3. Tightness and possible cramping in the posterior thigh

4. Slight pain with muscle stretching and/or activation

5. Stiness that may subside during activity but returns fol-

lowing activity

6. Minimal strength loss

7. Less than a 15° deﬁcit with the AKE test

Grade II (Moderate Strain)

1. Moderate tearing of muscle ﬁbers, but the muscle is still

intact

2. Local pain covering a larger area than in a grade I strain

3. Greater pain with muscle stretching and/or activation

4. Stiness, weakness, and possible hemorrhaging and

bruising

5. Limited ability to walk, especially for 24 to 48 hours after

injury

6. A 16° to 25° deﬁcit with the AKE test

Grade III (Severe Strain)

1. Complete tear of the muscle

2. Diuse swelling and bleeding

3. A possible palpable mass of muscle tissue at the tear site

4. Extreme diculty or inability to walk

5. A 26° to 35° deﬁcit with the AKE test

The CPG team believes that clinicians practicing in a di-

rect-access model should refer individuals with suspected

grade III injuries to a physician.

While the above grading criteria are commonly used as part

of the clinical examination, research is needed to support

their reliability and validity. Also, these criteria do not con-

sider the exact location of the injury, which can be identiﬁed

with MRI and US imaging.

EVIDENCE SYNTHESIS AND RATIONALE

Although evidence for the use of clinical examination to di-

agnose an HSI is limited, an individual with an acute injury

typically presents with a sudden onset of well-localized poste-

rior thigh pain, muscle tenderness, and loss of function. The

mechanism of injury is commonly related to an overloading

and/or overstretching of the hamstring muscle group. The

injury may be associated with a popping and/or tearing sen-

sation and result in localized ecchymosis. Hamstring group

stretching and/or activation may reproduce the pain. How-

ever, these symptoms may be absent in some individuals with

complete tears. When the area of maximal tenderness is at

either the origin or insertion of the hamstring muscle group,

tendon pathology should be considered as part of the dier-

ential diagnosis. When direct trauma to the posterior thigh

is the mechanism of injury, the clinician should consider

a dierent diagnosis, such as a contusion. Although it can

occur on rare occasions in those with an HSI, an insidious

onset of vague posterior symptoms should raise concerns for

referred pain from the lumbar spine. The beneﬁts of prop-

erly diagnosing an HSI would allow for appropriate injury

management, including RTP decisions and injury preven-

tion measures. The harms of not appropriately recognizing

the clinical features of an HSI could result in further inju-

ry or reinjury if the individual is not removed from athletic

participation.

RECOMMENDATION

Clinicians should make a diagnosis of HSI when an

individual presents with a sudden onset of posteri-

or thigh pain during activity, pain reproduced with

hamstring stretching and/or activation, muscle tenderness

with palpation, and loss of function.

DIFFERENTIAL DIAGNOSIS

The dierential diagnosis for those with primarily proximal

or distal posterior thigh symptoms may need to include hip

and knee pathologies, as well as isolated tendon lesions,

apophysitis, and avulsion fractures. Speciﬁcally, for those

with posterior thigh symptoms, dierential diagnosis in-

cludes the following52:

• Lumbar radiculopathy

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Hamstring Strain Injury in Athletes: Clinical Practice GuidelinesHamstring Strain Injury in Athletes: Clinical Practice Guidelines

• Sacroiliac dysfunction

• Deep gluteal syndrome with nerve entrapment

• Ischial tunnel syndrome

• Adductor muscle strain

• Contusion

• Compartment syndrome

• Thrombosis

Imaging

Imaging is typically not needed in those diagnosed with a

grade I or II HSI, based on clinical examination. This may

be especially true in those with less severe injuries, as stud-

ies have found that they may not be identiﬁable on MRI.24,83

Magnetic resonance imaging assessment is recommended

in those with a suspected grade III HSI.67 Detailed systems

to classify HSIs based on MRI ﬁndings are available, such

as the British Athletics Muscle Injury Classiﬁcation,71 the

modiﬁed Peetrons classiﬁcation,23 and the anatomically

based system described by Chan et al.9 However, the role of

MRI in helping to determine the clinical course, including

RTP and risk of reinjuries, is unclear. Evidence suggests

that the addition of MRI does not improve the prediction

of RTP beyond clinical examination.83,105 However, with

suspicion of a nonmusculoskeletal pain source, such as a

thrombosis, imaging may be indicated. While the Ameri-

can College of Radiology Appropriateness Criteria do not

speciﬁcally outline guidelines for those with an HSI, the

criteria for chronic hip pain note that MRI and US are

“usually appropriate” in those with chronic symptoms and

suspected extra-articular noninfectious soft tissue abnor-

malities (www.acr.org/). Therefore, MRI or US imaging can

be useful in decision making in individuals with an atypical

presentation of symptoms or who do not have satisfacto-

ry results with nonsurgical care. Radiographs are usually

not required, unless the symptoms are proximal and radio-

graphs may be useful to rule out avulsion fractures.

Examination

PHYSICAL IMPAIRMENT MEASURES

Overview

Activities that involve eccentric overloading of the hamstring

muscles in a lengthened position are not only associated with

HSI, but may also remain impaired after injury. Examples

include high-speed running, jumping, kicking, and/or other

explosive lower extremity movements. These activities are

integral to sports such as track and ﬁeld, soccer, Australian

rules football, American football, and rugby. Therefore, a

physical examination should include measures of ham-

string-related impairments (strength and muscle length)

and direct and self-reported assessments of sport-speciﬁc

activities. An assessment of potential risk factors that may

have contributed to injury also may be appropriate (TABLES

4 though 10).

Gaps in Knowledge

Individuals with an HSI present with knee ﬂexor weakness,

hamstring tightness, and muscle tenderness. However, the

best method for assessing hamstring muscle strength (eg, iso-

metric, eccentric, or isokinetic) and the clinical interpretation

of strength deﬁcits remain undetermined. Future studies also

should examine the reliability of measures other than using

an inclinometer to assess hamstring muscle length with the

hip ﬂexed to 90°. Mapping hamstring muscle tenderness is a

valuable component of a clinical examination, but more evi-

dence is needed to deﬁne its usefulness in HSI management.

While abnormal trunk and pelvic posture and control during

movements may be risk factors for an initial HSI,38,49,64 further

evidence is needed to support the usefulness of assessing these

impairments over the course of treatment.

Evidence Synthesis and Rationale

There is strong evidence for strength and ROM measures

after HSI. Current evidence suggests good reliability for

measures of knee flexor weakness following HSI with

isometric, isokinetic, and eccentric contractions, using a

handheld dynamometer (HHD) or isokinetic dynamom-

eter, as well as for hamstring muscle length (hip flexed

to 90° and SLR methods) using an inclinometer. The

degree of knee extension deficit measured with the hip

flexed to 90° is potentially useful for grading the severity

of injury. Weak evidence exists for mapping the location

and area of muscle tenderness. Percentage length of ten-

derness and age are predictors of days to RTP; athletes

with more proximal pain had a longer time to RTP. Proper

assessment of knee flexor strength, hamstring flexibility,

and muscle tenderness may be used in conjunction with

a criterion-based functional activity progression. This

approach allows injured athletes to effectively RTP in a

time-sensitive manner, while minimizing the risk of rein-

jury. A harm of inadequate injury assessment is allowing

the athlete to return to sport, which may put the athlete

at risk for reinjury.

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Hamstring Strain Injury in Athletes: Clinical Practice GuidelinesHamstring Strain Injury in Athletes: Clinical Practice Guidelines

Recommendations

Clinicians should quantify knee ﬂexor strength fol-

lowing HSI by using either an HHD or an isokinet-

ic dynamometer.

Clinicians should use an inclinometer to assess

hamstring length by measuring knee extension

deﬁcit with the hip ﬂexed to 90°.

Clinicians may use the length of muscle tenderness

and proximity to the ischial tuberosity to assist in

predicting timing of RTP.

Clinicians may assess for abnormal trunk and pel-

vic posture and control during functional

movements.

TABLE 4 Isometric Knee Flexor Muscle Strength

Abbreviations: CI, conﬁdence interval; HHD, handheld dynamometer; HSI, hamstring strain injury; ICC, intraclass correlation coecient; ICF, Interna-

tional Classiﬁcation of Functioning, Disability and Health; MDC, minimal detectable change; SEM, standard error of measurement.

ICF category Measurement of impairment of body function, power of isolated muscles and muscle groups

Description Resistive measures of knee ﬂexion strength with an isometric muscle contraction

Measurement method While positioned in prone or supine, the individual performs an isometric knee ﬂexion contraction against an HHD that is

placed on the posterior aspect of the distal tibia. The highest force of 3 trials is recorded for each position. Pain level during

the test can be recorded using a visual analog scale. The hip and knee positions may be altered to aect the length of the

hamstring muscle group

Speciﬁc testing positions include:

• Inner range: strength is measured with the individual positioned in prone, with the knee in 90° of ﬂexion. The athlete gradu-

ally builds up force to a maximum generated knee ﬂexor force, against an HHD, that creates a “make” force107

• Midrange: strength is measured in prone, with the knee extended and the dorsum of the foot on the table. The therapist

passively lifts the leg o the table to a height equal to the distance of the foot length. The individual pushes up against the

HHD for 3 seconds. The examiner applies a “break” force once peak force is achieved107

• Outer range: strength is measured with the individual supine, with the hip and knee in 90° of ﬂexion. The individual pushes

against the HHD for 3 seconds. The examiner applies a “break” force once peak force is achieved107

• 15° of knee ﬂexion: strength is measured with the individual positioned in prone, with the knee in 15° of ﬂexion. The individu-

al gradually builds up force to a maximum generated knee ﬂexor force, against an HHD, that creates a “make” force75

Nature of variable Continuous

Unit of measurement Kilograms or Newtons

Measurement properties (reliability)

Inner range Intrarater107

• ICC3,1 = 0.87; 95% CI: 0.84, 0.89; SEM, 1.78 kg; MDC95, 4.9 kg

Interrater

• ICC1,1 = 0.71; 95% CI: 0.62, 0.82; SEM, 26 N75

• ICC2,1 = 0.69; 95% CI: 0.45, 0.83; SEM, 2.01 kg; MDC95, 5.6 kg107

Midrange Intrarater107

• ICC3,1 = 0.89; 95% CI: 0.87, 0.90; SEM, 2.02 kg; MDC95, 5.6 kg

Interrater107

• ICC2,1 = 0.83; 95% CI: 0.68, 0.90; SEM, 1.05 kg; MDC95, 4.1 kg

Outer range Intrarater107

• ICC3,1 = 0.90; 95% CI: 0.88, 0.92; SEM, 2.19 kg; MDC95, 6.1 kg

Interrater107

• ICC2,1 = 0.79; 95% CI: 0.62, 0.88; SEM, 2.17 kg; MDC95, 6.0 kg

15° of knee ﬂexion Interrater75

• ICC1,1 = 0.83; 95% CI: 0.73, 0.90; SEM, 29 N

Measurement properties (validity) Isometric strength deﬁcits, when assessed less than 7 days post injury, were found in the injured limbs compared to the

noninjured side (eect size, –1.72; 95% CI: –3.43, 0.00)57

Deﬁcits in knee ﬂexor strength were noted between the previously injured limb and the contralateral noninjured limb for mean force

with an isometric contraction (eect size at 0°/0°, d = –1.06; 90% CI: –1.93, –0.19 and at 45°/45°, d = –0.88; 90% CI: –1.74, –0.02)43

Individuals with HSI generated signiﬁcantly less isometric knee ﬂexor force than those without HSI. Mean dierence between groups:

peak torque, –44.8 N; 95% CI: –86.3, –3 N; normalized, –22.2 Nm; 95% CI: –40.5, –3.7 Nm; normalized to body weight, –0.2; 95%

CI: –0.4, 0.010

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Hamstring Strain Injury in Athletes: Clinical Practice GuidelinesHamstring Strain Injury in Athletes: Clinical Practice Guidelines

ACTIVITY LIMITATION AND PARTICIPATION

RESTRICTION

Hickey et al45 provided general guidelines for assess-

ing activity limitations that include a progression

sequence of pain-free walking, pain-free normal jog-

ging, running at 70% perceived maximum speed, pain-free

change of direction, and pain-free 100% running speed.

Røksund et al79 established excellent reliability (in-

traclass correlation coecient [ICC] = 0.978; 95%

CI: 0.96, 0.98; standard error of measurement

[SEM], 0.008 seconds; minimal detectable change [MDC]95,

0.022 seconds) for the repeated sprint test in 75 semiprofes-

sional and professional soccer players (19 ± 3 years of age).

Athletes with a previous HSI showed a signiﬁcant decrease

in speed with repeated sprinting (0.07 seconds versus 0.02

seconds, P = .007).79

III

Ishøi et al47 found that 11 soccer players with a prior

history of an HSI had a higher mean maximal

sprinting velocity when compared to 33 controls

(mean dierence, 0.45 m/s; 95% CI: 0.06, 0.85 m/s).

Gaps in Knowledge

Information is needed to allow clinicians to select and in-

terpret scores from measures of activity and participation in

those with HSI. Because athletes make up the population

that typically sustains an HSI, evidence to support the valid-

ity, reliability, and responsiveness of sport-related functional

activities, including high-speed running, jumping, kicking,

and/or explosive lower extremity movements, would be

useful.

Evidence Synthesis and Rationale

Limited evidence exists regarding the most appropriate activ-

ity and participation measures that should be used to docu-

TABLE 5 Isokinetic Knee Extensor and Flexor Muscle Strength

ICF category Measurement of impairment of body function, power of isolated muscles and muscle groups

Description Resistive measures of the strength of the knee extensors and ﬂexors, using an isokinetic dynamometer

Measurement method The individual is seated, with the hip and knee ﬂexed to 90°. The distal tibia is ﬁxed with a cu attached to a load cell just

proximal to the malleoli. Straps are used to secure the thigh just proximal to the knee. After a brief warm-up, the individual

exerts a maximal contraction through an arc of motion for both knee extension and ﬂexion at selected speeds

Nature of variable Continuous

Unit of measurement Newton meters, foot-pounds, or the H/Q ratio

Measurement properties (reliability) Intratester (noninjured individuals)54

• ICC2,1 = 0.82 for eccentric contractions; SEM, 2.84 Nm; MDC, 7.87 Nm

Measurement properties (validity) Individuals with an HSI generated signiﬁcantly less knee ﬂexor force than controls at speeds of 60°/s (P<.0013) and 180°/s

(P<.0036). When comparing knee ﬂexor strength between the uninjured (within the previous 12 months) and injured

sides, injured-side knee ﬂexors were weaker at 60°/s during concentric (P<.038) and eccentric (P<.03) contractions. They

were also weaker with eccentric contractions at 180°/s (P<.038)65

A between-limb eccentric knee ﬂexor muscle strength imbalance of greater than 15% to 20% was associated with an

increased risk of HSI by 2.4 times (95% CI: 1.1, 5.5) and 3.4 times (95% CI: 1.5, 7.6), respectively7

At 60°/s, individuals with HSI showed eccentric hamstring-to-concentric quadriceps asymmetry, with imbalances of H/Q

ratios less than 0.60 being able to best identify those with a previous HSI20

Concentric isokinetic testing at 60°/s showed a dierence in injured versus noninjured knee ﬂexor strength, with an area

under the receiver operating characteristic curve of 0.773 (P<.05). No signiﬁcant dierences were noted at 120°/s46

Isokinetic quadriceps-hamstring strength ratios (concentric and eccentric) were not predictive of HSI19

At 60°/s, individuals with an HSI demonstrated a 9.6% deﬁcit in peak torque and a 6.4% deﬁcit in work, compared to the

uninjured side, at the time of RTP81

Injured individuals also generated signiﬁcantly less peak torque and work than the contralateral side when tested at 240°/s.

The H/Q ratio (eccentric, 30°/s and concentric, 240°/s) revealed that the injured limb had a lower ratio than the uninjured

limb81

Individuals with prior HSI demonstrated signiﬁcantly lower eccentric strength (at 25° to 5° of knee ﬂexion, 81.2 Nm/kg versus

75.2 Nm/kg; P<.025)87

Greater peak quadriceps concentric torque, adjusted for body weight, at 300°/s (greater than 1 SD above the mean, 2.2-3.7

Nm/kg) was identiﬁed as a risk factor for injury (HR = 2.06; 95% CI: 1.21, 3.51)99

A signiﬁcant small eect for a lower conventional H/Q ratio was found in previously injured legs compared to the uninjured

contralateral legs at 60°/s:60°/s (eect size, –0.32; 95% CI: –0.54, –0.11) and 240°/s:240°/s (eect size, –0.43; 95% CI:

–0.83, 0.03), but not 180°/s:180°/s or 300°/s:300°/s57

Abbreviations: CI, conﬁdence interval; H/Q, hamstring-quadriceps; HR, hazard ratio; HSI, hamstring strain injury; ICC, intraclass correlation coef-

ﬁcient; ICF, International Classiﬁcation of Functioning, Disability and Health; MDC, minimal detectable change; RTP, return to play; SEM, standard

error of measurement.

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Hamstring Strain Injury in Athletes: Clinical Practice GuidelinesHamstring Strain Injury in Athletes: Clinical Practice Guidelines

ment progress over the course of treatment. Because injuries

often occur with high-speed running, combined with the fact

that gait, running, and change in direction/cutting movements

are typically impaired after an HSI, it would seem appropriate

that objective measures of activity and participation should

include these activities in sport-speciﬁc task analysis.

Recommendation

Clinicians should include objective measures of an

individual’s ability to walk, run, and sprint when

documenting changes in activity and participation

over the course of treatment.

OUTCOME MEASURES

The Functional Assessment Scale for Acute Ham-

string Injuries (FASH) is a reliable and valid 10-

item questionnaire used to assess function after an

acute HSI. The FASH has excellent test-retest reliability (ICC

= 0.9), internal consistency (Cronbach’s α = .98), and respon-

siveness (3.8 and 5.32 using baseline and pooled SDs). The

FASH also has established face validity, content validity, and

construct validity (eg, its ability to discriminate between

acute HSI and noninjured hamstrings).56

The hamstring outcome score (HaOS) is a 5-do-

main questionnaire that assesses an athlete’s sore-

ness, symptoms, pain, activities (sports), and

quality of life. Questions on the HaOS are scored 0 to 4, from

no complaints to maximum complaints. A score of 100% sug-

gests no complaints in all domains. A score of 80% or more

indicates a low risk for HSI, while below 80% indicates a

high risk for HSI. Based on a study of 365 amateur soccer

players, the scale is a predictor of new HSI in athletes with

lower HaOS scores (P<.005).28,96

TABLE 6 Nordic Eccentric Knee Flexor Muscle Strength Test

Abbreviations: CI, conﬁdence interval; ICC, intraclass correlation coecient; ICF, International Classiﬁcation of Functioning, Disability and Health;

MDC, minimal detectable change.

ICF category Measurement of impairment of body function, power of isolated muscles and muscle groups

Description Resistive measure of eccentric knee ﬂexor strength

Measurement method The individual is positioned in a tall kneeling position, with the arms across the chest and both ankles ﬁrmly secured to a

load-cell instrumented device. The athlete performs a Nordic hamstring test by slowly lowering the trunk toward the ﬂoor,

keeping the spine and hips in neutral

Nature of variable Continuous

Unit of measurement Kilograms or Newtons

Measurement properties (reliability)

Intertester (noninjured individuals) Left and right sides pooled62

• ICC95 = 0.87-0.92; MDC95, 55.6 N

Same day22

• ICC = 0.60; 95% CI: 0.38, 0.75 (left leg)

• ICC = 0.62; 95% CI: 0.41, 0.76 (right leg)

1 wk apart22

• ICC = 0.67; 95% CI: 0.38, 0.84 (left leg)

• ICC = 0.76; 95% CI: 0.53, 0.89 (right leg)

TABLE 7 Knee Flexor Muscle Strength: Single-Leg Bridge Test

Abbreviations: HSI, hamstring strain injury; ICF, International Classiﬁcation of Functioning, Disability and Health.

ICF category Measurement of impairment of body function, power of isolated muscles and muscle groups

Description Resistive measure of concentric knee ﬂexor strength

Measurement method The individual lies down on the ground, with one heel on a box measuring 60 cm high. The test leg is positioned in 20° of ﬂex-

ion. The individual crosses the arms over the chest and pushes down through the heel to lift the buttocks o the ground,

with as many repetitions as possible until failure

Nature of variable Continuous

Unit of measurement Number of repetitions fully completed

Measurement properties (validity) In 482 athletes tested prospectively, 28 developed an HSI. Those with a right HSI had a signiﬁcantly lower mean right

single-leg bridge test score (P = .029)33

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Hamstring Strain Injury in Athletes: Clinical Practice GuidelinesHamstring Strain Injury in Athletes: Clinical Practice Guidelines

TABLE 8 Knee Extension Test for Hamstring Length (Hip/Knee: 90°/90°)

Abbreviations: AKE, active knee extension; CI, conﬁdence interval; HSI, hamstring strain injury; ICC, intraclass correlation coecient; ICF, Internation-

al Classiﬁcation of Functioning, Disability and Health; MDC, minimal detectable change; ROM, range of motion; SEM, standard error of measurement;

US, ultrasound.

