Predictors of time to return to play and re-injury following hamstring injury with and without intramuscular tendon involvement in adult professional footballers: A retrospective cohort study

Published:October 14, 2021DOI:



      In one English Premier League football club over four seasons, 1) describe the number of hamstring strain injuries (HSI) sustained using the British Athletics Muscle Injury Classification (BAMIC); 2) determine if intramuscular tendon HSI influenced the time to return to play (TTRTP) and reinjury rate; 3) determine the predictors of TTRTP and reinjury.


      Retrospective cohort design.


      All first team players who sustained a HSI between 2014 and 2018 were included. Players underwent an MRI scan that was graded by a Radiologist using the BAMIC (0a-4) criteria. TTRTP, reinjury rate and information on suspected predictors were recorded.


      Thirty-five HSI experienced by 24 players (age = 26 ± 4 years) were recorded over the 4 seasons. There was a difference in TTRTP between grades 1a and 2c (P = 0.007), but not between 2b and 2c (P = 0.845). Grade of HSI (P ≤ 0.001) and removal of the player (P < 0.001) were predictors of TTRTP, with each increase in grade resulting in an additional 3 days of TTRTP, and being removed, an additional 11 days. Grade and all other predictors did not influence reinjury rate, albeit higher odds were evident for previous HSI, experiencing the HSI during sprinting, passing a ball or stretching, and reported increase days of pain during walking.