ICF category Measurement of impairment of body function, mobility of a single joint

Description Measures knee ﬂexor muscle length

Measurement method The individual lies supine, with the hip and knee ﬂexed to 90°; the knee is then maximally extended, either passively or actively, with

the ankle in an open pack position. A goniometer or inclinometer can be used to measure the knee extension deﬁcit. Compari-

sons are made with the uninjured side

Nature of variable Continuous

Unit of measurement Degrees

Measurement properties (reliability)

Inclinometer interrater (same day) With knee passive ROM76

• ICC1,1 = 0.77; 95% CI: 0.63, 0.86; SEM, 7.6°; MDC, 21°

With knee active ROM76

• ICC1,1 = 0.89; 95% CI: 0.81, 0.94; SEM, 5.3°; MDC, 15°

Measurement properties (validity) AKE test: individuals with an HSI were categorized into grades based on the lack of full AKE compared to the uninjured side. Individ-

uals with a grade I injury had less than a 15° deﬁcit and required 25.9 days of rehabilitation. Those with a grade II injury exhibited

a 16° to 25° deﬁcit and required 30.7 days of rehabilitation. Athletes with a grade III injury demonstrated a 26° to 35° deﬁcit and

required 75.0 days of rehabilitation86

In those with a US-conﬁrmed diagnosis of HSI, the AKE test found the injured limb to have a mean ± SD deﬁcit of 12.8° ± 6.8° when

compared to the uninjured side86

Modiﬁcations Maximum hip ﬂexion AKE assesses hamstring ﬂexibility with the athlete positioned in maximum hip ﬂexion

Intrarater reliability107

• ICC3,1 = 0.83; 95% CI: 0.80, 0.86; SEM, 6.2°; MDC, 17.2°

Interrater reliability107

• ICC2,1 = 0.96; 95% CI: 0.92, 0.98; SEM, 3.3°; MDC, 9.3°

TABLE 9 SLR for Assessing Hamstring Length

Abbreviations: CI, conﬁdence interval; ICC, intraclass correlation coecient; ICF, International Classiﬁcation of Functioning, Disability and Health;

MDC, minimal detectable change; RTP, return to play; SEM, standard error of measurement; SLR, straight leg raise.

ICF category Measurement of impairment of body function, mobility of a single joint

Description Measures of knee ﬂexor muscle length

Measurement method The individual lies supine, with the hip and knee extended. The examiner passively ﬂexes the hip to the individual’s pain

tolerance, while keeping the knee extended. A modiﬁcation is to perform the maneuver and stop when the individual

reports pain in the posterior thigh of 3/10 (“moderate”) on a pain scale, with 0 as no pain and 10 as maximal pain

Nature of variable Continuous

Unit of measurement Degrees

Measurement properties (reliability)

Inclinometer (to pain tolerance) Intrarater107

• ICC3,1 = 0.88; 95% CI: 0.86, 0.90; SEM, 4.7°; MDC, 13.0°

Interrater107

• ICC

2,1 = 0.74; 95% CI: 0.52, 0.86; SEM, 6.54°; MDC, 18.1°

Inclinometer (stopping point of pain rated at 3/10) Intrarater4

• ICC3,1 = 0.98; 95% CI: 0.95, 0.99

Modiﬁcation for determining RTP using an inclinome-

ter (Askling H-test)

The clinician passively ﬂexes the hip, with the knee extended, to the individual’s tolerance. The individual then performs 3

SLRs as fast and as high as possible to the point of not sustaining reinjury. The examiner records the highest value of

the 3 trials5

• ICC

1,1 = 0.96; 95% CI: 0.84, 0.99

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Hamstring Strain Injury in Athletes: Clinical Practice GuidelinesHamstring Strain Injury in Athletes: Clinical Practice Guidelines

Evidence Synthesis and Rationale

The FASH and HaOS are the only evidence-based instru-

ments designed to assess athletes with an HSI. While other

potential instruments (eg, the Copenhagen Hip and Groin

Outcome Score) are available, no evidence exists for their use

in those with an HSI. Although the FASH has established

reliability and validity, future works should determine the

MDC and minimal clinically important dierence for im-

proved score interpretation and responsiveness. The HaOS

has established construct validity for predicting HSI in ath-

letes but does not have established reliability and is used pri-

marily before athletic sport participation begins to identify

athletes who may be susceptible to an HSI.

Recommendation

Clinicians should use the FASH before and after

interventions to alleviate the impairments of body

function and structure, activity limitations, and

participation restrictions in those diagnosed with an acute

HSI.

INJURY PREVENTION

Prevention of First-Time Injury

Hamstring injuries are common in sports that require high-

speed running, jumping, kicking, explosive rapid changes in

direction, and/or lifting objects from the ground. Prevention

of a ﬁrst-time HSI is important because of the considerable

impairment, activity limitation, and participation restric-

tion, including time lost from competitive sports, that may

occur after injury. Prevention may be particularly important

in professional sports, where HSIs can be associated with

signiﬁcant ﬁnancial costs.18

An umbrella review by Raya-Gonzalez et al74 identi-

ﬁed 8 systematic reviews and concluded that exer-

cise prevention programs that included the NHE

were eective in reducing the incidence of HSI. This included

a systematic review and meta-analysis by van Dyk et al,101 who

noted that the NHE reduced HSI by 51% (RR = 0.49; 95% CI:

0.32, 0.74) in 15 studies with 8459 athletes. Also included was

a systematic review by Goode et al37 that found that the eec-

tiveness of the NHE may be dependent on exercise compli-

ance. A systematic review not in the umbrella review also

concluded that the NHE may be eective in reducing the in-

cidence of HSI.80

When speciﬁcally looking at female soccer players,

a systematic review by Crossley et al16 found, in 5

studies, that exercise-based (single-component and

multicomponent) strategies signiﬁcantly reduced the inci-

dence of HSIs (incidence rate ratio = 0.40; 95% CI: 0.17,

0.95). They concluded that although the evidence was not as

robust in female soccer players, exercise-based strategies can

reduce HSI by 40% to 60%, similar to the rate found in their

male counterparts.16

An RCT with 259 male high school soccer players

found the time lost to injury to be lower in the NHE

group (113.7/10000 hours) compared to the control

group (1116.3/10000 hours) (P<.001).40

III

Within the umbrella review by Raya-Gonzalez et

al,74 the systematic review by Rogan et al78 reported

inconclusive evidence in low-level studies to sup-

port the role of hamstring stretching. Hibbert et al42 noted

weak evidence for eccentric hamstring exercises other than

the NHE in HSI prevention. Not included in the Raya-Gon-

zalez et al74 review, a systematic review by McCall et al59 also

found weak evidence in 3 studies to support eccentric ham-

string exercises other than the NHE. While evidence sup-

ports the NHE in HSI prevention, Elerian et al26 did not ﬁnd

a signiﬁcant dierence in HSI rates between seasons when

TABLE 10 Muscle Tenderness

Abbreviations: HSI, hamstring strain injury; ICF, International Classiﬁcation of Functioning, Disability and Health; RTP, return to play.

ICF category Measurement of impairment of body structure

Description Assess the location of peak tenderness and the region of tenderness of the knee ﬂexor muscles after an HSI

The individual lies prone on a treatment table, with the knee fully extended

Measurement method The examiner palpates the muscle to identify the location of peak hamstring tenderness and measures the distance from the

ischial tuberosity. Next, marks are placed at the most proximal and distal and medial and lateral points of tenderness (at the

point that tenderness subsides) to establish the length and width of tenderness. The area is “mapped” by expressing the

length and width of tenderness as a percentage of the posterior thigh length and width82

Nature of variable Continuous

Unit of measurement Centimeters or inches

Measurement properties (validity) Percentage length of tenderness and age were the best predictors of days to RTP following HSI (R2 = 0.73, P<.001), with the

following predictive equation: [number of days before return to sport = (% length of tenderness × 2.1) + (age × 1.5) – 43.4]82

Athletes who report more proximal pain have a longer time to RTP6

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Hamstring Strain Injury in Athletes: Clinical Practice GuidelinesHamstring Strain Injury in Athletes: Clinical Practice Guidelines

34 soccer players performed the NHE and a season when

they did not perform the NHE.

In 613 male collegiate sprinters followed over a pe-

riod of 24 seasons by the same coach, the incidence

of HSI decreased as agility and ﬂexibility were add-

ed to strength training.88 Results from a case series further

supported the use of isokinetic strengthening exercises for

reducing HSI rate.41

Gaps in Knowledge

Further research is needed to specifically define the most

effective prevention programs with warm-up, stretching,

balance, strengthening, and functional movements, as

well as potentially other eccentric hamstring exercises,

that should be added to the NHE. Additionally, frequency

and load progression of all preventive interventions need

to be further defined. Recommendations regarding dosing

of the NHE can vary, with volumes that range from 2 sets

of 3 repetitions once per week to 3 sets of 10 repetitions

twice a week and a gradual progression to 4 sessions per

week. These exercises are generally performed after train-

ing and on days before a rest day to allow for adequate

recovery.36

Evidence Synthesis and Rationale

Evidence supports injury prevention exercise programs that

include the NHE and other components of warm-up, stretch-

ing, stability training, strengthening, and functional move-

ments (sport speciﬁc, agility, and high-speed running). The

International Federation of Association Football (Fédération

Internationale de Football Association [FIFA]) 11+, Harmo-

Knee, and “New Warm-up Program” are examples of speciﬁc

injury prevention programs.80 The FIFA 11+ and HarmoKnee

programs include the NHE, as well as components of warm-

up, stretching, stability training, strengthening, and functional

movements (sport speciﬁc, agility, and high-speed running).

Recommendation

Clinicians should include the NHE as part of an

HSI prevention program, along with other compo-

nents of warm-up, stretching, stability training,

strengthening, and functional movements (sport speciﬁc,

agility, and high-speed running).

Interventions

INTERVENTION AFTER INJURY

Only studies of interventions within the scope of physical

therapy that directly assessed time to RTP and reinjury rates

were included in the review process. While clinicians mea-

sure intervention eectiveness in many ways (eg, strength,

ROM, and pain levels), the ultimate success of the rehabil-

itation process is determined by the athlete’s ability to RTP

while preventing reinjury.

A high-quality RCT found that individuals re-

turning to play following a standardized progres-

sive rehabilitation protocol, comprising

hamstring-strengthening exercises and running per-

formed within either pain-free (n = 21) or pain-threshold

limits (n = 22), reported 2 reinjuries per group, with no

difference in RTP time. The median time from HSI to RTP

was 15 days (95% CI: 13, 17) for the pain-free group and 17

days (95% CI: 11, 24) for the pain-threshold group (P =

.37).44

A systematic review and meta-analysis by Pas et al70

identiﬁed 2 RCTs with fair evidence to support a

program that added eccentric strengthening exer-

cises to a conventional program of stretching, strengthening,

and stabilization after an HSI. Participating in these pro-

grams resulted in a signiﬁcantly reduced time to RTP (HR =

3.22; 95% CI: 2.17, 4.77) but had no eect on reinjury rate

(RR = 0.25; 95% CI: 0.03, 2.20).

A systematic review of 5 studies found that pro-

gressive agility and trunk stabilization, added to

a rehabilitation program focusing on stretching

and strengthening, did not improve RTP time but may de-

crease reinjury rate.21 Included within this systematic re-

view, Sherry and Best85 specifically found a significant

reduction in reinjury rates in favor of progressive agility

and trunk stabilization exercises, as they found no reinju-

ries in 13 participants within 16 days after RTP and 1 re-

injury within 1 year, versus 6 reinjuries in 11 athletes and

7 reinjuries in 10 athletes, respectively, in the static

stretching, isolated progressive hamstring resistance exer-

cise, and icing group (P<.001).

Systematic reviews found insucient evidence to

support the use of stretching as an isolated treat-

ment in the management of HSI.21,58,70,73,77

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Hamstring Strain Injury in Athletes: Clinical Practice GuidelinesHamstring Strain Injury in Athletes: Clinical Practice Guidelines

An RCT (n = 48 male semiprofessional soccer play-

ers) found that an individualized criterion-based

treatment program consisting of comprehensive

impairment-based treatments reduced the risk of reinjury

compared to a standard NHE program (RR = 6; 90% CI: 1,

35). However, there was no dierence in RTP time (25.5 days

versus 23.2 days, –13.8%; 90% CI: –34%, 3.4%).60

A systematic review by Hickey et al45 identiﬁed 9

studies (n = 601) that examined individuals diag-

nosed with an acute HSI and concluded that speciﬁc

criteria for progression of rehabilitation were not well

deﬁned.

III

In a case-control study that compared professional

male soccer players (mean age, 24.3 years) over 2

seasons, reinjury rate was reduced from 7 of 35 to

1 of 34 in the season that the NHE was instituted.26

A study found that 50 of 54 athletes (mean age, 36

years; 30 male, 20 female) who were compliant

with a rehabilitation program that emphasized ec-

centric hamstring strengthening in a lengthened position

reported no reinjuries.94

A retrospective case series consisting of 48 consec-

utive HSIs in intercollegiate athletes found that

early mobilization with progressive stretching and

sport-related functional exercises were successful in allowing

athletes to return to sport after HSI at an average of 11.9 days

(range, 5-23 days), with 3 reinjuries.51

It is the opinion of the CPG team that clinicians

should incorporate neural tissue mobilization after

injury to reduce adhesions to surrounding tissue

and therapeutic modalities to control pain and swelling early

in the healing process.

Gaps in Knowledge

While evidence supports exercise in the treatment of HSI,

future works should examine the beneﬁts of other common-

ly used treatments, such as soft tissue mobilization, nerve

glides, and therapeutic modalities. These commonly used

treatments may assist in the healing process and shorten the

period of disability after an HSI. Research is needed to de-

termine the ecacy of these treatments in reducing time to

RTP and decreasing reinjury rates.

Evidence Synthesis and Rationale

Evidence supports initiating hamstring-strengthening exer-

cises, including eccentrics, early in the rehabilitation process,

guided by patient pain tolerance. Successful interventions

included 6 to 12 repetitions, depending on the intensity of

the exercise, with both load and ROM increased as tolerat-

ed. Patients should perform the exercises 2 to 3 times per

week. The evidence behind eccentric hamstring exercises

includes, but is not limited to, the NHE. Evidence also sup-

ports progressive agility and trunk stabilization exercises and

a running program involving acceleration and deceleration

phases, with a progressive increase in speed and distance,

throughout the rehabilitation process as tolerated. The ben-

eﬁts of eccentric training, added to stretching, strengthening,

stabilization, and progressive running programs, are im-

proved RTP times and reduced reinjury rates. Although the

harms of initiating and progressing exercise and running are

poorly described, there is a potential to aggravate symptoms

if the load of the activity is beyond the individual’s tolerance.

Potential harms may be mitigated if the clinician recognizes

the primary phase of healing (inﬂammatory, proliferation, or

remodeling) and uses a logical systematic method to begin,

monitor, and progress tissue loading.

Recommendations

Clinicians should use eccentric training to patient

tolerance, added to stretching, strengthening, sta-

bilization, and progressive running programs, to

improve RTP time after an individual sustains an HSI.

Clinicians should use progressive agility and trunk

stabilization, added to a comprehensive impair-

ment-based treatment program with stretching,

strengthening, and functional exercises, to reduce reinjury

rate after an individual sustains an HSI.

Clinicians may perform neural tissue mobilization

after injury to reduce adhesions to surrounding tis-

sue and use therapeutic modalities to control pain

and swelling early in the healing process.

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journal of orthopaedic & sports physical therapy | volume 52 | number 3 | march 2022 | cpg21

Hamstring Strain Injury in Athletes: Clinical Practice GuidelinesHamstring Strain Injury in Athletes: Clinical Practice Guidelines

Decision Tree

MEDICAL SCREENING (CLASSIFY CONDITION AND

ASSESS REINJURY RISK)

Patient Examination

• Sudden onset of posterior thigh pain – B

• Reproduction of pain with hamstring stretching and acti-

vation – B

• Muscle tenderness with palpation – B

• Loss of function – B

• Use the following criteria to grade muscle injury – F

- Grade I (mild strain): (1) microtearing of a few muscle

ﬁbers, (2) local pain of smaller dimensions, (3) tightness

and possible cramping in the posterior thigh, (4) slight

pain with muscle stretching and/or activation, (5) sti-

ness that may subside during activity but returns follow-

ing activity, (6) minimal strength loss, and (7) less than

a 15° deﬁcit with the AKE test

- Grade II (moderate strain): (1) moderate tearing of

muscle fibers, but the muscle is still intact, (2) local

pain covering a larger area than in grade I, (3) greater

pain with muscle stretch and/or activation, (4) stiff-

ness, weakness, and possible hemorrhaging and bruis-

ing, (5) limited ability to walk, especially for 24 to 48

hours after injury, and (6) a 16° to 25° deficit with the

AKE test

- Grade III (severe strain): (1) complete tear of the muscle,

(2) diuse swelling and bleeding, (3) possible palpable

mass of muscle tissue at the tear site, (4) extreme di-

culty or inability to walk, and (5) a 26° to 35° deﬁcit with

the AKE test

• Previous HSI – B

• Grade III HSIs are referred to a physician – F

OUTCOME MEASURES TO DOCUMENT PROGRESS

• Knee ﬂexor strength using either an HHD or isokinetic

dynamometer – A

• Hamstring length and measuring knee extension deﬁcit

with the hip ﬂexed to 90° using an inclinometer – A

• Measure the length of muscle tenderness to palpation and

the location relative to the ischial tuberosity

• Clinicians may assess for abnormal trunk and pelvic pos-

ture and control during functional movements – F

• Objective measures to quantify and grade an individual’s

ability to walk, run, and sprint – B

• FASH – B

MEASURES TO ESTIMATE TIME TO RTP

• Knee ﬂexor strength using either an HHD or isokinetic

dynamometer – B

• Pain level at the time of injury – B

• Number of days to walk pain free after injury – B

• Area of tenderness to palpation measured at initial evalu-

ation – B

INTERVENTION STRATEGIES

• Eccentric training to patient tolerance, added to an impair-

ment-based treatment program with stretching, strength-

ening, stabilization, agility, and progressive running – B

• Nerve mobilization – F

• Therapeutic modalities for symptom management – F

INJURY PREVENTION

• The NHE, with other components of warm-up, stretch-

ing, stability training, strengthening, and functional move-

ments (sport speciﬁc, agility, and high-speed running) – A

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cpg22 | march 2022 | volume 52 | number 3 | journal of orthopaedic & sports physical therapy

Hamstring Strain Injury in Athletes: Clinical Practice GuidelinesHamstring Strain Injury in Athletes: Clinical Practice Guidelines

AUTHORS

RobRoy L. Martin, PT, PhD

Editor

ICF-Based Clinical Practice Guidelines

AOPT, APTA, Inc

La Crosse, WI

and

Professor

Department of Physical Therapy

Rangos School of Health Science

Duquesne University

and

Sta Physical Therapist

UPMC Center for Sports Medicine

Pittsburgh, PA

martinr280@duq.edu

Michael T. Cibulka, PT, DPT, OCS

Catherine Worthingham Fellow, APTA

and

Associate Professor, Physical Therapy

Myrtle E. and Earl E. Walker College of

Health Professions

Maryville University

St Louis, MO

mcibulka@maryville.edu

Lori A. Bolgla, PT, PhD

Professor and Kellett Chair in Allied

Health Sciences

Department of Physical Therapy in the

College of Allied Health Sciences

Department of Orthopaedic Surgery at

the Medical College of Georgia

The Graduate School

Augusta University

Augusta, GA

LBOLGLA@augusta.edu

Thomas A. Koc, Jr., PT, DPT

Assistant Professor

School of Physical Therapy

Kean University

Union, NJ

tkoc@kean.edu

Janice K. Loudon, PT, PhD

Professor

Saint Luke’s College of Nursing and

Health Sciences

Rockhurst University

Kansas City, MO

janice.loudon@rockhurst.edu

Robert C. Manske, PT, DPT

Professor

Department of Physical Therapy

Wichita State University

Wichita, KS

Robert.Manske@wichita.edu

Leigh Weiss, PT, DPT, ATC, OCS, SCS

Director of Rehabilitation/Physical

Therapist

New York Football Giants

East Rutherford, NJ

Leigh.Weiss@Giants.NFL.net

John J. Christoforetti, MD, FAAOS

Sports Medicine and Arthroscopic

Surgery

Texas Health Sports Medicine

Allen, TX

johnchristoforetti@texashealth.org

Bryan C. Heiderscheit, PT, PhD, FAPTA

Fredrick Gaenslen Professor

Vice-Chair of Research, Department of

Orthopedics and Rehabilitation

University of Wisconsin-Madison

Madison, WI

Heiderscheit@ortho.wisc.edu

REVIEWERS

Mike Voight, PT, DHSc, OCS, SCS, ATC,

FA PTA

Professor

Belmont University School of Physical

Therapy

Nashville, TN

and

Editor-in-Chief

International Journal of Sports Physical

Therapy

Mike.voight@belmont.edu

John DeWitt, PT, DPT, AT

Associate Director, Education and

Professional Development

Wexner Medical Center, Jameson Crane

Sports Medicine Institute

and

Assistant Clinical Professor

School of Health and Rehabilitation

Sciences, Physical Therapy Division

The Ohio State University

Columbus, OH

John.dewitt@osumc.edu

Brian Young, PT, DSc

Clinical Associate Professor

Assistant Program Director, Doctor of

Physical Therapy Program

Graduate Program Director, Physical

Therapy Department

Baylor University

Waco, TX

Brian_A_Young@baylor.edu

Liran Lifshitz, PT, MSc

Lecturer and Sport Clinic Manager

Physio & More

Tel Aviv, Israel

and

Chairman of the Sports Interest Group

of the Israeli Physiotherapy Society

ptliran@gmail.com

Douglas White, PT, DPT, OCS, RMSK

Milton Orthopaedic & Sports Physical

Therapy, PC

Milton, MA

Dr.white@miltonortho.com

David Killoran, PhD

Professor Emeritus

Loyola Marymount University

Los Angeles, CA

David.Killoran@lmu.edu

Sandra Kaplan, PT, DPT, PhD, FAPTA

Professor

Department of Rehabilitation and

Movement Services

and

Vice-Chair, Curriculum and

Accreditation

Stuart D. Cook, M.D. Master Educators’

Guild

Rutgers, The State University of New

Jersey

New Brunswick, NJ

kaplansa@shp.rutgers.edu

Steve Paulseth, PT, DPT, SCS, ATC

Clinical Specialist

Paulseth & Associates Physical

Therapy, Inc

Los Angeles, CA

Paulsethpt@yahoo.com

James A. Dauber, DPT, DSc

Associate Professor

School of Physical Therapy

Marshall University

Huntington, WV

dauber@marshall.edu

GUIDELINES EDITORS

Christine M. McDonough, PT, PhD,

CEEAA

Editor

ICF-Based Clinical Practice Guidelines

AOPT, APTA, Inc

La Crosse, WI

and

Assistant Professor of Physical Therapy

School of Health and Rehabilitation

Sciences

University of Pittsburgh

Pittsburgh, PA

cmm295@pitt.edu

Christopher Carcia, PT, PhD

Physical Therapy Program Director and

Associate Professor

Department of Kinesiology

Colorado Mesa University

Grand Junction, CO

ccarcia@coloaradomesa.edu

Guy Simoneau, PT, PhD, FAPTA

Editor

ICF-Based Clinical Practice Guidelines

AOPT, APTA, Inc

La Crosse, WI

and

Professor

Physical Therapy

Marquette University

Marquette, WI

guy.simoneau@marquette.edu

AFFILIATIONS AND CONTACTS

ACKNOWLEDGMENTS: We thank the medical librarians at Augusta University for their assistance in researching the articles included in

these guidelines.

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journal of orthopaedic & sports physical therapy | volume 52 | number 3 | march 2022 | cpg23

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Hamstring Strain Injury in Athletes: Clinical Practice GuidelinesHamstring Strain Injury in Athletes: Clinical Practice Guidelines

SEARCH STRATEGIES AND RESULTS

Physical Impairment Measures

All search results, n = 3610; original citations, n = 2686

Patient-Reported Outcome Measures

All search results, n = 1433; original citations, n = 1112

PubMed (June 7, 2020)

Search Term Result

1“Hamstring Tendons”[Mesh] OR Biceps Femoris[tw] OR hamstring[tw] OR hamstrings[tw] OR Semimembranosus[tw] OR Semitendinosus[tw] OR

thigh[tw]

45670

2Myofascial pain syndromes[mh:noexp] OR soft tissue injuries[mh:noexp] OR strains[mh] OR myositis ossiﬁcans[mh] OR leg injuries[mh:noexp] OR

Pain[mesh:noexp] OR Acute Pain[mesh] OR Chronic Pain[mesh] OR Musculoskeletal Pain[mesh:noexp] OR Pain[tiab] OR Painful[tw] OR Ache[tw] OR

Injury[tw] OR Injuries[tw]

17 96 745

31 AND 2 13942

4Hamstring strain[mesh] OR Hamstring strain[tw] OR Hamstring tear[tw] OR Torn Hamstring[tw] OR Hamstring injury[tw] OR Hamstring injuries[tw] OR

Hamstring pain[tw] OR Hamstring ache[tw] OR Hamstring Myositis Ossiﬁcans[tw]

829

53 OR 4 13956

6“Sensitivity and Speciﬁcity”[Mesh] OR sensitivity[tw] OR speciﬁcity[tw] OR “Evaluation Studies as Topic”[Mesh] OR evaluation indexes[tw] OR evaluation

report[tw] OR evaluation reports[tw] OR evaluation research[tw] OR use-eectiveness[tw] OR use eectiveness[tw] OR preposttests[tw] OR pre

post test[tw] OR preposttest[tw] OR pre post test[tw] OR qualitative evaluation[tw] OR qualitative evaluations[tw] OR quantitative evaluation[tw] OR

quantitative evaluations[tw] OR theoretical eectiveness[tw] OR critique[tw] OR critiques[tw] OR evaluation methodology[tw] OR evaluation method-

ologies[tw] OR “Validation Studies as Topic”[Mesh] OR “Reproducibility of Results”[Mesh] OR reproducibility[tw] OR validity[tw] OR validation[tw] OR

reliability[tw] OR “Data Accuracy”[Mesh] OR data accuracy[tw] OR data accuracies[tw] OR data quality[tw] OR data qualities[tw] OR precision[tw]

OR responsiveness[tw] OR consistency[tw] OR consistencies[tw] OR consistent[tw] OR log-likelihood ratio[tw] OR likelihood-ratio[tw] OR likelihood

ratio[tw] OR LR test[tiab] OR “Epidemiologic Research Design”[Mesh] OR “Research Design”[Mesh] OR research design[tw] OR research designs[tw]

OR research strategy[tw] OR research strategies[tw] OR research techniques[tw] OR research technique[tw] OR research methodology[tw] OR research

methodologies[tw] OR experimental design[tw] OR experimental designs[tw]

4199739

7“Gait”[Mesh] OR “Gait Analysis”[Mesh] OR gait[tw] OR “strength test”[tw] OR isokinetic[tw] OR “range of motion”[tw] OR ﬂexibility[tw] OR full move-

ment[tw] OR “lower extremity alignment”[tw] OR “posture”[tw] OR movement pattern[tw] OR movement patterns[tw] OR “straight leg raise”[tw] OR

“McConnell test”[tw] OR “dynamic horizontal side support”[tw] OR “dynamic valgus”[tw] OR “single leg bride” [tw] OR “Active hamstring test”[tw]

OR “Hamstring 90/90 Test”[tw] OR “endurance test”[tw] OR “single leg squat”[tw] OR “single-leg stance”[tw] OR “single leg balance”[tw] OR “step

down”[tw] OR Agility testing[tw] OR sprinting[tw] OR jumping[tw] OR “Timed hop for distance”[tw] OR “Star Excursion balance test”[tw] OR “step-down

test”[tw] OR “cross-over”[tw] OR “Copenhagen ﬁve second squeeze test”[tw] OR “Double straight leg lower test”[tw] OR “Rehabilitation”[Mesh] OR re-

habilitation[tw] OR physical function[tw] OR physical functions[tw] OR physical functioning[tw] OR performance status[tw] OR “Return to Sport”[Mesh]

OR “back-to-sport”[tw] OR “return-to-sport”[tw] OR “back to sport”[tw] OR “return to sport”[tw] OR “back-to-sports”[tw] OR “return-to-sports”[tw]

OR “back to sports”[tw] OR “return to sports”[tw] OR “sporting activity resumption”[tw] OR “recreational activities resumption”[tw] OR “return to

recreation”[tw] OR “return to recreational”[tw] OR “return to play”[tw]

874126

8“Pain”[Majr] OR pain rating[tw] OR pain scale[tw] OR visual analogue scale[tw] OR visual analog scale[tw] OR numerical rating scale[tw] OR number rating

scale[tw] OR Perth Hamstring Assessment Tool[tw] OR “Copenhagen Hip and Groin Outcome Score”[tw] OR “Hip and Groin Outcome Score”[tw] OR

NAHS[tiab] OR lower extremity functional scale[tw] OR LEFS[tiab] OR short form health survey[tw] OR short-form health survey[tw] OR SF36[tw] OR

SF-36[tw] OR “SF 36”[tw] OR “short form 36”[tw] OR “shortform 36”[tw] OR shortform36[tw] OR “36 item short form”[tw] OR “36-item short form”[tw]

OR SF12[tw] OR SF-12[tw] OR “SF 12”[tw] OR “short form 12”[tw] OR “shortform 12”[tw] OR shortform12[tw] OR “12 item short form”[tw] OR “12-item

short form”[tw] OR tegner activity level scale[tw] OR hip sports activity scale[tw] OR HSAS[tiab]

329938

95 AND 6 AND 7 AND English[language] 681

10 5 AND 6 AND 8 AND English[language] 323

APPENDIX A

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cpg28 | march 2022 | volume 52 | number 3 | journal of orthopaedic & sports physical therapy

Hamstring Strain Injury in Athletes: Clinical Practice GuidelinesHamstring Strain Injury in Athletes: Clinical Practice Guidelines

Embase (June 7, 2020)

Search Term Result

1‘Hamstring Tendon’/exp OR ‘biceps femoris tendon’/exp OR “Biceps Femoris”: ti,ab,de,tn OR hamstring:ti,ab,de,tn OR hamstrings:ti,ab,de,tn OR ‘semimem-

branosus tendon’/exp OR Semimembranosus:ti,ab,de,tn OR Semitendinosus:ti,ab,de,tn OR thigh:ti,ab,de,tn

60500

2‘Myofascial pain’/de OR ‘soft tissue injury’/de OR ‘ossifying myositis’/exp OR ‘leg injury’/de OR ‘Pain’/de OR ‘Chronic Pain’/exp OR ‘Musculoskeletal Pain’/de

OR Pain:ti,ab OR Painful:ti,ab,de,tn OR Ache:ti,ab,de,tn OR Injury:ti,ab,de,tn OR Injuries:ti,ab,de,tn

2610373

31 AND 2 19523

4“Hamstring strain”:ti,ab,de,tn OR “Hamstring strains”:ti,ab,de,tn OR “Hamstring tear”:ti,ab,de,tn OR “Torn Hamstring”:ti,ab,de,tn OR “Hamstring inju-

ry”:ti,ab,de,tn OR “Hamstring injuries”:ti,ab,de,tn OR “Hamstring pain”:ti,ab,de,tn OR “Hamstring ache”:ti,ab,de,tn OR “Hamstring Myositis Ossiﬁ-

cans”:ti,ab,de,tn

850

53 OR 4 19539

6‘sensitivity’/exp OR sensitivity:ti,ab,de OR ‘speciﬁcity’/exp OR speciﬁcity:ti,ab,de OR ‘evaluation indexes’/exp OR ‘evaluation indexes’:ti,ab,de OR ‘evaluation

report’/exp OR ‘evaluation report’:ti,ab,de OR ‘evaluation reports’:ti,ab,de OR ‘evaluation research’/exp OR ‘evaluation research’:ti,ab,de OR ‘use

eectiveness’/exp OR ‘use eectiveness’:ti,ab,de OR ‘pre post tests’/exp OR ‘pre post tests’:ti,ab,de OR ‘prepost test’:ti,ab,de OR ‘qualitative evaluation’/

exp OR ‘qualitative evaluation’:ti,ab,de OR ‘qualitative evaluations’:ti,ab,de OR ‘quantitative evaluation’/exp OR ‘quantitative evaluation’:ti,ab,de OR

‘quantitative evaluations’:ti,ab,de OR ‘theoretical eectiveness’/exp OR ‘theoretical eectiveness’:ti,ab,de OR ‘critique’/exp OR critique:ti,ab,de OR cri-

tiques:ti,ab,de OR ‘evaluation methodology’/exp OR ‘evaluation methodology’:ti,ab,de OR ‘evaluation methodologies’:ti,ab,de OR ‘reproducibility’/exp OR

reproducibility:ti,ab,de OR ‘validity’/exp OR validity:ti,ab,de OR ‘reliability’/exp OR reliability:ti,ab,de OR ‘data accuracy’/exp OR ‘data accuracy’:ti,ab,de

OR ‘data accuracies’:ti,ab,de OR ‘data quality’/exp OR ‘data quality’:ti,ab,de OR ‘data qualities’:ti,ab,de OR ‘precision’/exp OR precision:ti,ab,de OR

‘responsiveness’/exp OR responsiveness:ti,ab,de OR ‘consistency’/exp OR consistency:ti,ab,de OR consistencies:ti,ab,de OR consistent:ti,ab,de

OR ‘log-likelihood ratio’ OR ‘likelihood-ratio’:ti,ab,de OR ‘likelihood ratio’/exp OR ‘likelihood ratio’:ti,ab,de OR ‘research design’/exp OR ‘research

design’:ti,ab,de OR ‘research designs’:ti,ab,de OR ‘research strategy’:ti,ab,de OR ‘research strategies’:ti,ab,de OR ‘research techniques’:ti,ab,de OR

‘research technique’:ti,ab,de OR ‘research methodology’/exp OR ‘research methodology’:ti,ab,de OR ‘research methodologies’:ti,ab,de OR ‘experimental

design’/exp OR ‘experimental design’:ti,ab,de OR ‘experimental designs’:ti,ab,de

8608226

7‘Gait’/exp OR gait:ti,ab,de,tn OR “strength test”:ti,ab,de,tn OR isokinetic:ti,ab,de,tn OR “range of motion”:ti,ab,de,tn OR ﬂexibility:ti,ab,de,tn OR “full

movement”:ti,ab,de,tn OR “lower extremity alignment”:ti,ab,de,tn OR posture:ti,ab,de,tn OR “movement pattern”:ti,ab,de,tn OR “movement pat-

terns”:ti,ab,de,tn OR “straight leg raise”:ti,ab,de,tn OR “McConnell test”:ti,ab,de,tn OR “dynamic horizontal side support”:ti,ab,de,tn OR “dynamic

valgus”:ti,ab,de,tn OR “single leg bride”:ti,ab,de,tn OR “Active hamstring test”:ti,ab,de,tn OR “Hamstring 90/90 Test”:ti,ab,de,tn OR “endurance

test”:ti,ab,de,tn OR “single leg squat”:ti,ab,de,tn OR “single-leg stance”:ti,ab,de,tn OR “single leg balance”:ti,ab,de,tn OR “step down”:ti,ab,de,tn

OR “Agility testing”:ti,ab,de,tn OR sprinting:ti,ab,de,tn OR jumping:ti,ab,de,tn OR “Timed hop for distance”:ti,ab,de,tn OR “Star Excursion balance

test”:ti,ab,de,tn OR “step-down test”:ti,ab,de,tn OR cross-over:ti,ab,de,tn OR “Copenhagen ﬁve second squeeze test”:ti,ab,de,tn OR “Double straight

leg lower test”:ti,ab,de,tn OR ‘Rehabilitation’/de OR rehabilitation:ti,ab,de,tn OR “physical function”:ti,ab,de,tn OR “physical functions”:ti,ab,de,tn OR

“physical functioning”:ti,ab,de,tn OR “performance status”:ti,ab,de,tn OR ‘Return to Sport’/exp OR back-to-sport:ti,ab,de,tn OR return-to-sport:ti,ab,de,tn

OR “back to sport”:ti,ab,de,tn OR “return to sport”:ti,ab,de,tn OR back-to-sports:ti,ab,de,tn OR return-to-sports:ti,ab,de,tn OR “back to sports”:ti,ab,de,tn

OR “return to sports”:ti,ab,de,tn OR “sporting activity resumption”:ti,ab,de,tn OR “recreational activities resumption”:ti,ab,de,tn OR “return to recre-

ation”:ti,ab,de,tn OR “return to recreational”:ti,ab,de,tn OR “return to play”:ti,ab,de,tn

675912

8‘Pain’/exp/mj OR “pain rating”:ti,ab,de,tn OR “pain scale”:ti,ab,de,tn OR “visual analogue scale”:ti,ab,de,tn OR “visual analog scale”:ti,ab,de,tn OR “numeri-

cal rating scale”:ti,ab,de,tn OR “number rating scale”:ti,ab,de,tn OR “Perth Hamstring Assessment Tool”:ti,ab,de,tn OR “Copenhagen Hip and Groin Out-

come Score”:ti,ab,de,tn OR “Hip and Groin Outcome Score”:ti,ab,de,tn OR NAHS:ti,ab OR “lower extremity functional scale”:ti,ab,de,tn OR LEFS:ti,ab OR

“short form health survey”:ti,ab,de,tn OR “short-form health survey”:ti,ab,de,tn OR SF36:ti,ab,de,tn OR SF-36:ti,ab,de,tn OR “SF 36”:ti,ab,de,tn OR “short

form 36”:ti,ab,de,tn OR “shortform 36”:ti,ab,de,tn OR shortform36:ti,ab,de,tn OR “36 item short form”:ti,ab,de,tn OR “36-item short form”:ti,ab,de,tn

OR SF12:ti,ab,de,tn OR SF-12:ti,ab,de,tn OR “SF 12”:ti,ab,de,tn OR “short form 12”:ti,ab,de,tn OR “shortform 12”:ti,ab,de,tn OR shortform12:ti,ab,de,tn OR

“12 item short form”:ti,ab,de,tn OR “12-item short form”:ti,ab,de,tn OR “tegner activity level scale”:ti,ab,de,tn OR “hip sports activity scale”:ti,ab,de,tn OR

HSAS:ti,ab

558290

95 AND 6 AND 7 AND [english]/lim AND [embase]/lim NOT ‘conference abstract’/it 887

10 5 AND 6 AND 8 AND [english]/lim AND [embase]/lim NOT ‘conference abstract’/it 619

APPENDIX A

Journal of Orthopaedic & Sports Physical Therapy®

Downloaded from www.jospt.org at Maryville University on March 1, 2022. For personal use only. No other uses without permission.

journal of orthopaedic & sports physical therapy | volume 52 | number 3 | march 2022 | cpg29

Hamstring Strain Injury in Athletes: Clinical Practice GuidelinesHamstring Strain Injury in Athletes: Clinical Practice Guidelines

CINAHL (June 7, 2020)

Search Term Result

1“Biceps Femoris” OR hamstring OR hamstrings OR Semimembranosus OR Semitendinosus OR thigh 14767

2(MH “Myofascial pain syndromes”) OR (MH “soft tissue injuries”) OR (MH “Sprains and Strains”) OR (MH “Myositis Ossiﬁcans”) OR (MH “Leg Injuries”) OR

(MH “Pain”) OR (MH “Chronic Pain”) OR Pain OR Painful OR Ache OR Injury OR Injuries

628076

31 AND 2 6892

4“Hamstring strain” OR “Hamstring tear” OR “Hamstring injury” OR “Hamstring injuries” OR “Hamstring pain” OR “Hamstring ache” OR “Hamstring

Myositis Ossiﬁcans”

633

53 OR 4 6896

6((MH “Sensitivity and Speciﬁcity+”) OR sensitivity OR speciﬁcity OR “evaluation indexes” OR “evaluation report” OR “evaluation reports” OR “evaluation

research” OR use-eectiveness OR “use eectiveness” OR preposttests OR “pre post test” OR preposttest OR “pre post test” OR “qualitative evaluation”

OR “qualitative evaluations” OR “quantitative evaluation” OR “quantitative evaluations” OR “theoretical eectiveness” OR critique OR critiques OR “eval-

uation methodology” OR “evaluation methodologies” OR reproducibility OR validity OR validation OR reliability OR “data accuracy” OR “data accuracies”

OR “data quality” OR “data qualities” OR precision OR responsiveness OR consistency OR consistencies OR consistent OR “log-likelihood ratio” OR like-

lihood-ratio OR “likelihood ratio” OR TI “LR test” OR AB “LR test” OR (MH “Study Design+”) OR “research design” OR “research designs” OR “research

strategy” OR “research strategies” OR “research techniques” OR “research technique” OR “research methodology” OR “research methodologies” OR

“experimental design” OR “experimental designs”)