      HSIs extending into the intramuscular tendon (2b cf. 2c) did not influence TTRTP or re-injury, albeit TTRTP was affected by the BAMIC grade and if the player was removed from activity.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Science and Medicine in Sport
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Ekstrand J.
        • Walden M.
        • Hagglund M.
        Hamstring injuries have increased by 4% annually in men’s professional football since 2001: a 13-year longitudinal analysis of the UEFA Elite Club injury study.
        Br J Sports Med. 2016; 50: 731-737
        • Ekstrand J.
        • Krutsch W.
        • Spreco W.
        • et al.
        Time before return to play for the most common injuries in professional football: a 16-year follow-up of the UEFA elite club injury study.
        Br J Sports Med. 2020; 54: 421-426
        • Diemer W.M.
        • Winters M.
        • Tol J.L.
        • et al.
        Incidence of acute hamstring injuries in soccer: a systematic review of 13 studies involving more than 3800 athletes with 2 million sport exposure hours.
        J Orthop Sports Phys Ther. 2021; 51: 27-36
        • Ekstrand J.
        Keeping your top players on the pitch: the key to football medicine at a professional level.
        Br J Sports Med. 2013; 47: 723-724
      1. (accessed on 14th January 2020)
        • Ardern C.L.
        • Glasgow P.
        • Schneiders A.
        • et al.
        Consensus statement on return to sport from the First World Congress in sports physical therapy, Bern.
        Br J Sports Med. 2016; 50: 853-864
        • Dunlop G.
        • Ardern C.L.
        • Andersen T.E.
        • et al.
        Return-to-play practices following hamstring injury: a worldwide survey of 131 premier league football teams.
        Sports Med. 2020; 50: 829-840
        • Zambaldi M.
        • Beasley I.
        • Rushton A.
        Return to play criteria after hamstring muscle injury in professional football: a Delphi consensus study.
        Br J Sports Med. 2017; 51: 1221-1226
        • van der Horst N.
        • Backx F.
        • Goedhart E.A.
        • et al.
        Return to play after hamstring injuries in football (soccer): a worldwide Delphi procedure regarding definition, medical criteria, and decision-making.
        Br J Sports Med. 2017; 51: 1583-1591
        • Pollock N.
        • Patel A.
        • Chakraverty J.
        • et al.
        Time to return to full training is delayed and recurrence rate is higher in intratendinous (’c’) acute hamstring injury in elite track and field athletes: clinical application of the British Athletics Muscle Injury Classification.
        Br J Sports Med. 2016; 50: 305-310
        • De Visser H.
        • Reijman M.
        • Heijboer M.
        • et al.
        Risk factors of recurrent hamstring injuries: a systematic review.
        Br J Sports Med. 2011; 46: 124-130
        • Reurink G.
        • Brilman E.G.
        • de Vos R.J.
        • et al.
        Magnetic resonance imaging in acute hamstring injury: can we provide a return to play prognosis?.
        Sports Med. 2015; 45: 133-146
        • Wangensteen A.
        • Guermazi A.
        • Tol J.L.
        • et al.
        New MRI muscle classification systems and associations with return to sport after acute hamstring injuries: a prospective study.
        Eur Radiol. 2018; 28: 3532-3541
        • Comin J.
        • Malliaras P.
        • Baquie P.
        • et al.
        Return to competitive play after hamstring injuries involving disruption of the central tendon.
        Am J Sports Med. 2013; 41: 111-115
        • Wangensteen A.
        • Tol J.L.
        • Roemer F.W.
        • et al.
        Intra-and interrater reliability of three different MRI grading and classification systems after acute hamstring injuries.
        Eur J Radiol. 2017; 89: 182-190
        • Askling C.M.
        • Tengvar M.
        • Saartok T.
        • et al.
        Acute first-time hamstring strains during high-speed running: a longitudinal study including clinical and magnetic resonance imaging findings.
        Am J Sports Med. 2007; 35: 197-206
        • Vermeulen R.
        • Almusa E.
        • Buckens S.
        • et al.
        Complete resolution of a hamstring intramuscular tendon injury on MRI is not necessary for a clinically successful return to play.
        Br J Sports Med. 2020;
        • van der Made A.D.
        • Almusa E.
        • Whiteley R.
        • et al.
        Intramuscular tendon involvement on MRI has limited value for predicting time to return to play following acute hamstring injury.
        Br J Sports Med. 2018; 52: 83-88
        • van der Made A.D.
        • Almusa E.
        • Reurink G.
        • et al.
        Intramuscular tendon injury is not associated with an increased hamstring reinjury rate within 12 months after return to play.
        Br J Sports Med. 2018; 52: 1261-1266
        • Ekstrand J.
        • Lee J.C.
        • Healy J.C.
        MRI findings and return to play in football: a prospective analysis of 255 hamstring injuries in the UEFA elite Club injury study.
        Br J Sports Med. 2016; 50: 738-743
        • Fuller C.W.
        • Ekstrand J.
        • Junge A.
        • et al.
        Consensus statement on injury definitions and data collection procedures in studies of football (soccer) injuries.
        Br J Sports Med. 2006; 40: 83-92
        • Green B.
        • Bourne M.N.
        • van Dyk N.
        • et al.
        Recalibrating the risk of hamstring strain injury (HSI): a 2020 systematic review and meta-analysis of risk factors for index and recurrent HSI in sport.
        Br J Sports Med. 2020; 54: 1081-1088
        • van Heumen M.
        • Tol J.L.
        • de Vos R.
        • et al.
        The prognostic value of MRI in determining reinjury risk following acute hamstring injury: a systematic review.
        Br J Sports Med. 2017; 51: 1355-1363
        • Jacobsen P.
        • Witvrouw E.
        • Muxart P.
        • et al.
        A combination of initial and follow-up physiotherapist examination predicts physician-determined time to return to play after hamstring injury, with no added value of MRI.
        Br J Sports Med. 2016; 50: 431-439
        • Bengtsson H.
        • Ekstrand J.
        • Walden M.
        • et al.
        Few training sessions between return to play and first match appearance are associated with an increased propensity for injury: a prospective cohort study of male professional football players during 16 consecutive seasons.
        Br J Sports Med. 2020; 54: 427-432
        • Wangensteen A.
        • Tol J.L.
        • Witvrouw E.
        • et al.
        Hamstring reinjuries occur at the same location and early after return to sport: a descriptive study of MRI-confirmed reinjuries.
        Am J Sports Med. 2016; 44: 2112-2121
        • Heiderscheit B.C.
        • Hoerth D.M.
        • Chumanov E.S.
        • et al.
        Identifying the time of occurrence of a hamstring strain injury during treadmill running: a case study.
        Clin Biomech. 2005; 20: 1072-1078
        • Woodley S.J.
        • Mercer S.R.
        Hamstring muscles: architecture and innervation.
        Cells Tissues Organs. 2005; 179: 125-141
        • Malliaropoulos N.
        • Isinkaye T.
        • Tsitas K.
        • et al.
        Reinjury after acute posterior thigh muscle injuries in elite track and field athletes.
        Am J Sports Med. 2011; 39: 304-310
        • Brooks J.H.M.
        • Fuller C.W.
        • Kemp S.P.T.
        • et al.
        Incidence, risk and prevention of hamstring muscle injuries in professional Rugby union.
        Am J Sports Med. 2006; 34: 1297-1306
        • Pieters D.
        • Wezenbeek E.
        • Schuermans J.
        • et al.
        Return to play after a hamstring strain injury: it is time to consider natural healing.
        Sports Med. 2021;
        • Verrall G.M.
        • Slavotinek J.P.
        • Barnes P.G.
        • et al.
        Diagnostic and prognostic value of clinicial findings in 83 athletes with posterior thigh injury: comparison of clinicial findings with magnetic resonance imaging documentation of hamstring muscle strain.
        Am J Sports Med. 2003; 31: 969-973
        • Buckthorpe M.
        • Wright S.
        • Bruce-Low S.
        • et al.
        Recommendations for hamstring injury prevention in elite football: translating research into practice.
        Br J Sports Med. 2019; 53: 449-456
        • Van Dyk N.
        • Behan F.P.
        • Whiteley R.
        Including the Nordic hamstring exercise in injury prevention programmes halves the rate of hamstring injuries: a systematic review and meta-analysis of 8459 athletes.
        Br J Sports Med. 2019; 53: 1362-1370