1943500

7(MH “Gait+”) OR (MH “Gait Analysis+”) OR gait OR “strength test” OR isokinetic OR “range of motion” OR ﬂexibility OR “full movement” OR “lower extrem-

ity alignment” OR posture OR “movement pattern” OR “movement patterns” OR “straight leg raise” OR “McConnell test” OR “dynamic horizontal side

support” OR “dynamic valgus” OR “single leg bride” OR “Active hamstring test” OR “Hamstring 90/90 Test” OR “endurance test” OR “single leg squat”

OR “single-leg stance” OR “single leg balance” OR “step down” OR “Agility testing” OR sprinting OR jumping OR “Timed hop for distance” OR “Star

Excursion balance test” OR “step-down test” OR cross-over OR “Copenhagen ﬁve second squeeze test” OR “Double straight leg lower test” OR (MH

“Rehabilitation+”) OR rehabilitation OR “physical function” OR “physical functions” OR “physical functioning” OR “performance status” OR (MH “Sports

Re-Entry+”) OR back-to-sport OR return-to-sport OR “back to sport” OR “return to sport” OR back-to-sports OR return-to-sports OR “back to sports”

OR “return to sports” OR “sporting activity resumption” OR “recreational activities resumption” OR “return to recreation” OR “return to recreational” OR

“return to play”

512742

8(MM “Pain”) OR “pain rating” OR “pain scale” OR “visual analogue scale” OR “visual analog scale” OR “numerical rating scale” OR “number rating scale”

OR “Perth Hamstring Assessment Tool” OR “Copenhagen Hip and Groin Outcome Score” OR “Hip and Groin Outcome Score” OR TI NAHS OR AB NAHS

OR “lower extremity functional scale” OR TI LEFS OR AB LEFS OR “short form health survey” OR “short-form health survey” OR SF36 OR SF-36 OR “SF

36” OR “short form 36” OR “shortform 36” OR shortform36 OR “36 item short form” OR “36-item short form” OR SF12 OR SF-12 OR “SF 12” OR “short

form 12” OR “shortform 12” OR shortform12 OR “12 item short form” OR “12-item short form” OR “tegner activity level scale” OR “hip sports activity

scale” OR TI HSAS OR AB HSAS

96485

95 AND 6 AND 7 AND Language: English 1709

10 5 AND 6 AND 8 AND Language: English 317

APPENDIX A

Journal of Orthopaedic & Sports Physical Therapy®

Downloaded from www.jospt.org at Maryville University on March 1, 2022. For personal use only. No other uses without permission.

cpg30 | march 2022 | volume 52 | number 3 | journal of orthopaedic & sports physical therapy

Hamstring Strain Injury in Athletes: Clinical Practice GuidelinesHamstring Strain Injury in Athletes: Clinical Practice Guidelines

Cochrane Library (June 7, 2020)

Search Term Result

1“Hamstring Tendons” OR “Biceps Femoris” OR hamstring OR hamstrings OR Semimembranosus OR Semitendinosus OR thigh 6171

2“Myofascial pain syndromes” OR “soft tissue injuries” OR strains OR “myositis ossiﬁcans” OR “leg injuries” OR “Acute Pain” OR “Chronic Pain” OR “Muscu-

loskeletal Pain” OR Pain OR Painful OR Ache OR Injury OR Injuries

232755

31 AND 2 2858

4“Hamstring strain” OR “Hamstring tear” OR “Hamstring injury” OR “Hamstring injuries” OR “Hamstring pain” OR “Hamstring ache” OR “Hamstring

Myositis Ossiﬁcans”

128

53 OR 4 2861

6(sensitivity OR speciﬁcity OR “evaluation indexes” OR “evaluation report” OR “evaluation reports” OR “evaluation research” OR use-eectiveness OR “use

eectiveness” OR preposttests OR “pre post test” OR preposttest OR “pre post test” OR “qualitative evaluation” OR “qualitative evaluations” OR “quan-

titative evaluation” OR “quantitative evaluations” OR “ theoretical eectiveness” OR critique OR critiques OR “evaluation methodology” OR “evaluation

methodologies” OR reproducibility OR validity OR validation OR reliability OR “data accuracy” OR “data accuracies” OR “data quality” OR “data quali-

ties” OR precision OR responsiveness OR consistency OR consistencies OR consistent OR “log-likelihood ratio” OR likelihood-ratio OR “likelihood ratio”

OR “LR test” OR “research design” OR “research designs” OR “research strategy” OR “research strategies” OR “research techniques” OR “research

technique” OR “research methodology” OR “research methodologies” OR “experimental design” OR “experimental designs”)

159592

7Gait OR “strength test” OR isokinetic OR “range of motion” OR ﬂexibility OR “full movement” OR “lower extremity alignment” OR posture OR “movement

pattern” OR “movement patterns” OR “straight leg raise” OR “McConnell test” OR “dynamic horizontal side support” OR “dynamic valgus” OR “single

leg bride” OR “Active hamstring test” OR “Hamstring 90/90 Test” OR “endurance test” OR “single leg squat” OR “single-leg stance” OR “single leg bal-

ance” OR “step down” OR “Agility testing” OR sprinting OR jumping OR “Timed hop for distance” OR “Star Excursion balance test” OR “step-down test”

OR cross-over OR “Copenhagen ﬁve second squeeze test” OR “Double straight leg lower test” OR rehabilitation OR “physical function” OR “physical

functions” OR “physical functioning” OR “performance status” OR back-to-sport OR return-to-sport OR “back to sport” OR “return to sport” OR back-

to-sports OR return-to-sports OR “back to sports” OR “return to sports” OR “sporting activity resumption” OR “recreational activities resumption” OR

“return to recreation” OR “return to recreational” OR “return to play”

167411

8“pain rating” OR “pain scale” OR “visual analogue scale” OR “visual analog scale” OR “numerical rating scale” OR “number rating scale” OR “Perth Ham-

string Assessment Tool” OR “Copenhagen Hip and Groin Outcome Score” OR “Hip and Groin Outcome Score” OR NAHS OR “lower extremity functional

scale” OR LEFS OR “short form health survey” OR “short-form health survey” OR SF36 OR SF-36 OR “SF 36” OR “short form 36” OR “shortform 36” OR

shortform36 OR “36 item short form” OR “36-item short form” OR SF12 OR SF-12 OR “SF 12” OR “short form 12” OR “shor tform 12” OR shortform12 OR

“12 item short form” OR “12-item short form” OR “tegner activity level scale” OR “hip sports activity scale” OR HSAS

65171

95 AND 6 AND 7 333

10 5 AND 6 AND 8 174

Reinjury Risk

April 6, 2021: total results before duplicate removal, n = 1485; unique results after duplicate removal, n = 969. Updated on June 28,

2021: total results before duplicate removal, n = 1526; new unique results after duplicate removal, n = 33

PubMed

Search Term Result

1“Hamstring Tendons”[Mesh] OR Biceps Femoris[tw] OR hamstring[tw] OR hamstrings[tw] OR Semimembranosus[tw] OR Semitendinosus[tw] OR

thigh[tw]

48808

2Myofascial pain syndromes[mh:noexp] OR soft tissue injuries[mh:noexp] OR strains[mh] OR myositis ossiﬁcans[mh] OR leg injuries[mh:noexp] OR

Pain[mesh:noexp] OR Acute Pain[mesh] OR Chronic Pain[mesh] OR Musculoskeletal Pain[mesh:noexp] OR Pain[tiab] OR Painful[tw] OR Ache[tw] OR

Injury[tw] OR Injuries[tw]

1918350

31 AND 2 15217

4Hamstring strain[mesh] OR Hamstring strain[tw] OR Hamstring tear[tw] OR Torn Hamstring[tw] OR Hamstring injury[tw] OR Hamstring injuries[tw] OR

Hamstring pain[tw] OR Hamstring ache[tw] OR Hamstring Myositis Ossiﬁcans[tw]

939

53 OR 4 15230

6(“Recurrence”[Mesh] OR recur*[tw] OR reoccur*[tw] OR re-occur*[tw] OR re-injur*[tw] OR reinjur*[tw] OR “secondary injury”[tw] OR “secondary

injuries”[tw] OR “secondary prevention”[tw] OR “preventing secondary”[tw] OR recidiv*[tw] OR relaps*[tw]) AND (Risk Assessment[Mesh] OR “Risk

Adjustment”[Mesh] OR “Health Risk Behaviors”[Mesh] OR “Odds Ratio”[Mesh]OR risk[tw] OR risks[tw] OR prospective[tw] OR longitudinal[tw]

OR long-term[tw] OR longterm[tw] OR predict*[tw] OR prognostic[tw] OR prognosis[tw] OR epidemiolog*[tw] OR “multivariate analysis”[tw] OR

prevent*[tw] OR “odds ratio”[tw])

515934

75 AND 6 AND English[language] NOT (“comment”[Publication Type] OR “editorial”[Publication Type] OR “letter”[Publication Type] OR “news”[Publication

Type] OR “retracted publication”[Publication Type] OR “retraction of publication”[Publication Type] OR “Case Reports”[Publication Type])

513

APPENDIX A

Journal of Orthopaedic & Sports Physical Therapy®

Downloaded from www.jospt.org at Maryville University on March 1, 2022. For personal use only. No other uses without permission.

journal of orthopaedic & sports physical therapy | volume 52 | number 3 | march 2022 | cpg31

Hamstring Strain Injury in Athletes: Clinical Practice GuidelinesHamstring Strain Injury in Athletes: Clinical Practice Guidelines

Embase

Search Term Result

1‘Hamstring Tendon’/exp OR ‘biceps femoris tendon’/exp OR “Biceps Femoris”:ti,ab,de,tn OR hamstring:ti,ab,de,tn OR hamstrings:ti,ab,de,tn OR ‘semimem-

branosus tendon’/exp OR Semimembranosus:ti,ab,de,tn OR Semitendinosus:ti,ab,de,tn OR thigh:ti,ab,de,tn

65504

2‘Myofascial pain’/de OR ‘soft tissue injury’/de OR ‘ossifying myositis’/exp OR ‘leg injury’/de OR ‘Pain’/de OR ‘Chronic Pain’/exp OR ‘Musculoskeletal Pain’/de

OR Pain:ti,ab OR Painful:ti,ab,de,tn OR Ache:ti,ab,de,tn OR Injury:ti,ab,de,tn OR Injuries:ti,ab,de,tn

2801563

31 AND 2 21512

4“Hamstring strain”:ti,ab,de,tn OR “Hamstring strains”:ti,ab,de,tn OR “Hamstring tear”:ti,ab,de,tn OR “Torn Hamstring”:ti,ab,de,tn OR “Hamstring inju-

ry”:ti,ab,de,tn OR “Hamstring injuries”:ti,ab,de,tn OR “Hamstring pain”:ti,ab,de,tn OR “Hamstring ache”:ti,ab,de,tn OR “Hamstring Myositis Ossiﬁ-

cans”:ti,ab,de,tn

963

53 OR 4 21530

6(‘recurrence risk’/exp OR recur*:ti,ab,de,tn OR reoccur*:ti,ab,de,tn OR re-occur*:ti,ab,de,tn OR re-injur*:ti,ab,de,tn OR reinjur*:ti,ab,de,tn OR “second-

ary injury”:ti,ab,de,tn OR “secondary injuries”:ti,ab,de,tn OR “secondary prevention”:ti,ab,de,tn OR “preventing secondary”:ti,ab,de,tn OR recidi-

v*:ti,ab,de,tn OR relaps*:ti,ab,de,tn) AND (‘recurrence risk’/exp OR ‘risk assessment’/exp OR ‘risk behavior’/exp OR ‘odds ratio’/exp OR risk:ti,ab,de,tn

OR risks:ti,ab,de,tn OR prospective:ti,ab,de,tn OR longitudinal:ti,ab,de,tn OR long-term:ti,ab,de,tn OR longterm:ti,ab,de,tn OR predict*:ti,ab,de,tn OR

prognostic:ti,ab,de,tn OR prognosis:ti,ab,de,tn OR epidemiolog*:ti,ab,de,tn OR “multivariate analysis”:ti,ab,de,tn OR prevent*:ti,ab,de,tn OR “odds

ratio”:ti,ab,de,tn)

796351

75 AND 6 AND [english]/lim AND [embase]/lim NOT (‘conference abstract’/it OR ‘editorial’/it OR ‘letter’/it OR ‘note’/it) 420

CINAHL

Search Term Result

1“Biceps Femoris” OR hamstring OR hamstrings OR Semimembranosus OR Semitendinosus OR thigh 14880

2(MH “Myofascial pain syndromes”) OR (MH “soft tissue injuries”) OR (MH “Sprains and Strains”) OR (MH “Myositis Ossiﬁcans”) OR (MH “Leg Injuries”) OR

(MH “Pain”) OR (MH “Chronic Pain”) OR Pain OR Painful OR Ache OR Injury OR Injuries

632767

31 AND 2 6936

4“Hamstring strain” OR “Hamstring tear” OR “Hamstring injury” OR “Hamstring injuries” OR “Hamstring pain” OR “Hamstring ache” OR “Hamstring

Myositis Ossiﬁcans”

634

53 OR 4 6941

6((MH “Recurrence+”) OR recur* OR reoccur* OR re-occur* OR re-injur* OR reinjur* OR “secondary injury” OR “secondary injuries” OR “secondary preven-

tion” OR “preventing secondary” OR recidiv* OR relaps*) AND ((MH “Risk Assessment+”) OR (MH “Risk Taking Behavior+”) OR (MH “Odds Ratio+”)

OR risk OR risks OR prospective OR longitudinal OR long-term OR longterm OR predict* OR prognostic OR prognosis OR epidemiolog* OR “multivariate

analysis” OR prevent* OR “odds ratio”)

131078

75 AND 6 AND Language: English and Source Type: Academic Journals 402

Cochrane Library

Search Term Result

1“Hamstring Tendons” OR “Biceps Femoris” OR hamstring OR hamstrings OR Semimembranosus OR Semitendinosus OR thigh 6171

2“Myofascial pain syndromes” OR “soft tissue injuries” OR strains OR “myositis ossiﬁcans” OR “leg injuries” OR “Acute Pain” OR “Chronic Pain” OR “Muscu-

loskeletal Pain” OR Pain OR Painful OR Ache OR Injury OR Injuries

232755

31 AND 2 2858

4“Hamstring strain” OR “Hamstring tear” OR “Hamstring injury” OR “Hamstring injuries” OR “Hamstring pain” OR “Hamstring ache” OR “Hamstring

Myositis Ossiﬁcans”

128

53 OR 4 2861

6(recur* OR reoccur* OR re-occur* OR re-injur* OR reinjur* OR “secondary injury” OR “secondary injuries” OR “secondary prevention” OR “preventing sec-

ondary” OR recidiv* OR relaps*) AND (risk OR risks OR prospective OR longitudinal OR long-term OR longterm OR predict* OR prognostic OR prognosis

OR epidemiolog* OR “multivariate analysis” OR prevent* OR “odds ratio”)

7476 8

75 AND 6 191

APPENDIX A

Journal of Orthopaedic & Sports Physical Therapy®

Downloaded from www.jospt.org at Maryville University on March 1, 2022. For personal use only. No other uses without permission.

cpg32 | march 2022 | volume 52 | number 3 | journal of orthopaedic & sports physical therapy

Hamstring Strain Injury in Athletes: Clinical Practice GuidelinesHamstring Strain Injury in Athletes: Clinical Practice Guidelines

Return to Play

April 6, 2021: total results before duplicate removal, n = 1690; unique results after duplicate removal, n = 1103. Updated June 28, 2021:

total results before duplicate removal, n = 1765; new unique results after duplicate removal, n = 53

PubMed

Search Term Result

1“Hamstring Tendons”[Mesh] OR Biceps Femoris[tw] OR hamstring[tw] OR hamstrings[tw] OR Semimembranosus[tw] OR Semitendinosus[tw] OR

thigh[tw]

48808

2Myofascial pain syndromes[mh:noexp] OR soft tissue injuries[mh:noexp] OR strains[mh] OR myositis ossiﬁcans[mh] OR leg injuries[mh:noexp] OR

Pain[mesh:noexp] OR Acute Pain[mesh] OR Chronic Pain[mesh] OR Musculoskeletal Pain[mesh:noexp] OR Pain[tiab] OR Painful[tw] OR Ache[tw] OR

Injury[tw] OR Injuries[tw]

1918350

31 AND 2 15217

4Hamstring strain[mesh] OR Hamstring strain[tw] OR Hamstring tear[tw] OR Torn Hamstring[tw] OR Hamstring injury[tw] OR Hamstring injuries[tw] OR

Hamstring pain[tw] OR Hamstring ache[tw] OR Hamstring Myositis Ossiﬁcans[tw]

939

53 OR 4 15230

6“Return to Sport”[Mesh] OR “Athletic Performance”[Mesh] OR “back-to-sport”[tw] OR “return-to-sport”[tw] OR “back to sport”[tw] OR “return to sport”[tw]

OR “back-to-sports”[tw] OR “return-to-sports”[tw] OR “back to sports”[tw] OR “return to sports”[tw] OR “return to recreation”[tw] OR “return to recre-

ational”[tw] OR “return to play”[tw] OR “return to activity”[tw] OR “return to competition”[tw] OR “competition return”[tw] OR “resume competition”[tw]

OR “resume play”[tw] OR “resume sport”[tw] OR “resume sports”[tw] OR “resume activity”[tw] OR “resume activities”[tw] OR “return to perfor-

mance”[tw] OR “sport resumption”[tw] OR “sports resumption”[tw] OR “sporting activity resumption”[tw] OR “play resumption”[tw] OR “competition

resumption”[tw] OR “activity resumption”[tw] OR “activities resumption”[tw] OR “unrestricted sport”[tw] OR “unrestricted sports”[tw] OR “unrestricted

activity”[tw] OR “unrestricted play”[tw] OR “full recovery”[tw] OR “level of play”[tw] OR “athletic performance”[tw] OR “sports performance”[tw] OR

“sports re-entry”[tw]

75457

75 AND 6 AND English[language] NOT (“comment”[Publication Type] OR “editorial”[Publication Type] OR “letter”[Publication Type] OR “news”[Publication

Type] OR “retracted publication”[Publication Type] OR “retraction of publication”[Publication Type] OR “Case Reports”[Publication Type])

673

Embase

Search Term Result

1‘Hamstring Tendon’/exp OR ‘biceps femoris tendon’/exp OR “Biceps Femoris”:ti,ab,de,tn OR hamstring:ti,ab,de,tn OR hamstrings:ti,ab,de,tn OR ‘semimem-

branosus tendon’/exp OR Semimembranosus:ti,ab,de,tn OR Semitendinosus:ti,ab,de,tn OR thigh:ti,ab,de,tn

65504

2‘Myofascial pain’/de OR ‘soft tissue injury’/de OR ‘ossifying myositis’/exp OR ‘leg injury’/de OR ‘Pain’/de OR ‘Chronic Pain’/exp OR ‘Musculoskeletal Pain’/de

OR Pain:ti,ab OR Painful:ti,ab,de,tn OR Ache:ti,ab,de,tn OR Injury:ti,ab,de,tn OR Injuries:ti,ab,de,tn

2801563

31 AND 2 21512

4“Hamstring strain”:ti,ab,de,tn OR “Hamstring strains”:ti,ab,de,tn OR “Hamstring tear”:ti,ab,de,tn OR “Torn Hamstring”:ti,ab,de,tn OR “Hamstring inju-

ry”:ti,ab,de,tn OR “Hamstring injuries”:ti,ab,de,tn OR “Hamstring pain”:ti,ab,de,tn OR “Hamstring ache”:ti,ab,de,tn OR “Hamstring Myositis Ossiﬁ-

cans”:ti,ab,de,tn

963

53 OR 4 21530

6‘return to sport’/exp OR ‘athletic performance’/exp OR back-to-sport:ti,ab,de,tn OR return-to-sport:ti,ab,de,tn OR “back to sport”:ti,ab,de,tn OR “return to

sport”:ti,ab,de,tn OR back-to-sports:ti,ab,de,tn OR return-to-sports:ti,ab,de,tn OR “back to sports”:ti,ab,de,tn OR “return to sports”:ti,ab,de,tn OR “return

to recreation”:ti,ab,de,tn OR “return to recreational”:ti,ab,de,tn OR “return to play”:ti,ab,de,tn OR “return to activity”:ti,ab,de,tn OR “return to compe-

tition”:ti,ab,de,tn OR “competition return”:ti,ab,de,tn OR “resume competition”:ti,ab,de,tn OR “resume play”:ti,ab,de,tn OR “resume sport”:ti,ab,de,tn

OR “resume sports”:ti,ab,de,tn OR “resume activity”:ti,ab,de,tn OR “resume activities”:ti,ab,de,tn OR “return to performance”:ti,ab,de,tn OR “sport re-

sumption”:ti,ab,de,tn OR “sports resumption”:ti,ab,de,tn OR “sporting activity resumption”:ti,ab,de,tn OR “play resumption”:ti,ab,de,tn OR “competition

resumption”:ti,ab,de,tn OR “activity resumption”:ti,ab,de,tn OR “activities resumption”:ti,ab,de,tn OR “unrestricted sport”:ti,ab,de,tn OR “unrestricted

sports”:ti,ab,de,tn OR “unrestricted activity”:ti,ab,de,tn OR “unrestricted play”:ti,ab,de,tn OR “full recovery”:ti,ab,de,tn OR “level of play”:ti,ab,de,tn OR

“athletic performance”:ti,ab,de,tn OR “sports performance”:ti,ab,de,tn OR ‘sports re-entry’:ti,ab,de,tn

36409

75 AND 6 AND [english]/lim AND [embase]/lim NOT (‘conference abstract’/it OR ‘editorial’/it OR ‘letter’/it OR ‘note’/it) 382

APPENDIX A

Journal of Orthopaedic & Sports Physical Therapy®

Downloaded from www.jospt.org at Maryville University on March 1, 2022. For personal use only. No other uses without permission.

journal of orthopaedic & sports physical therapy | volume 52 | number 3 | march 2022 | cpg33

Hamstring Strain Injury in Athletes: Clinical Practice GuidelinesHamstring Strain Injury in Athletes: Clinical Practice Guidelines

CINAHL

Search Term Result

1“Biceps Femoris” OR hamstring OR hamstrings OR Semimembranosus OR Semitendinosus OR thigh 14880

2(MH “Myofascial pain syndromes”) OR (MH “soft tissue injuries”) OR (MH “Sprains and Strains”) OR (MH “Myositis Ossiﬁcans”) OR (MH “Leg Injuries”) OR

(MH “Pain”) OR (MH “Chronic Pain”) OR Pain OR Painful OR Ache OR Injury OR Injuries

632767

31 AND 2 6936

4“Hamstring strain” OR “Hamstring tear” OR “Hamstring injury” OR “Hamstring injuries” OR “Hamstring pain” OR “Hamstring ache” OR “Hamstring

Myositis Ossiﬁcans”

634

53 OR 4 6941

6(MH “Sports Re-Entry”) OR (MH “Athletic Performance”) OR back-to-sport OR return-to-sport OR “back to sport” OR “return to sport” OR back-to-sports

OR return-to-sports OR “back to sports” OR “return to sports” OR “return to recreation” OR “return to recreational” OR “return to play” OR “return to

activity” OR “return to competition” OR “competition return” OR “resume competition” OR “resume play” OR “resume sport” OR “resume sports” OR

“resume activity” OR “resume activities” OR “return to performance” OR “sport resumption” OR “sports resumption” OR “sporting activity resumption”

OR “play resumption” OR “competition resumption” OR “activity resumption” OR “activities resumption” OR “unrestricted sport” OR “unrestricted

sports” OR “unrestricted activity” OR “unrestricted play” OR “full recovery” OR “level of play” OR “athletic performance” OR “sports performance” OR

“sports re-entry”

20789

75 AND 6 AND Language: English and Source Type: Academic Journals 562

Cochrane Library

Search Term Result

1“Hamstring Tendons” OR “Biceps Femoris” OR hamstring OR hamstrings OR Semimembranosus OR Semitendinosus OR thigh 6171

2“Myofascial pain syndromes” OR “soft tissue injuries” OR strains OR “myositis ossiﬁcans” OR “leg injuries” OR “Acute Pain” OR “Chronic Pain” OR “Muscu-

loskeletal Pain” OR Pain OR Painful OR Ache OR Injury OR Injuries

232755

31 AND 2 2858

4“Hamstring strain” OR “Hamstring tear” OR “Hamstring injury” OR “Hamstring injuries” OR “Hamstring pain” OR “Hamstring ache” OR “Hamstring

Myositis Ossiﬁcans”

128

53 OR 4 2861

6back-to-sport OR return-to-sport OR “back to sport” OR “return to sport” OR back-to-sports OR return-to-sports OR “back to sports” OR “return to

sports” OR “return to recreation” OR “return to recreational” OR “return to play” OR “return to activity” OR “return to competition” OR “competition

return” OR “resume competition” OR “resume play” OR “resume sport” OR “resume sports” OR “resume activity” OR “resume activities” OR “return to

performance” OR “sport resumption” OR “sports resumption” OR “sporting activity resumption” OR “play resumption” OR “competition resumption”

OR “activity resumption” OR “activities resumption” OR “unrestricted sport” OR “unrestricted sports” OR “unrestricted activity” OR “unrestricted play”

OR “full recovery” OR “level of play” OR “athletic performance” OR “sports performance” OR “sports re-entry”

4041

75 AND 6 148

APPENDIX A

Journal of Orthopaedic & Sports Physical Therapy®

Downloaded from www.jospt.org at Maryville University on March 1, 2022. For personal use only. No other uses without permission.

cpg34 | march 2022 | volume 52 | number 3 | journal of orthopaedic & sports physical therapy

Hamstring Strain Injury in Athletes: Clinical Practice GuidelinesHamstring Strain Injury in Athletes: Clinical Practice Guidelines

Intervention

September 6, 2019: all search results, n = 11 432; original citations, n = 9624. Updated on June 30, 2021: all search results, n = 6017;

new original citations, n = 1825

2019 Search

PubMed

Search Term Result

1(((thigh [mh] OR quadriceps muscle [mh] OR lower extremity [mh:noexp] OR hamstring tendons [mh] OR hamstring muscles [mh] OR gracilis muscle

[mh]) OR (“Adductor” [tiab] OR “Biceps Femoris” [tiab] OR “Gracilis” [tiab] OR “hamstring” [tiab] OR “Iliotibial Band” [tiab] OR “Ischial” [tiab] OR

“Quadriceps” [tiab] OR “Quadriceps Femoris” [tiab] OR “Rectus Femoris” [tiab] OR “Semimembranosus” [tiab] OR “Semitendinosis” [tiab] OR “Tensor

fascia lata” [tiab] OR “thigh” [tiab] OR “Vastus” [tiab])) AND ((myofascial pain syndromes [mh:noexp] OR soft tissue injuries [mh:noexp] OR tendon

injuries [mh:noexp] OR tendinopathy [mh:noexp] OR sprains and strains [mh] OR myositis ossiﬁcans [mh] OR leg injuries [mh:noexp]) OR (“Avulsion”

[tiab] OR “Ischiofemoral impingement” [tiab] OR “Muscle Strain” [tiab] OR “Muscle Tear” [tiab] OR “Myositis Ossiﬁcans” [tiab] OR soft tissue injuries

[tiab] OR “injury” [tiab] OR “sprains and strains” [tiab] OR sprain* [tiab] OR “strains” [tiab])) AND ((Acupuncture Therapy [mh:noexp] OR Chiropractic

[mh] OR Combined Modality Therapy [mh] OR Cryotherapy [mh] OR Diathermy [mh] OR Iontophoresis [mh] OR Muscle Contraction [mh] OR Orthotic

Devices [mh] OR Patient Education as Topic [mh:noexp] OR Physical Therapy Modalities [mh] OR Rehabilitation [mh:noexp] OR Self Care [mh] OR

Telerehabilitation [mh] OR Ultrasonography [mh]) OR (“Astym Treatment” [tiab] OR “Augmented Soft-Tissue” [tiab] OR “Mobilization” [tiab] OR “Mobil-

isation” [tiab] OR Brace* [tiab] OR Chiropract* [tiab] OR “Compression” [tiab] OR “Contract-relax stretching” [tiab] OR “Cross-Friction Massage” [tiab]

OR Dry needl* [tiab] OR “Dynamic stretching” [tiab] OR “Exercise” [tiab] OR “Graston” [tiab] OR “Joint Mobilization” [tiab] OR “ Kinesio tape” [tiab]

OR “Manipulation” [tiab] OR Manual Therapy* [tiab] OR “Massage” [tiab] OR cryotherap* [Tiab] OR thermotherap* [Tiab] OR “Moist Heat” [tiab] OR

“Ice” [tiab] OR “diathermy” [tiab] OR ultrasound* [Tiab] OR electrical* [Tiab] OR muscle stimul* [Tiab] OR neuromuscular stimulat* [Tiab] OR “electric

muscle stimulation” [tiab] OR “functional electrical stimulation” [tiab] OR “neuromuscular electrical stimulation” [tiab] OR “transcutaneous electrical

nerve stimulation” [tiab] OR “laser” [tiab] OR “iontophoresis” [tiab] OR “cryo-cu” [tiab] OR “therapeutic modalities” [tiab] OR “physical agents” [tiab]

OR “physical modalities” [tiab] OR “physical interventions” [tiab] OR Physical therap* [tiab] OR Physiotherap* [tiab] OR “passive modalities” [tiab]

OR muscleso* [Tiab] OR “Nerve Mobilization” [tiab] OR “osteopathic manipulative treatment” [tiab] OR “orthotherapy” [Tiab] OR orthoti* [Tiab] OR

“proprioceptive neuromuscular facilitation” [tiab] OR “stretching” [tiab] OR “Resistance Training” [tiab] OR “Soft-Tissue Therapy” [tiab] OR “Spray and

stretch” [tiab] OR strength* [Tiab] OR stretch* [Tiab] OR “ tape” [tiab] OR “taping” [tiab] OR trigger point* [Tiab] OR “Yoga” [tiab] OR “Platelet rich

plasma injection” [tiab] OR “Shock wave therapy” [tiab] OR “Antiinﬂammatory medicine” [tiab] OR “Injection” [tiab] OR “Cortisone” [tiab] OR “repair”

[tiab]) NOT (“animals”[MeSH Terms] NOT “humans”[MeSH Terms]))

4095

Ovid: Journals@Ovid

Search Term Result

1((exp thigh / OR muscle, skeletal / OR exp quadriceps muscle / OR lower extremity / OR exp hamstring tendons / OR exp hamstring muscles / OR

exp gracilis muscle /) OR (Adductor.ti,ab. OR Biceps Femoris.ti,ab. OR Gracilis.ti,ab. OR hamstring.ti,ab. OR Iliotibial Band.ti,ab. OR Ischial.ti,ab. OR

Quadriceps.ti,ab. OR Quadriceps Femoris.ti,ab. OR Rectus Femoris.ti,ab. OR Semimembranosus.ti,ab. OR Semitendinosis.ti,ab. OR Tensor fascia lata.

ti,ab. OR thigh.ti,ab. OR Vastus.ti,ab.)) AND ((myofascial pain syndromes / OR soft tissue injuries / OR tendon injuries / OR tendinopathy / OR sprains

AND exp strains / OR exp myositis ossiﬁcans / OR myofascial pain syndromes / OR leg injuries /) OR (Avulsion.ti,ab. OR Ischiofemoral impingement.

ti,ab. OR Muscle Strain.ti,ab. OR Muscle Tear.ti,ab. OR Myositis Ossiﬁcans.ti,ab. OR soft tissue injuries.ti,ab. OR injury.ti,ab. OR sprains and strains.ti,ab.

OR sprain*.ti,ab. OR strains.ti,ab.)) AND ((Acupuncture Therapy / OR exp Chiropractic / OR exp Combined Modality Therapy / OR exp Cryotherapy / OR

exp Diathermy / OR exp Iontophoresis / OR exp Muscle Contraction / OR exp Orthotic Devices / OR Patient Education as Topic / OR exp Physical Thera-

py Modalities / OR Rehabilitation / OR exp Self Care / OR exp Telerehabilitation / OR exp Ultrasonography /) OR (Astym Treatment.ti,ab. OR Augmented

Soft-Tissue.ti,ab. OR Mobilization.ti,ab. OR Mobilisation.ti,ab. OR Brace*.ti,ab. OR Chiropract*.ti,ab. OR Compression.ti,ab. OR Contract-relax stretching.

ti,ab. OR Cross-Friction Massage.ti,ab. OR Dry needl*.ti,ab. OR Dynamic stretching.ti,ab. OR Exercise.ti,ab. OR Graston.ti,ab. OR Joint Mobilization.ti,ab.

OR Kinesio tape.ti,ab. OR Manipulation.ti,ab. OR Manual Therapy*.ti,ab. OR Massage.ti,ab. OR cryotherap*.ti,ab. OR thermotherap*.ti,ab. OR Moist Heat.

ti,ab. OR Ice.ti,ab. OR diathermy.ti,ab. OR ultrasound*.ti,ab. OR electrical*.ti,ab. OR muscle stimul*.ti,ab. OR neuromuscular stimulat*.ti,ab. OR EMS.

ti,ab. OR FES.ti,ab. OR NMES.ti,ab. OR TENS.ti,ab. OR laser.ti,ab. OR iontophoresis.ti,ab. OR cryo-cu.ti,ab. OR therapeutic modalities.ti,ab. OR physical

agents.ti,ab. OR physical modalities.ti,ab. OR physical interventions.ti,ab. OR Physical therap*.ti,ab. OR Physiotherap*.ti,ab. OR passive modalities.ti,ab.

OR muscleso*.ti,ab. OR Nerve Mobilization.ti,ab. OR OMT.ti,ab. OR orthotherapy.ti,ab. OR orthoti*.ti,ab. OR PNF.ti,ab. OR proprioceptive neuromuscu-

lar facilitation.ti,ab. OR stretching.ti,ab. OR Resistance Training.ti,ab. OR Soft-Tissue Therapy.ti,ab. OR Spray and stretch.ti,ab. OR strength*.ti,ab. OR

stretch*.ti,ab. OR tape.ti,ab. OR taping.ti,ab. OR trigger point*.ti,ab. OR Yoga.ti,ab. OR Platelet rich plasma injection.ti,ab. OR RPP.ti,ab. OR Shock wave

therapy.ti,ab. OR Antiinﬂammatory medicine.ti,ab. OR Injection.ti,ab. OR Cortisone.ti,ab. OR repair.ti,ab.))

APPENDIX A

Journal of Orthopaedic & Sports Physical Therapy®

Downloaded from www.jospt.org at Maryville University on March 1, 2022. For personal use only. No other uses without permission.

journal of orthopaedic & sports physical therapy | volume 52 | number 3 | march 2022 | cpg35

Hamstring Strain Injury in Athletes: Clinical Practice GuidelinesHamstring Strain Injury in Athletes: Clinical Practice Guidelines

CINAHL

Search Term Result

1(((MH “thigh +”) OR (MH “quadriceps muscle +”) OR (MH “lower extremity “) OR (MH “hamstring tendons +”) OR (MH “hamstring muscles +”) OR (MH

“gracilis muscle +”)) OR (TI Adductor OR AB Adductor OR TI “Biceps Femoris” OR AB “Biceps Femoris” OR TI Gracilis OR AB Gracilis OR TI hamstring

OR AB hamstring OR TI “Iliotibial Band” OR AB “Iliotibial Band” OR TI Ischial OR AB Ischial OR TI Quadriceps OR AB Quadriceps OR TI “Quadriceps

Femoris” OR AB “Quadriceps Femoris” OR TI “Rectus Femoris” OR AB “Rectus Femoris” OR TI Semimembranosus OR AB Semimembranosus OR TI

Semitendinosis OR AB Semitendinosis OR TI “Tensor fascia lata” OR AB “Tensor fascia lata” OR TI thigh OR AB thigh OR TI Vastus OR AB Vastus)) AND

(((MH “myofascial pain syndromes “) OR (MH “soft tissue injuries “) OR (MH “tendon injuries “) OR (MH “tendinopathy “) OR sprains AND (MH “strains

+”) OR (MH “myositis ossiﬁcans +”) OR (MH “myofascial pain syndromes “) OR (MH “leg injuries “)) OR (TI Avulsion OR AB Avulsion OR TI “Ischiofem-

oral impingement” OR AB “Ischiofemoral impingement” OR TI “Muscle Strain” OR AB “Muscle Strain” OR TI “Muscle Tear” OR AB “Muscle Tear” OR TI

“Myositis Ossiﬁcans” OR AB “Myositis Ossiﬁcans” OR TI “soft tissue injuries” OR AB “soft tissue injuries” OR TI injury OR AB injury OR TI “sprains and

strains” OR AB “sprains and strains” OR TI sprain* OR AB sprain* OR TI strains OR AB strains)) AND (((MH “Acupuncture Therapy “) OR (MH “Chiro-

practic +”) OR (MH “Combined Modality Therapy +”) OR (MH “Cryotherapy +”) OR (MH “Diathermy +”) OR (MH “Iontophoresis +”) OR (MH “Muscle

Contraction +”) OR (MH “Orthotic Devices +”) OR (MH “Patient Education as Topic “) OR (MH “Physical Therapy Modalities +”) OR (MH “Rehabilitation

“) OR (MH “Self Care +”) OR (MH “Telerehabilitation +”) OR (MH “Ultrasonography +”)) OR (TI “Astym Treatment” OR AB “Astym Treatment” OR TI

“Augmented Soft-Tissue” OR AB “Augmented Soft-Tissue” OR TI Mobilization OR AB Mobilization OR TI Mobilisation OR AB Mobilisation OR TI Brace*

OR AB Brace* OR TI Chiropract* OR AB Chiropract* OR TI Compression OR AB Compression OR TI “Contract-relax stretching” OR AB “Contract-relax

stretching” OR TI “Cross-Friction Massage” OR AB “Cross-Friction Massage” OR TI “Dry needl*” OR AB “Dry needl*” OR TI “Dynamic stretching” OR AB

“Dynamic stretching” OR TI Exercise OR AB Exercise OR TI Graston OR AB Graston OR TI “Joint Mobilization” OR AB “Joint Mobilization” OR TI “ Kinesio

tape” OR AB “ Kinesio tape” OR TI Manipulation OR AB Manipulation OR TI “Manual Therapy*” OR AB “Manual Therapy*” OR TI Massage OR AB

Massage OR TI cryotherap* OR AB cryotherap* OR TI thermotherap* OR AB thermotherap* OR TI “Moist Heat” OR AB “Moist Heat” OR TI Ice OR AB

Ice OR TI diathermy OR AB diathermy OR TI ultrasound* OR AB ultrasound* OR TI electrical* OR AB electrical* OR TI “muscle stimul*” OR AB “muscle

stimul*” OR TI “neuromuscular stimulat*” OR AB “neuromuscular stimulat*” OR TI “electric muscle stimulation” OR AB “electric muscle stimulation”

OR TI “functional electrical stimulation” OR AB “functional electrical stimulation” OR TI “neuromuscular electrical stimulation” OR AB “neuromuscular

stimulation” OR TI “transcutaneous electrical nerve stimulation” OR AB “transcutaneous electrical nerve stimulation” OR TI laser OR AB laser OR TI ion-

tophoresis OR AB iontophoresis OR TI cryo-cu OR AB cryo-cu OR TI “ therapeutic modalities” OR AB “therapeutic modalities” OR TI “physical agents”

OR AB “physical agents” OR TI “physical modalities” OR AB “physical modalities” OR TI “physical interventions” OR AB “physical interventions” OR TI

“Physical therap*” OR AB “Physical therap*” OR TI Physiotherap* OR AB Physiotherap* OR TI “passive modalities” OR AB “passive modalities” OR TI

muscleso* OR AB muscleso* OR TI “Nerve Mobilization” OR AB “Nerve Mobilization” OR TI “osteopathic manipulative treatment” OR AB “osteopathic

manipulative treatment” OR TI orthotherapy OR AB orthotherapy OR TI orthoti* OR AB orthoti* OR TI “proprioceptive neuromuscular facilitation” OR AB

“proprioceptive neuromuscular facilitation” OR TI stretching OR AB stretching OR TI “Resistance Training” OR AB “Resistance Training” OR TI “Soft-Tis-

sue Therapy” OR AB “Soft-Tissue Therapy” OR TI “Spray and stretch” OR AB “Spray and stretch” OR TI strength* OR AB strength* OR TI stretch* OR

AB stretch* OR TI tape OR AB tape OR TI taping OR AB taping OR TI “trigger point*” OR AB “trigger point*” OR TI Yoga OR AB Yoga OR TI “Platelet rich

plasma injection” OR AB “Platelet rich plasma injection” OR TI “Shock wave therapy” OR AB “Shock wave therapy” OR TI “Antiinﬂammatory medicine”

OR AB “Antiinﬂammatory medicine” OR TI Injection OR AB Injection OR TI Cortisone OR AB Cortisone OR TI repair OR AB repair))

385

Cochrane Library

Search Term Result

1(([mh thigh] OR [mh ^”muscle, skeletal”] OR [mh “quadriceps muscle”] OR [mh ^”lower extremity”] OR [mh “hamstring tendons”] OR [mh “hamstring

muscles”] OR [mh “gracilis muscle”] OR Adductor:ti,ab OR “Biceps Femoris”:ti,ab OR Gracilis:ti,ab OR hamstring:ti,ab OR “Iliotibial Band”:ti,ab OR

Ischial:ti,ab OR Quadriceps:ti,ab OR “Quadriceps Femoris”:ti,ab OR “Rectus Femoris”:ti,ab OR Semimembranosus:ti,ab OR Semitendinosis:ti,ab OR

“Tensor fascia lata”:ti,ab OR thigh:ti,ab OR Vastus:ti,ab)) AND (([mh ^”myofascial pain syndromes”] OR [mh ^”soft tissue injuries”] OR [mh ^”tendon

injuries”] OR [mh ^tendinopathy] OR sprains AND [mh strains] OR [mh “myositis ossiﬁcans”] OR [mh ^”myofascial pain syndromes”] OR [mh ^”leg

injuries”]) OR (Avulsion:ti,ab OR “Ischiofemoral impingement”:ti,ab OR “Muscle Strain”:ti,ab OR “Muscle Tear”:ti,ab OR “Myositis Ossiﬁcans”:ti,ab OR

“soft tissue injuries”:ti,ab OR injury:ti,ab OR “sprains and strains”:ti,ab OR sprain*:ti,ab OR strains:ti,ab)) AND (([mh ^”Acupuncture Therapy”] OR [mh

Chiropractic] OR [mh “Combined Modality Therapy”] OR [mh Cryotherapy] OR [mh Diathermy] OR [mh Iontophoresis] OR [mh “Muscle Contraction”]

OR [mh “Orthotic Devices”] OR [mh ^”Patient Education as Topic”] OR [mh “Physical Therapy Modalities”] OR [mh ^Rehabilitation] OR [mh “Self

Care”] OR [mh Telerehabilitation] OR [mh Ultrasonography]) OR (“Astym Treatment”:ti,ab OR “Augmented Soft-Tissue”:ti,ab OR Mobilization:ti,ab OR

Mobilisation:ti,ab OR Brace*:ti,ab OR Chiropract*:ti,ab OR Compression:ti,ab OR “Contract-relax stretching”:ti,ab OR “Cross-Friction Massage”:ti,ab

OR “Dry needl*”:ti,ab OR “Dynamic stretching”:ti,ab OR Exercise:ti,ab OR Graston:ti,ab OR “Joint Mobilization”:ti,ab OR “ Kinesio tape”:ti,ab OR

Manipulation:ti,ab OR “Manual Therapy*”:ti,ab OR Massage:ti,ab OR cryotherap*:ti,ab OR thermotherap*:ti,ab OR “Moist Heat”:ti,ab OR Ice:ti,ab OR

diathermy:ti,ab OR ultrasound*:ti,ab OR electrical*:ti,ab OR “muscle stimul*”:ti,ab OR “neuromuscular stimulat*”:ti,ab OR “electric muscle stimula-

tion”:ti,ab OR “functional electric stimulation”:ti,ab OR “neuromuscular electric stimulation”:ti,ab OR “ transcutaneous electrical nerve stimulation”:ti,ab

OR laser:ti,ab OR iontophoresis:ti,ab OR cryo-cu:ti,ab OR “therapeutic modalities”:ti,ab OR “physical agents”:ti,ab OR “physical modalities”:ti,ab OR

“physical interventions”:ti,ab OR “Physical therap*”:ti,ab OR Physiotherap*:ti,ab OR “passive modalities”:ti,ab OR muscleso*:ti,ab OR “Nerve Mobiliza-

tion”:ti,ab OR “osteopathic manipulative treatment”:ti,ab OR orthotherapy:ti,ab OR orthoti*:ti,ab OR “proprioceptive neuromuscular facilitation”:ti,ab

OR stretching:ti,ab OR “Resistance Training”:ti,ab OR “Soft-Tissue Therapy”:ti,ab OR “Spray and stretch”:ti,ab OR strength*:ti,ab OR stretch*:ti,ab OR

tape:ti,ab OR taping:ti,ab OR “trigger point*”:ti,ab OR Yoga:ti,ab OR “Platelet rich plasma injection”:ti,ab OR “Shock wave therapy”:ti,ab OR “Antiinﬂam-

matory medicine”:ti,ab OR Injection:ti,ab OR Cortisone:ti,ab OR repair:ti,ab))

658

APPENDIX A

Journal of Orthopaedic & Sports Physical Therapy®

Downloaded from www.jospt.org at Maryville University on March 1, 2022. For personal use only. No other uses without permission.

cpg36 | march 2022 | volume 52 | number 3 | journal of orthopaedic & sports physical therapy

Hamstring Strain Injury in Athletes: Clinical Practice GuidelinesHamstring Strain Injury in Athletes: Clinical Practice Guidelines

SPORTDiscus

Search Term Result

1(((MH “thigh +”) OR (MH “muscle, skeletal “) OR (MH “quadriceps muscle +”) OR (MH “lower extremity “) OR (MH “hamstring tendons +”) OR (MH

“hamstring muscles +”) OR (MH “gracilis muscle +”)) OR (TI Adductor OR AB Adductor OR TI “Biceps Femoris” OR AB “Biceps Femoris” OR TI Gracilis

OR AB Gracilis OR TI hamstring OR AB hamstring OR TI “Iliotibial Band” OR AB “Iliotibial Band” OR TI Ischial OR AB Ischial OR TI Quadriceps OR AB

Quadriceps OR TI “Quadriceps Femoris” OR AB “Quadriceps Femoris” OR TI “Rectus Femoris” OR AB “Rectus Femoris” OR TI Semimembranosus OR

AB Semimembranosus OR TI Semitendinosis OR AB Semitendinosis OR TI “Tensor fascia lata” OR AB “Tensor fascia lata” OR TI thigh OR AB thigh OR

TI Vastus OR AB Vastus)) AND (((MH “myofascial pain syndromes “) OR (MH “soft tissue injuries “) OR (MH “tendon injuries “) OR (MH “tendinopathy “)

OR sprains AND (MH “strains +”) OR (MH “myositis ossiﬁcans +”) OR (MH “myofascial pain syndromes “) OR (MH “leg injuries “)) OR (TI Avulsion OR

AB Avulsion OR TI “Ischiofemoral impingement” OR AB “Ischiofemoral impingement” OR TI “Muscle Strain” OR AB “Muscle Strain” OR TI “Muscle Tear”

OR AB “Muscle Tear” OR TI “Myositis Ossiﬁcans” OR AB “Myositis Ossiﬁcans” OR TI “soft tissue injuries” OR AB “soft tissue injuries” OR TI injury OR

AB injury OR TI “sprains and strains” OR AB “sprains and strains” OR TI sprain* OR AB sprain* OR TI strains OR AB strains)) AND (((MH “Acupuncture

Therapy “) OR (MH “Chiropractic +”) OR (MH “Combined Modality Therapy +”) OR (MH “Cryotherapy +”) OR (MH “Diathermy +”) OR (MH “Iontopho-

resis +”) OR (MH “Muscle Contraction +”) OR (MH “Orthotic Devices +”) OR (MH “Patient Education as Topic “) OR (MH “Physical Therapy Modalities

+”) OR (MH “Rehabilitation “) OR (MH “Self Care +”) OR (MH “Telerehabilitation +”) OR (MH “Ultrasonography +”)) OR (TI “Astym Treatment” OR AB

“Astym Treatment” OR TI “Augmented Soft-Tissue” OR AB “Augmented Soft-Tissue” OR TI Mobilization OR AB Mobilization OR TI Mobilisation OR AB

Mobilisation OR TI Brace* OR AB Brace* OR TI Chiropract* OR AB Chiropract* OR TI Compression OR AB Compression OR TI “Contract-relax stretch-

ing” OR AB “Contract-relax stretching” OR TI “Cross-Friction Massage” OR AB “Cross-Friction Massage” OR TI “Dry needl*” OR AB “Dry needl*” OR TI

“Dynamic stretching” OR AB “Dynamic stretching” OR TI Exercise OR AB Exercise OR TI Graston OR AB Graston OR TI “Joint Mobilization” OR AB “Joint

Mobilization” OR TI “ Kinesio tape” OR AB “ Kinesio tape” OR TI Manipulation OR AB Manipulation OR TI “Manual Therapy*” OR AB “Manual Therapy*”

OR TI Massage OR AB Massage OR TI cryotherap* OR AB cryotherap* OR TI thermotherap* OR AB thermotherap* OR TI “Moist Heat” OR AB “Moist

Heat” OR TI Ice OR AB Ice OR TI diathermy OR AB diathermy OR TI ultrasound* OR AB ultrasound* OR TI electrical* OR AB electrical* OR TI “muscle

stimul*” OR AB “muscle stimul*” OR TI “neuromuscular stimulat*” OR AB “neuromuscular stimulat*” OR TI “electric muscle stimulation” OR AB “elec-

tric muscle stimulation” OR TI “functional electrical stimulation” OR AB “functional electrical stimulation” OR TI “neuromuscular electrical stimulation”

OR AB “neuromuscular electrical stimulation” OR TI “transcutaneous electrical nerve stimulation” OR AB “transcutaneous electrical nerve stimulation”

OR TI laser OR AB laser OR TI iontophoresis OR AB iontophoresis OR TI cryo-cu OR AB cryo-cu OR TI “ therapeutic modalities” OR AB “therapeutic

modalities” OR TI “physical agents” OR AB “physical agents” OR TI “physical modalities” OR AB “physical modalities” OR TI “physical interventions” OR

AB “physical interventions” OR TI “Physical therap*” OR AB “Physical therap*” OR TI Physiotherap* OR AB Physiotherap* OR TI “passive modalities”

OR AB “passive modalities” OR TI muscleso* OR AB muscleso* OR TI “Nerve Mobilization” OR AB “Nerve Mobilization” OR TI “osteopathic manipulative

treatment” OR AB “osteopathic manipulative treatment” OR TI orthotherapy OR AB orthotherapy OR TI or thoti* OR AB orthoti* OR TI “proprioceptive

neuromuscular facilitation” OR AB “proprioceptive neuromuscular facilitation” OR TI stretching OR AB stretching OR TI “Resistance Training” OR AB

“Resistance Training” OR TI “Soft-Tissue Therapy” OR AB “Soft-Tissue Therapy” OR TI “Spray and stretch” OR AB “Spray and stretch” OR TI strength* OR

AB strength* OR TI stretch* OR AB stretch* OR TI tape OR AB tape OR TI taping OR AB taping OR TI “trigger point*” OR AB “trigger point*” OR TI Yoga

OR AB Yoga OR TI “Platelet rich plasma injection” OR AB “Platelet rich plasma injection” OR TI “Shock wave therapy” OR AB “Shock wave therapy” OR

TI “Antiinﬂammatory medicine” OR AB “Antiinﬂammatory medicine” OR TI Injection OR AB Injection OR TI Cortisone OR AB Cortisone OR TI repair OR

AB repair))

741

2021 Search Update

PubMed

Search Term Result

1(“Hamstring Tendons”[Mesh] OR “Biceps Femoris”[tw] OR hamstring[tw] OR hamstrings[tw] OR Semimembranosus[tw] OR Semitendinosus[tw] OR

thigh[tw])

48828

2(“Myofascial pain syndromes” [mh:noexp] OR “soft tissue injuries” [mh:noexp] OR strains[mh] OR “myositis ossiﬁcans”[mh] OR “leg injuries”[mh:noexp]

OR Pain[mesh:noexp] OR “Acute Pain” [mesh] OR “Chronic Pain” [mesh] OR “Musculoskeletal Pain”[mesh:noexp] OR Pain[tiab] OR Painful[tw] OR

Ache[tw] OR Injury[tw] OR Injuries[tw])

1918733

31 AND 2 15225

4(“Hamstring strain”[mesh] OR Hamstring strain[tw] OR Hamstring tear[tw] OR Torn Hamstring[tw] OR Hamstring injury[tw] OR Hamstring injuries[tw] OR

Hamstring pain[tw] OR Hamstring ache[tw] OR Hamstring Myositis Ossiﬁcans[tw])

846

53 OR 4 15244

Table continues on page CPG37.

APPENDIX A

Journal of Orthopaedic & Sports Physical Therapy®

Downloaded from www.jospt.org at Maryville University on March 1, 2022. For personal use only. No other uses without permission.

journal of orthopaedic & sports physical therapy | volume 52 | number 3 | march 2022 | cpg37

Hamstring Strain Injury in Athletes: Clinical Practice GuidelinesHamstring Strain Injury in Athletes: Clinical Practice Guidelines

Search Term Result

6(“Combined Modality Therapy”[Mesh:NoExp] OR Cryotherapy[mh] OR Diathermy[mh] OR Iontophoresis[mh] OR “Orthotic Devices”[mh] OR “Physical

Therapy Modalities”[mh] OR Rehabilitation[mh:noexp]) OR (“Astym Treatment”[tiab] OR “Augmented Soft-Tissue”[tiab] OR “Mobilization”[tiab] OR

“Mobilisation”[tiab] OR Brace[tiab] OR Braces[tiab] OR “Compression”[tiab] OR “Contract-relax stretching”[tiab] OR “Cross-Friction Massage”[tiab] OR

“Dry needle”[tiab] OR “Dry needles”[tiab] OR “Dry needling”[tiab] OR “Dynamic stretching”[tiab] OR “Exercise”[tiab] OR “Graston”[tiab] OR “Joint Mo-

bilization”[tiab] OR “Manipulation”[tiab] OR “Manual Therapy*”[tiab] OR “Massage”[tiab] OR cryotherapy[tiab] OR cryotherapies[tiab] OR thermother-

apeutic[tiab] OR thermotherapy[tiab] OR thermotherapies[tiab] OR “Moist Heat”[tiab] OR “Ice”[tiab] OR “diathermy”[tiab] OR “muscle stimulation”[-

tiab] OR “neuromuscular stimulation”[tiab] OR “electric muscle stimulation”[tiab] OR “neuromuscular electrical stimulation”[tiab] OR “transcutaneous

electrical nerve stimulation”[tiab] OR “laser therapy”[tiab] OR “laser therapies”[tiab] OR “iontophoresis”[tiab] OR “cryo-cu”[tiab] OR “therapeutic

modalities”[tiab] OR “physical agents”[tiab] OR “physical modalities”[tiab] OR “physical interventions”[tiab] OR “Physical therapeutic*”[tiab] OR

“Physical therapy”[tiab] OR “Physical therapies”[tiab] OR Physiotherapy[tiab] OR Physiotherapies[tiab] OR Physiotherapeutic[tiab] OR “passive modali-

ties”[tiab] OR “Nerve Mobilization”[tiab] OR “osteopathic manipulative treatment”[tiab] OR “orthotherapy”[tiab] OR orthotic*[tiab] OR “proprioceptive

neuromuscular facilitation”[tiab] OR “stretching”[tiab] OR “Resistance Training”[tiab] OR “Strength Training”[tiab] OR “Soft-Tissue Therapy”[tiab] OR

“Spray and stretch”[tiab] OR “strengthen”[tiab] OR “strengthens”[tiab] OR “strengthening”[tiab] OR stretch[tiab] OR stretches[tiab] OR stretching[tiab]

OR “kinesiology tape”[tiab] OR “kinesiology taping”[tiab] OR “kinesio tape”[tiab] OR “kinesio taping”[tiab] OR “therapeutic tape”[tiab] OR “therapeutic

taping”[tiab] OR “trigger point*”[tiab] OR “Yoga”[tiab])

1142488

75 AND 6 AND English[language] NOT (“animals”[MeSH Terms] NOT “humans”[MeSH Terms]) 2801

CINAHL

Search Term Result

1(“Biceps Femoris” OR hamstring OR hamstrings OR Semimembranosus OR Semitendinosus OR thigh) 14889

2(MH “Myofascial pain syndromes”) OR (MH “soft tissue injuries”) OR (MH “Sprains and Strains”) OR (MH “Myositis Ossiﬁcans”) OR (MH “Leg Injuries”) OR

(MH “Pain”) OR (MH “Chronic Pain”) OR Pain OR Painful OR Ache OR Injury OR Injuries

632844

31 AND 2 6942

4“Hamstring strain” OR “Hamstring tear” OR “Hamstring injury” OR “Hamstring injuries” OR “Hamstring pain” OR “Hamstring ache” OR “Hamstring

Myositis Ossiﬁcans”

634

53 OR 4 6947

6(MH “Combined Modality Therapy +”) OR (MH “Cryotherapy +”) OR (MH “Diathermy +”) OR (MH “Iontophoresis +”) OR (MH “Muscle Contraction +”) OR

(MH “Orthotic Devices +”) OR (MH “Physical Therapy Modalities +”) OR (MH “Rehabilitation “) OR ((TI “Astym Treatment” OR AB “Astym Treatment”)

OR (TI “Augmented Soft-Tissue” OR AB “Augmented Soft-Tissue”) OR (TI Mobilization OR AB Mobilization) OR (TI Mobilisation OR AB Mobilisation) OR

(TI Brace OR AB Brace) OR (TI Braces OR AB Braces) OR (TI Compression OR AB Compression) OR (TI “Contract-relax stretching” OR AB “Contract-re-

lax stretching”) OR (TI “Cross-Friction Massage” OR AB “Cross-Friction Massage”) OR (TI “Dry needle” OR AB “Dry needle”) OR (TI “Dry needles”

OR AB “Dry needles”) OR (TI “Dry needling” OR AB “Dry needling”) OR (TI “Dynamic stretching” OR AB “Dynamic stretching”) OR (TI Exercise OR

AB Exercise) OR (TI Graston OR AB Graston) OR (TI “Joint Mobilization” OR AB “Joint Mobilization”) OR (TI Manipulation OR AB Manipulation) OR (TI

“Manual Therapy*” OR AB “Manual Therapy*”) OR (TI Massage OR AB Massage) OR (TI cryotherapy OR AB cryotherapy) OR (TI cryotherapies OR

AB cryotherapies) OR (TI thermotherapeutic OR AB thermotherapeutic) OR (TI thermotherapy OR AB thermotherapy) OR (TI thermotherapies OR AB

thermotherapies) OR (TI “Moist Heat” OR AB “Moist Heat”) OR (TI Ice OR AB Ice) OR (TI diathermy OR AB diathermy) OR (TI “muscle stimulation” OR

AB “muscle stimulation”) OR (TI “neuromuscular stimulation” OR AB “neuromuscular stimulation”) OR (TI “electric muscle stimulation” OR AB “electric

muscle stimulation”) OR (TI “neuromuscular electrical stimulation” OR AB “neuromuscular electrical stimulation”) OR (TI “transcutaneous electrical

nerve stimulation” OR AB “transcutaneous electrical nerve stimulation”) OR (TI “laser therapy” OR AB “laser therapy”) OR (TI “laser therapies” OR AB

“laser therapies”) OR (TI iontophoresis OR AB iontophoresis) OR (TI cryo-cu OR AB cryo-cu) OR (TI “therapeutic modalities” OR AB “therapeutic mo-

dalities”) OR (TI “physical agents” OR AB “physical agents”) OR (TI “physical modalities” OR AB “physical modalities”) OR (TI “physical interventions”

OR AB “physical interventions”) OR (TI “Physical therapeutic*” OR AB “Physical therapeutic*”) OR (TI “Physical therapy” OR AB “Physical therapy”) OR

(TI “Physical therapies” OR AB “Physical therapies”) OR (TI Physiotherapy OR AB Physiotherapy) OR (TI Physiotherapies OR AB Physiotherapies) OR

(TI Physiotherapeutic OR AB Physiotherapeutic) OR (TI “passive modalities” OR AB “passive modalities”) OR (TI “Nerve Mobilization” OR AB “Nerve

Mobilization”) OR (TI “osteopathic manipulative treatment” OR AB “osteopathic manipulative treatment”) OR (TI orthotherapy OR AB or thotherapy) OR

(TI orthotic* OR AB orthotic*) OR (TI “proprioceptive neuromuscular facilitation” OR AB “proprioceptive neuromuscular facilitation”) OR (TI stretching

OR AB stretching) OR (TI “Resistance Training” OR AB “Resistance Training”) OR (TI “Strength Training” OR AB “Strength Training”) OR (TI “Soft-Tissue

Therapy” OR AB “Soft-Tissue Therapy”) OR (TI “Spray and stretch” OR AB “Spray and stretch”) OR (TI strengthen OR AB strengthen) OR (TI strengthens

OR AB strengthens) OR (TI strengthening OR AB strengthening) OR (TI stretch OR AB stretch) OR (TI stretches OR AB stretches) OR (TI stretching OR

AB stretching) OR (TI “kinesiology tape” OR AB “kinesiology tape”) OR (TI “kinesiology taping” OR AB “kinesiology taping”) OR (TI “kinesio tape” OR AB

“kinesio tape”) OR (TI “kinesio taping” OR AB “kinesio taping”) OR (TI “therapeutic tape” OR AB “therapeutic tape”) OR (TI “therapeutic taping” OR AB

“therapeutic taping”) OR (TI “trigger point*” OR AB “trigger point*”) OR (TI Yoga OR AB Yoga))

282834

75 AND 6 AND Language: English 1676

APPENDIX A

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Hamstring Strain Injury in Athletes: Clinical Practice GuidelinesHamstring Strain Injury in Athletes: Clinical Practice Guidelines

Cochrane Library

Search Term Result

1“Hamstring Tendons” OR “Biceps Femoris” OR hamstring OR hamstrings OR Semimembranosus OR Semitendinosus OR thigh 7072

2“Myofascial pain syndromes” OR “soft tissue injuries” OR strains OR “myositis ossiﬁcans” OR “leg injuries” OR “Acute Pain” OR “Chronic Pain” OR “Muscu-

loskeletal Pain” OR Pain OR Painful OR Ache OR Injury OR Injuries

257943

31 AND 2 3275

4“Hamstring strain” OR “Hamstring tear” OR “Hamstring injury” OR “Hamstring injuries” OR “Hamstring pain” OR “Hamstring ache” OR “Hamstring

Myositis Ossiﬁcans”

151

53 OR 4 3278

6([mh ^”Combined Modality Therapy”] OR [mh Cryotherapy] OR [mh Diathermy] OR [mh Iontophoresis] OR [mh “Orthotic Devices”] OR [mh “Physical

Therapy Modalities”] OR [mh ^Rehabilitation]) OR (“Astym Treatment”:ti,ab OR “Augmented Soft-Tissue”:ti,ab OR Mobilization:ti,ab OR Mobilisation:ti,ab

OR Brace:ti,ab OR Braces:ti,ab OR Compression:ti,ab OR “Contract-relax stretching”:ti,ab OR “Cross-Friction Massage”:ti,ab OR “Dry needle”:ti,ab OR

“Dry needles”:ti,ab OR “Dry needling”:ti,ab OR “Dynamic stretching”:ti,ab OR Exercise:ti,ab OR Graston:ti,ab OR “Joint Mobilization”:ti,ab OR Manipula-

tion:ti,ab OR “Manual Therapy”:ti,ab OR Massage:ti,ab OR cryotherapy:ti,ab OR cryotherapies:ti,ab OR thermotherapeutic:ti,ab OR thermotherapy:ti,ab

OR thermotherapies:ti,ab OR “Moist Heat”:ti,ab OR Ice:ti,ab OR diathermy:ti,ab OR “muscle stimulation”:ti,ab OR “neuromuscular stimulation”:ti,ab

OR “electric muscle stimulation”:ti,ab OR “neuromuscular electrical stimulation”:ti,ab OR “transcutaneous electrical nerve stimulation”:ti,ab OR “laser

therapy”:ti,ab OR “laser therapies”:ti,ab OR iontophoresis:ti,ab OR cryo-cu:ti,ab OR “therapeutic modalities”:ti,ab OR “physical agents”:ti,ab OR

“physical modalities”:ti,ab OR “physical interventions”:ti,ab OR “Physical therapeutic”:ti,ab OR “Physical therapy”:ti,ab OR “Physical therapies”:ti,ab OR

Physiotherapy:ti,ab OR Physiotherapies:ti,ab OR Physiotherapeutic:ti,ab OR “passive modalities”:ti,ab OR “Nerve Mobilization”:ti,ab OR “osteopathic

manipulative treatment”:ti,ab OR orthotherapy:ti,ab OR orthotic*:ti,ab OR “proprioceptive neuromuscular facilitation”:ti,ab OR stretching:ti,ab OR “Re-

sistance Training”:ti,ab OR “Strength Training”:ti,ab OR “Soft-Tissue Therapy”:ti,ab OR “Spray and stretch”:ti,ab OR strengthen:ti,ab OR strengthens:ti,ab

OR strengthening:ti,ab OR stretch:ti,ab OR stretches:ti,ab OR stretching:ti,ab OR “kinesiology tape”:ti,ab OR “kinesiology taping”:ti,ab OR “kinesio

tape”:ti,ab OR “kinesio taping”:ti,ab OR “therapeutic tape”:ti,ab OR “therapeutic taping”:ti,ab OR “trigger point”:ti,ab OR Yoga:ti,ab)

170452

75 AND 6 1540

APPENDIX A

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Hamstring Strain Injury in Athletes: Clinical Practice GuidelinesHamstring Strain Injury in Athletes: Clinical Practice Guidelines

ARTICLE INCLUSION AND EXCLUSION CRITERIA

Return to Play

Inclusion Exclusion

• Strain injury of 1 or more of the hamstring muscles

• 10 or more participants

• Primarily adult and adolescent (12 years old or older) participants

• Studies reporting on persons younger than 12 years old if the proportion in the

sample is small (less than 5%) or if separate data are available for adults

• Includes the outcome of return to play, deﬁned by any of the following terms:

return/resume: play, sport, recreation, activity, competition

• Studies that follow participants from onset of injury to return to play

• Studies not published in English

• Fewer than 10 participants

• Primarily infant and child (younger than 12 years old) participants

• Surgical management of hamstring strain injury

• Any condition other than hamstring muscle strain injury, such as

- Adductor or quadriceps strain

- Contusions

- Tendinosis and tendinopathy, including of the hamstring muscles

- Fractures (including stress fracture and avulsion)

- Postoperative thigh pain from hip/knee surgery

- Compar tment syndrome

- Nonmusculoskeletal thigh pain

- Primary peripheral nerve entrapment

- Peripheral vascular disease

- Tumors

Reinjury Risk

Inclusion Exclusion

• Strain injury of 1 or more of the hamstring muscles

• 10 or more participants

• Primarily adult and adolescent (12 years old or older) participants

• Studies reporting on persons younger than 12 years old if the proportion in the

sample is small (less than 5%) or if separate data are available for adults

• Longitudinal studies that follow participants from onset of injury to reinjury

• Studies not published in English

• Fewer than 10 participants

• Primarily infant and child (younger than 12 years old) participants

• Surgical management of hamstring strain injury

• Any condition other than hamstring muscle strain injury, such as

- Adductor or quadriceps strain

- Contusions

- Tendinosis and tendinopathy, including of the hamstring muscles

- Fractures (including stress fracture and avulsion)

- Postoperative thigh pain from hip/knee surgery

- Compar tment syndrome

- Nonmusculoskeletal thigh pain

- Primary peripheral nerve entrapment

- Peripheral vascular disease

- Tumors

Evaluation

Inclusion Exclusion

• Individuals with a hamstring strain injury of 1 or more of the hamstring muscles

• Studies that assess hamstring strain, including diagnosis (likelihood ratios,

sensitivity and speciﬁcity, positive and negative predictive values, all pertinent

evaluations, and patient-reported outcome measures in those with a hamstring

strain)

• Outcome must include injury risk or occurrence

• 10 or more participants

• Primarily adult and adolescent (12 years old or older) participants

• Studies reporting on persons younger than 12 years old if the proportion in the

sample is small (less than 5%) or if separate data are available for adults

• Diagnostic imaging (ultrasound, MRI, etc) for hamstring muscle strains

• Interventions within the scope of physical therapy practice

• Outcome that does not include injury risk or occurrence

• Fewer than 10 participants

• Primarily infant and child (younger than 12 years old) participants

• Diagnostic imaging (ultrasound, MRI, etc) for hamstring muscle tendon injuries

• Studies that include surgical management of hamstring strain injury

• Adductor or quadriceps strain, contusions

• Tendinosis and tendinopathy, including of the hamstring muscles

• Fractures (including stress fractures)

• Postoperative thigh pain from hip/knee surgery

• Compartment syndrome, nonmusculoskeletal thigh pain

• Primary peripheral nerve entrapment, peripheral vascular disease, tumors

Abbreviation: MRI, magnetic resonance imaging.

APPENDIX AAPPENDIX B

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Intervention

Inclusion Exclusion

Prevention

• Healthy individuals; a history of hamstring strain injury is acceptable

• Interventions within the scope of physical therapy practice

• Outcome must include injury risk or occurrence (longitudinal prospective)

• 10 or more participants

• Primarily adult and adolescent (12 years old or older) participants

• Studies reporting on persons younger than 12 years old if the proportion in the

sample is small (less than 5%) or if separate data are available for adults

Rehabilitation

• Strain injury of 1 or more of the hamstring muscles

• Interventions within the scope of physical therapy practice

• 10 or more participants

• Primarily adult and adolescent (12 years old or older) participants

• Studies reporting on persons younger than 12 years old if the proportion in the

sample is small (less than 5%) or if separate data are available for adults

Prevention

• Interventions not speciﬁcally targeting hamstring strain injury prevention

• Interventions outside the scope of physical therapy practice

• Outcome that does not include injury risk or occurrence

• Fewer than 10 participants

• Primarily infant and child (younger than 12 years old) participants

Interventions

• Interventions outside the scope of physical therapy practice

• Fewer than 10 participants

• Primarily infant and child (younger than 12 years old) participants

• Surgical management of hamstring strain injury

• Any condition other than hamstring muscle strain injury, such as

- Adductor or quadriceps strain

- Contusions

- Tendinosis and tendinopathy, including of the hamstring muscles

- Fractures (including stress fractures)

- Postoperative thigh pain from hip/knee surgery

- Compar tment syndrome

- Nonmusculoskeletal thigh pain

- Primary peripheral nerve entrapment

- Peripheral vascular disease

- Tumors

APPENDIX B

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Hamstring Strain Injury in Athletes: Clinical Practice GuidelinesHamstring Strain Injury in Athletes: Clinical Practice Guidelines

FLOW CHARTS OF ARTICLES

Evaluation

Total search results, n = 4772

Title and abstract review, n = 3572

Full-text review, n = 110

Categorized by topic, n = 44

Clinical course, n = 12 Diagnosis, n = 6 Outcome, n = 3 Examination, n = 23

Duplicates removed, n = 1200

Excluded, n = 3462

Full texts excluded, n = 66

• Wrong methodology, n = 25

• Outside scope, n = 29

• Wrong population, n = 12

Return to Play and Reinjury Risk

Total search results, n = 1156

Title and abstract review, n =

1156

Full-text review, n = 96

Included, n = 11

No duplicates removed

Excluded, n = 1060

Full texts excluded, n = 85

• Wrong design, n = 36

• Wrong outcome, n = 13

• Clinical commentary, n = 14

• In systematic reviews, n = 12

• Published abstract, n = 7

• Wrong patient population, n = 3

Duplicates removed, n = 1

Excluded, n = 900

Full texts excluded, n = 90

• Wrong design, n = 39

• In systematic reviews, n = 23

• Clinical commentary, n = 9

• Wrong patient population, n = 8

• Wrong outcome, n = 6

• Published abstract, n = 3

• Duplicate, n = 1

• Not in English, n = 1

Total search results, n = 1002

Title and abstract review, n =

1001

Full-text review, n = 101

Included, n = 11

Return to Play Reinjury Risk

Included, n = 22

Duplicates removed, n = 3

Included, n = 19

APPENDIX AAPPENDIX C

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Injury Prevention and Intervention

Total search results, n = 10880

Title and abstract review, n = 9059

Full-text review, n = 704

Included, n = 24

Duplicates removed, n = 1821

Excluded, n = 8355

Full texts excluded, n = 680

• Wrong patient population, n = 198

• Wrong outcome, n = 195

• Methodology, n = 139

• Editorial, n = 80

• In systematic reviews, n = 30

• Interventions outside scope of

physical therapy practice, n = 21

• Abstract only, n = 8

• Duplicate, n = 7

• Article retracted, n = 2

APPENDIX C

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LEVEL-OF-EVIDENCE TABLEa

Level Intervention/Prevention

Pathoanatomic/Risk/Clinical

Course/Prognosis/Dierential

Diagnosis Diagnosis/Diagnostic Accuracy

Prevalence of Condition/

Disorder Exam/Outcomes

ISystematic review of high-qual-

ity RCTs

High-quality RCTb

Systematic review of prospec-

tive cohort studies

High-quality prospective cohort

studyc

Systematic review of high-quali-

ty diagnostic studies

High-quality diagnostic studyd

with validation

Systematic review, high-quality

cross-sectional studies

High-quality cross-sectional

studye

Systematic review of prospec-

tive cohort studies

High-quality prospective cohort

study

II Systematic review of high-quali-

ty cohort studies

High-quality cohort studyc

Outcomes study or ecological

study

Lower-quality RCTf

Systematic review of retrospec-

tive cohort study

Lower-quality prospective

cohort study

High-quality retrospective

cohort study

Consecutive cohort

Outcomes study or ecological

study

Systematic review of explor-

atory diagnostic studies or

consecutive cohort studies

High-quality exploratory

diagnostic studies

Consecutive retrospective

cohort

Systematic review of studies

that allows relevant estimate

Lower-quality cross-sectional

study

Systematic review of low-

er-quality prospective cohort

studies

Lower-quality prospective

cohort study

III Systematic reviews of case-con-

trol studies

High-quality case-control study

Lower-quality cohort study

Lower-quality retrospective

cohort study

High-quality cross-sectional

study

Case-control study

Lower-quality exploratory

diagnostic studies

Nonconsecutive retrospective

cohort

Local nonrandom study High-quality cross-sectional

study

IV Case series Case series Case-control study Lower-quality cross-sectional

study

VExpert opinion Expert opinion Expert opinion Exper t opinion Expert opinion

Abbreviation: RCT, randomized clinical trial.

aAdapted from Phillips B, Ball C, Sackett D, et al. Oxford Centre for Evidence-Based Medicine: levels of evidence (March 2009). Available at: https://www.cebm.

ox.ac.uk/resources/levels-of-evidence/oxford-centre-for-evidence-based-medicine-levels-of-evidence-march-2009. Accessed January 26, 2021. See also APPENDIX E.

bHigh quality includes RCTs with greater than 80% follow-up, blinding, and appropriate randomization procedures.

cHigh-quality cohort study includes greater than 80% follow-up.

dHigh-quality diagnostic study includes consistently applied reference standard and blinding.

eHigh-quality prevalence study is a cross-sectional study that uses a local and current random sample or censuses.

fWeaker diagnostic criteria and reference standards, improper randomization, no blinding, and less than 80% follow-up may add bias and threats to validity.

APPENDIX D

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PROCEDURES FOR ASSIGNING LEVELS OF EVIDENCE

• Level of evidence is assigned based on the study design, using

the levels-of-evidence table (APPENDIX D), assuming high

quality (eg, for intervention, randomized clinical trial starts at

level I)

• Study quality is assessed using the critical appraisal tool, and

the study is assigned 1 of 4 overall quality ratings, based on the

critical appraisal results

• Level of evidence assignment is adjusted based on the overall

quality rating

- High quality (high conﬁdence in the estimate/results): the

study remains at its assigned level of evidence (eg, if the

randomized clinical trial is rated high quality, then its ﬁnal

assignment is level I). High quality should include

• Randomized clinical trial with greater than 80% follow-up,

blinding, and appropriate randomization procedures

• Cohort study includes greater than 80% follow-up

• Diagnostic study includes a consistently applied reference

standard and blinding

• Prevalence study is a cross-sectional study that uses a

local and current random sample or censuses

- Acceptable quality (the study does not meet requirements for

high quality and weaknesses limit the conﬁdence in the accu-

racy of the estimate): downgrade 1 level

• Based on critical appraisal results

- Low quality: the study has signiﬁcant limitations that sub-

stantially limit conﬁdence in the estimate: downgrade 2 levels

• Based on critical appraisal results

- Unacceptable quality: serious limitations—exclude from con-

sideration in the guideline

• Based on critical appraisal results

APPENDIX E

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This article has been cited by:

1. 2022. Hamstring Strain Injury in Athletes: A Summary of Clinical Practice Guideline Recommendations. Journal of

Orthopaedic & Sports Physical Therapy 52:3, 127-128. [Abstract] [Full Text] [PDF] [PDF Plus]

Journal of Orthopaedic & Sports Physical Therapy®

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Hamstrings are stretched more and faster during accelerative running compared to speed-matched constant speed running

Preprint

Full-text available

Mar 2024

Background: Hamstring strain injuries are associated with significant time away from sport and high reinjury rates. Recent evidence suggests that hamstring injuries often occur during accelerative running, but investigations of hamstring mechanics have primarily examined constant speed running on a treadmill. To help fill this gap in knowledge, this study compares hamstring lengths and lengthening velocities between accelerative running and constant speed overground running. Methods: We recorded 2 synchronized videos of 10 participants (5 female, 5 male) during 6 accelerative running trials and 6 constant speed running trials. We used OpenCap (a markerless motion capture system) to estimate body segment kinematics for each trial and a 3-dimensional musculoskeletal model to compute peak length and step-average lengthening velocity of the biceps femoris (long head) muscle-tendon unit. To compare running conditions, we used linear mixed regression models with running speed (normalized by the subject-specific maximum) as the independent variable. Results: At running speeds below 75% of top speed accelerative running resulted in greater peak lengths than constant speed running. For example, the peak hamstring muscle-tendon length when a person accelerated from running at only 50% of top speed was equivalent to running at a constant 88% of top speed. Lengthening velocities were greater during accelerative running at all running speeds. Differences in hip flexion kinematics primarily drove the greater peak muscle-tendon lengths and lengthening velocities observed in accelerative running. Conclusion: Hamstrings are subjected to longer muscle-tendon lengths and faster lengthening velocities in accelerative running compared to constant speed running. This provides a biomechanical explanation for the observation that hamstring strain injuries often occur during acceleration. Our results suggest coaches who monitor exposure to high-risk circumstances (long lengths, fast lengthening velocities) should consider the accelerative nature of running in addition to running speed.

The Relationship Between Eccentric Hamstring Muscle Strength and Reaction Time in Elite Volleyball Players: Cross-Sectional Study

Article

Full-text available

Mar 2024

ABSTRACT Objective: The aim of this study was to investigate whether or not eccentric hamstring muscle strength has an effect on reaction time in elite volleyball players. Material and Methods: The study included 33 male volleyball players, aged 16-20 years, who met the study inclusion criteria. The eccentric hamstring strength was measured during Nordic hamstring exercises with an iVMES H-BORD®. The reaction time of the volleyball players was measured with the Light Trainer Flash Light Exercise System TM. Results: A strong level, negative, significant correlation was determined between the maximum eccentric hamstring muscle strength values of the dominant and non-dominant side of the study participants and the mean reaction time (r=-0.69, p<0.001; r=-0.78, p<0.001, respectively) and the best reaction time values (r=-0.70; p<0.001, r=-0.75; p<0.001, respectively). A strong level, negative, significant correlation was determined between the mean eccentric hamstring muscle strength values of the dominant and nondominant side and the mean reaction time (r=-0.69; p<0.001, r=-0.71; p<0.001, respectively) and the best reaction time values (r=-0.71; p<0.001, r=-0.68; p<0.001, respectively). At the same time, it was determined that there was no significant correlation between maximum and mean eccentric muscle strength difference and mean reaction time and best reaction time values (p>0.05). Conclusion: The results of this study showed a significant correlation between eccentric hamstring muscle strength and reaction time parameters in young, male volleyball players. Trainers and sports scientists should take this into consideration in training programs to improve the performance of volleyball players. Keywords: Volleyball; eccentric muscle strength; hamstring; reaction time

Measures Contributing to the Prevention of Hamstring Strain in Sprinters

Article

Full-text available

Dec 2023

Junlin Niu

One of the most typical injuries among sportsmen is hamstring injury. Extreme muscle stretching or high-speed running activities make athletes more vulnerable to hamstring injuries. Especially for sprinters, hamstring injuries rank among the most frequent in sports and cause a large amount cost of time. Despite its frequency, it is still unclear how hamstring injuries occur. It is crucial to keep sprinters injury-free because they also have a high rate of re-injury, which makes it difficult for athletes to heal entirely from injuries. It is important to use a variety of techniques to help athletes avoid hamstring injuries if they want to prevent sprinters from suffering them. This article is a review of the essays focus on methods to prevent hamstring injuries, which aims to provide scientific and comprehensive methods to instruct athletes and coaches to better deal with hamstring injuries.

Prognosticating Return-To-Play Time Following a Hamstring Strain Injury Using Early Flexibility Asymmetry and Musculoskeletal Ultrasound Imaging Outcomes: An Exploratory Study Among Canadian University Football Players

Article

Jun 2024
CLIN J SPORT MED

Objective Identify key flexibility and point-of-care musculoskeletal ultrasound (POCUS) measures for prognosticating return-to-play (RTP) following a first hamstring strain injury (HSI) and informing the clinical decision–making process. Design Exploratory prospective cohort study. Setting Sport medicine and rehabilitation clinic of a Canadian university. Participants One hundred and sixty-seven elite Canadian university football athletes followed over 5 seasons. Interventions Clinical and POCUS measures collected within 7 days after HSI and preseason clinical measures. Main Outcome Measures Active knee extension (AKE) and Straight Leg Raise (SLR) to quantify hamstring flexibility, POCUS-related outcomes to characterize tissue alteration, and RTP until full sport resumption were documented (categorized as Early [1-40 days] or Late [>40 days] RTP). Results A total of 19 and 14 athletes were included in the Early RTP (mean RTP = 28.84 ± 8.62 days) and Late RTP groups (mean 51.93 ± 10.54 days), respectively, after having been diagnosed with a first HSI. For the clinical results, height and a greater flexibility asymmetry measure with the AKE or SLR when compared with both ipsilateral preseason and acute contralateral values significantly increases the chance of facing a long delay before returning to play (ie, RTP). For the POCUS-related results, the Peetrons severity score, extent of the longitudinal fibrillary alteration, and novel score lead to similar results. Conclusions Early hamstring flexibility asymmetry following acute HSI, particularly the AKE, along with some POCUS-related measures are valuable in prognosticating late RTP following among Canadian university football athletes.

Laceration of the Distal Biceps Femoris Tendon

Article

May 2024

Jed Droge

BACKGROUND: Rehabilitation strategies addressing impairments caused by hamstring laceration injuries remain insufficiently explored in current literature. CASE PRESENTATION: This case study presents the effective management of a 62-year-old male who experienced pain, weakness, and range-of-motion loss secondary to a distal biceps femoris tendon laceration. Treatment incorporated interventions traditionally utilized for acute athletic hamstring injury. OUTCOME AND FOLLOW-UP: Clinically meaningful improvements were made in active knee extension range of motion, as well as isometric knee flexor and hip extensor strength over 10 weeks. He was able to return to running for aerobic fitness and improved his Lower Extremity Functional Scale score from 13/80, initially, to 76/80 at 12 months. DISCUSSION: This case suggests the use of evidence-based interventions for hamstring strain may be useful for management of partial tendon laceration injuries. JOSPT Cases 2024;4(2):74-78. Epub 2 May 2024. doi:10.2519/josptcases.2024.0003

Examination of the coverage of functional assessments in the OMOP common data model

Preprint

Full-text available

May 2024

Background High-value care aims to enhance meaningful patient outcomes while reducing costs. Curating data across healthcare systems with common data models (CDMs) would help these systems move towards high-value healthcare. However, meaningful patient outcomes, such as function, must be represented in commonly used CDMs, such as Observational Medical Outcomes Partnership Model (OMOP). Yet the extent that functional assessments are included in the OMOP CDM is unclear. Objective Examine the extent that functional assessments used in neurologic and orthopaedic conditions are included in the OMOP CDM. Methods After identifying functional assessments from clinical practice guideline, two reviewer teams independently mapped the neurologic and orthopaedic assessments into the OMOP CDM. After this mapping, we measured agreement with the reviewer team with the number of assessments mapped by both reviewers, one reviewer but not the other, or neither reviewer. The reviewer teams then reconciled disagreements, after which we again examined agreement and the average number of concept ID numbers per assessment. Results Of the 81 neurologic assessments, 48.1% were initially mapped by both reviewers, 9.9% were mapped by one reviewer but not the other, and 42% were unmapped. After reconciliation, 46.9% of neurologic assessments were mapped by both reviewers and 53.1% were unmapped. Of the 79 orthopaedic assessments, 46.8% were initially mapped by both reviewers, 12.7% were mapped by one reviewer but not the other, and 48.1% were unmapped. After reconciliation, 48.1% of orthopaedic assessments were mapped by both reviewers and 51.9% were unmapped. Most assessments that were mapped had more than one concept ID number (neurologic assessments: 2.2±1.3; orthopaedic assessments: 4.3±4.4). Conclusions The OMOP CDM includes a portion of functional assessments recommended for use in neurologic and orthopaedic conditions. Many assessments did not have any term in the OMOP CDM. Thus, expanding the OMOP CDM to include recommended functional assessments and creating guidelines for mapping functional assessments would improve our ability to harmonize these data across healthcare systems.

A qualitative inquiry to explore management of distal radius fracture by certified hand therapists

Article

Apr 2024

Hamstring Strain Injury in Athletes: A Summary of Clinical Practice Guideline Recommendations: Using the Evidence to Guide Physical Therapist Practice

Article

Mar 2024

Brian Young

Differences in Injury Profiles Between Female and Male Athletes Across the Participant Classification Framework: A Systematic Review and Meta-Analysis

Article

Full-text available

Mar 2024
SPORTS MED

Background Female sex is a significant determinant of anterior cruciate ligament (ACL) injury. It is not understood if sex is a key determinant of other sports-related injuries. Objective The aim of this systematic review was to identify where differences in injury profiles are most apparent between the sexes in all sports across the six-tiered participant classification framework. Methods This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and the 'implementing PRISMA in Exercise, Rehabilitation, Sport medicine and SporTs science’(PERSiST) guidance. The databases PubMed, CINAHL, Web of Science, SPORTDiscus, Medline, Scopus, Cochrane Library and EBSCO were searched from database inception to 24 April 2023. Longitudinal, prospective and retrospective cohort studies and cross-sectional and descriptive epidemiology studies that used standard injury data collection were included. Studies were excluded if injuries were not medically diagnosed and if injuries were not reported and/or analysed by sex. Two reviewers independently extracted data and assessed study quality using the Downs and Black checklist. Results Overall, 180 studies were included (8 tier-5, 40 tier-4, 98 tier-3, 30 tier-2, 5 tier-1 studies; one study included data in two tiers). Of those, 174 studies were of moderate quality and six studies were of limited quality. In sex-comparable sports, there was moderate evidence that female athletes had greater risk of knee injury (relative risk (RR) 2.7; 95% CI 1.4–5.5), foot/ankle injuries (RR 1.25; 95% CI 1.17–1.34), bone stress injury (RR 3.4; 95% CI 2.1–5.4) and concussion (RR 8.46; 95% CI 1.04–68.77) than male athletes. Male athletes were at increased risk of hip/groin injuries (RR 2.26; 95% CI 1.31–3.88) and hamstring injuries (RR 2.4; 95% CI 1.8–3.2) compared with females, particularly in dynamic sports. Male athletes were 1.8 (1.37–2.7) to 2.8 (2.45–3.24) times more likely to sustain acute fractures than female athletes, with the highest risk in competition. Discussion Most studies in all cohorts were of moderate quality (mean/range of scores tier-5: 17 ± 2.2 [14–20], tier-4: 16.9 ± 1.9 [11–21], tier-3: 16.9 ± 1.5 [11–20], tier-2: 16.3 ± 2.2 [11–20], tier-1 studies: 15.6 ± 1.3 [14–17] out of 28 on the Downs and Black checklist), with only six studies of limited quality. Female athletes’ propensity for bone stress injuries highlights opportunities to reinforce development of optimal bone health during adolescence and to outline the effects of energy availability. Earlier strength development and exposure to neuromuscular training programmes and modification of skill development in female athletes may be effective strategies for reducing lower limb injury risk. Key components of neuromuscular training programmes could be beneficial for reducing hip/groin and hamstring injury risk in male athletes. There may be a need for sex-specific prevention and return-to-sport protocols for sports-related concussion in female athletes. Conclusions Female sex was a key determinant of sports-related injuries beyond ACL injury including foot/ankle injury, bone stress injury and sports-related concussion. Male sex was a key determinant of hip/groin, hamstring injury and upper limb injury. Trial Registry PROSPERO registration number: CRD42017058806 (last updated on 7th June 2023).

Hamstring Injuries: A Paradigm for Return to Play

Article

Mar 2024
SEMIN MUSCULOSKEL R

Muscle injuries are the most common sports-related injuries, with hamstring involvement most common in professional athletes. These injuries can lead to significant time lost from play and have a high risk of reinjury. We review the anatomy, mechanisms of injury, diagnostic imaging modalities, and treatment techniques for hamstring injuries. We also present the latest evidence related to return to play (RTP) after hamstring injuries, including a review of articles targeted to RTP in European soccer (Union of European Football Associations), American football (National Football League), and other professional sports. Review of imaging findings in hamstring injury, grading systems for injuries, considerations for RTP, as well as advances in injury prevention, are discussed.

Fusion and beyond: Satellite cell contributions to loading‐induced skeletal muscle adaptation

Article

Full-text available

Sep 2021
FASEB J

Satellite cells support adult skeletal muscle fiber adaptations to loading in numerous ways. The fusion of satellite cells, driven by cell‐autonomous and/or extrinsic factors, contributes new myonuclei to muscle fibers, associates with load‐induced hypertrophy, and may support focal membrane damage repair and long‐term myonuclear transcriptional output. Recent studies have also revealed that satellite cells communicate within their niche to mediate muscle remodeling in response to resistance exercise, regulating the activity of numerous cell types through various mechanisms such as secretory signaling and cell–cell contact. Muscular adaptation to resistance and endurance activity can be initiated and sustained for a period of time in the absence of satellite cells, but satellite cell participation is ultimately required to achieve full adaptive potential, be it growth, function, or proprioceptive coordination. While significant progress has been made in understanding the roles of satellite cells in adult muscle over the last few decades, many conclusions have been extrapolated from regeneration studies. This review highlights our current understanding of satellite cell behavior and contributions to adaptation outside of regeneration in adult muscle, as well as the roles of satellite cells beyond fusion and myonuclear accretion, which are gaining broader recognition.

Acute Hamstring Injury Prevention Programs in Eleven-a-Side Football Players Based on Physical Exercises: Systematic Review

Article

Full-text available

May 2021

(1) Objective: To analyze the exercise programs used to prevent of acute hamstring injuries in eleven-a-side football players, and their effectiveness. (2) Methods: A systematic review (PRISMA) was conducted (2008–2020), including RCTs, that exclusively used physical exercises as a prevention method. (3) Results: Ten studies were selected considering 14 interventions, including nine different programs: FIFA11+ (11+), Harmoknee, eccentric Nordic Hamstring Exercise (NHE) exclusively, with eccentric exercises, with stretching or with proprioceptive, New Warm-up Program (NWP), Bounding Exercise Program (BEP), the only one with no positive results, and proprioceptive exercises. Incidence of injuries and strength were the most considered variables, both with favorable evidences. Programs including NHE, which assessed injury incidence, were always effective. The 11+ program was effective in injury incidence and strength; NWP was effective in balance, stability, and strength. (4) Conclusions: The exercise programs discussed were effective to prevent acute hamstring injuries in football players except BEP and partially Harmoknee. Exercises mostly used to reduce the risk of hamstring injuries are those of eccentric force due to its functionality, especially NHE. Only concentric contractions and isometric contractions obtained significant favorable results. The most complete and promising programs were 11+ (in injury incidence and strength) and NWP (strength, balance, and stability). NWP was the best in strength.

Is Pre-season Eccentric Strength Testing During the Nordic Hamstring Exercise Associated with Future Hamstring Strain Injury? A Systematic Review and Meta-analysis

Article

Full-text available

Sep 2021
SPORTS MED

Background Interventions utilising the Nordic hamstring exercise (NHE) have resulted in reductions in the incidence of hamstring strain injury (HSI). Subsequently, quantifying eccentric knee flexor strength during performance of the NHE to identify an association with the occurrence of future HSI has become increasingly common; however, the data to date are equivocal.Objective To systematically review the association between pre-season eccentric knee flexor strength quantified during performance of the NHE and the occurrence of future HSI.DesignSystematic review and meta-analysis.Data sourcesCINAHL, Cochrane Library, Medline Complete, Embase, Web of Science and SPORTDiscus databases were searched from January 2013 to January 10, 2020.Eligibility criteria for selecting studiesProspective cohort studies which assessed the association between pre-season eccentric knee flexor strength quantified during performance of the NHE and the occurrence of future HSI.Methods Following database search, article retrieval and title and abstract screening, articles were assessed for eligibility against pre-defined criteria then assessed for risk of bias. Meta-analysis was used to pool data across studies, with meta-regression utilised where possible.ResultsA total of six articles were included in the meta-analysis, encompassing 1100 participants. Comparison of eccentric knee flexor strength during performance of the NHE in 156 injured participants and the 944 uninjured participants revealed no significant differences, regardless of whether strength was expressed as absolute (N), relative to body mass (N kg−1) or between-limb asymmetry (%). Meta-regression analysis revealed that the observed effect sizes were generally not moderated by age, mass, height, strength, or sport played.Conclusion Eccentric knee flexor strength quantified during performance of the NHE during pre-season provides limited information about the occurrence of a future HSI.

The prognostic value of the hamstring outcome score to predict the risk of hamstring injuries

Article

Full-text available

Jan 2021
J SCI MED SPORT

Objectives Hamstring injuries are common among soccer players. The hamstring outcome score (HaOS) might be useful to identify amateur players at risk of hamstring injury. Therefore the aims of this study were: To determine the association between the HaOS and prior and new hamstring injuries in amateur soccer players, and to determine the prognostic value of the HaOS for identifying players with or without previous hamstring injuries at risk of future injury. Design Cohort study Methods HaOS scores and information about previous injuries were collected at baseline and new injuries were prospectively registered during a cluster-randomized controlled trial involving 400 amateur soccer players. Analysis of variance and t-tests were used to determine the association between the HaOS and previous and new hamstring injury, respectively. Logistic regression analysis indicated the prognostic value of the HaOS for predicting new hamstring injuries. Results Analysis of data of 356 players indicated that lower HaOS scores were associated with more previous hamstring injuries (F = 17,4; p = 0,000) and that players with lower HaOS scores sustained more new hamstring injuries (T = 3.59, df = 67.23, p = 0.001). With a conventional HaOS score cut-off of 80%, logistic regression models yielded a probability of hamstring injuries of 11%, 18%, and 28% for players with 0,1, or 2 hamstring injuries in the previous season, respectively. Conclusion The HaOS is associated with previous and future hamstring injury and might be a useful tool to provide players with insight into their risk of sustaining a new hamstring injury risk when used in combination with previous injuries.

SPRINT PERFORMANCE IN FOOTBALL (SOCCER) PLAYERS WITH AND WITHOUT A PREVIOUS HAMSTRING STRAIN INJURY: AN EXPLORATIVE CROSS-SECTIONAL STUDY

Article

Full-text available

Dec 2020
Int J Sports Phys Ther

Background: Hamstring strain injuries are common in many sports. Following a hamstring injury, deficits in peak and explosive strength may persist after return to sport potentially affecting sprint performance. Assessment of repeated-sprint ability is recognized as an important part of the return to sport evaluation after a hamstring injury.Purpose: This purpose of this exploratory cross-sectional study was to compare sprinting performance obtained during a repeated-sprint test between football players with and without a previous hamstring strain injury. Methods: Forty-four fully active sub-elite football players, 11 with a previous hamstring strain injury during the preceding 12 months (cases; mean age, SD: 25.6 ± 4.4) and 33 demographically similar controls (mean age, SD: 23.2 ± 3.7), were included from six clubs. All players underwent a repeated-sprint test, consisting of six 30-meter maximal sprints with 90 seconds of recovery between sprints. Sprint performance was captured using high-speed video-recording and subsequently assessed by a blinded tester to calculate maximal sprint velocity, maximal horizontal force, maximal horizontal power, and mechanical effectiveness. Results: A significant between-group difference was seen in favor of players having a previous hamstring injury over 6 sprints for maximal velocity (mean difference: 0.457 m/s, 95% CI: 0.059-0.849, p = 0.025) and mechanical effectiveness (mean difference: 0.009, 95% CI: 0.001-0.016, p = 0.020). Conclusion: Repeated-sprint performance was not impaired in football players with a previous hamstring strain injury; in fact, higher mean maximal sprinting velocity and better mechanical effectiveness were found in players with compared to without a previous hamstring injury. The higher sprinting velocity, which likely increases biomechanical load on the hamstring muscles, in previously injured players may increase the risk of recurrent injuries. Level of evidence: 3b.

The mechanism of hamstring injuries- A systematic review

Article

Full-text available

Sep 2020
BMC MUSCULOSKEL DIS

Background: Injuries to the hamstring muscles are among the most common in sports and account for significant time loss. Despite being so common, the injury mechanism of hamstring injuries remains to be determined. Purpose: To investigate the hamstring injury mechanism by conducting a systematic review. Study design: A systematic review following the PRISMA statement. Methods: A systematic search was conducted using PubMed, EMBASE and the Cochrane Library. Studies 1) written in English and 2) deciding on the mechanism of hamstring injury were eligible for inclusion. Literature reviews, systematic reviews, meta-analyses, conference abstracts, book chapters and editorials were excluded, as well as studies where the full text could not be obtained. Results: Twenty-six of 2372 screened original studies were included and stratified to the mechanism or methods used to determine hamstring injury: stretch-related injuries, kinematic analysis, electromyography-based kinematic analysis and strength-related injuries. All studies that reported the stretch-type injury mechanism concluded that injury occurs due to extensive hip flexion with a hyperextended knee. The vast majority of studies on injuries during running proposed that these injuries occur during the late swing phase of the running gait cycle. Conclusion: A stretch-type injury to the hamstrings is caused by extensive hip flexion with an extended knee. Hamstring injuries during sprinting are most likely to occur due to excessive muscle strain caused by eccentric contraction during the late swing phase of the running gait cycle. Level of evidence: Level IV.

Reliability of a Clinical Test for Measuring Eccentric Knee Flexor Strength Using a Handheld Dynamometer

Article

May 2021

Context: Eccentric knee flexor strength assessments have a key role in both prevention and rehabilitation of hamstring strain injuries. Objective: To verify the reliability of a clinical test for measuring eccentric knee flexor strength during the Nordic hamstring exercise using a commercially available handheld dynamometer. Design: Reliability study. Setting: Physical Therapy Laboratory, Federal University of Health Sciences of Porto Alegre (Brazil). Participants: Fifty male amateur athletes (soccer or rugby players; 24 [3] y). Main outcome measures: Eccentric knee flexor strength. Results: When compared with a load cell-based device, the clinical test using a handheld dynamometer provided smaller force values (P < .05) with large effect sizes (.92-1.21), moderate intraclass correlation (.60-.62), typical error of 30 to 31 N, and coefficient of variation of 10% to 11%. Regarding the test-retest reproducibility (2 sessions separated by 1 week), the clinical test provided similar force values (P > .05) with only small effect sizes (.20-.27), moderate to good correlation (.67-.76), typical error of 23 to 24 N, and coefficient of variation of 9% to 10%. Conclusion: The clinical test with handheld dynamometer proposed by this study can be considered an affordable and relatively reliable tool for eccentric knee flexor strength assessment in the clinical setting, but results should not be directly compared with those provided by load cell-based devices.

Injury prevention of hamstring injuries through exercise interventions: an umbrella review

Article

Jan 2021

BACKGROUND: Hamstring injuries are the most prevalent time-loss injuries in sport, mainly in those modalities characterized by high-intensity and short-term actions, especially accelerations and decelerations during high-speed running. Expanding the knowledge about this type of injury and its preventive programs could be a key strategy to reduce the hamstring injury incidence. Thus, this review aimed to study the effectiveness of different preventive programs based on exercise interventions on reducing the hamstring injury incidence in athletes. METHODS: An umbrella review was conducted through of PubMed/MEDLINE, Scopus, SPORTDiscus, Web of Science, Cochrane Library and Physiotherapy Evidence Database databases. The methodological quality of the included systematic reviews was assessed through the Assessing the Methodological Quality of Systematic Reviews 2 and the quality of the evidence was evaluated using the modified Grading of Recommendations Assessment, Development and Evaluation principles. RESULTS: Eight systematic reviews and meta-analysis (40 primary studies) met the inclusion criteria, which included interventions based on eccentric strength, Nordic hamstring, proprioceptive training, stretching, FIFA11 and combined programs. From the qualitative synthesizes, three studies showed that eccentric-based training programs were effective; seventeen studies reported that Nordic hamstring-based programs were effective; three studies observed that stability training-based interventions were effective; two studies indicated that flexibility were effective; three studies claimed that FIFA11+ based programs were effective; and two studies reported that combined programs were effective. CONCLUSION: In conclusion, exercise is a key strategy to reduce the hamstring injury incidence, being programs based on eccentric strength mainly by means of Nordic hamstring exercise, and on stability training, those programs which reported greater effectiveness.

Hamstring Structural Injury in Futsal Players. The Effect of Active Range of Motion (AROM) Deficit on Rehabilitation Period

Article

Nov 2020

Acute Muscle and Tendon Injuries in Athletes

Article

Mar 1983
CLIN SPORT MED

The goal of early treatment of acute soft tissue strains and contusions is prevention of further hemorrhage into injured tissues. Mild injuries are most common and routinely heal without incident; moderate and severe injuries may take weeks or months to heal and have a high incidence of complication such as myositis ossificans. The incidence of complication can be decreased by waiting for full painless range of motion of the injured extremity before allowing the athlete to return to competition. Rehabilitation minimizes the risk of reinjury.