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Hamstring Strain

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Other Names

  • Hamstring strain injuries (HSI)
  • Hamstring tear

Background

  • This page refers to acute Hamstring injuries (HSI)
    • Includes strains, partial and complete tears
    • Hamstring Tendinopathy is a separate clinical entity discussed separately

History

Epidemiology

  • General
    • Injury rates have not declined in recent decades despite the well know problem of HSI
    • Most common cause of lost playing time in Australian football
    • Most common cause of prolonged absence (>28) days from training, playing soccer
    • Average number of days lost ranges from 8 to 25, depending on severity and location[1]
    • Majority of studies on hamstring injuries in athletes report highest incidence between age 18 and 30
  • Financial Implications
    • HSI cost in excess of £74.4 million in English premier and football league clubs during the 1999–2000 season[2]
    • In elite Australian footballers, HSI cost $AU1.5 million in the 2009 season[3]
  • Incidence of HSI
    • Up to 29% of all injuries in athletes[4]
    • Track and field: estimated to account for 26% of track and field injuries[5]
    • Australian football: 13-15%
    • Soccer: 12-14%[6]
    • American football: 12%[7]
    • Rugby: 15%[8]
    • Over a 10 year span among NFL football players (1998-2007), incidence of HSI was second only to knee sprains[9]
  • Recurrence
    • Up to 1/3 of HSI recur, greatest risk is in the first 2 weeks following return to sport[10]
    • 27% of all HSIs in the Australian Football League are recurrences of previous injuries; however, recent evidence suggests this is trending downwards[11]
    • American Football: 32%
    • Rugby: 21%
    • Soccer: 16%

Pathophysiology

  • General
    • Hamstring injuries are one of the most common non-contact injuries in sports
    • They are the most common in Australian football, American football, rugby, soccer and sprinting[12]
    • Characterized by acute onset of pain of the posterior thigh
    • Injuries range from microscopic tearing and pain (grade I) to full muscle rupture and complete loss of function (grade III)
    • Most commonly occur at myotendinous junction

Etiology

  • Running accounts for the majority of HSI[13]
    • Can also occur due to kicking, tackling, cutting, slow-speed stretching
    • Typically a non-contact injury
  • Biomechanics
    • Hamstrings active during the entire gait cycle, peaking during terminal swing and early stance[14]
    • Hip is flexed, knee is extended
    • Terminal swing: eccentric contraction to decelerate extending knee and flexing hip, teach maximum length
    • Early stance: concentric contraction while in contact with ground, possibly still some eccentric component
    • Also can be related to sudden takeoff phase of running
  • Eccentric contraction
    • Occurs primarily during terminal swing, to a lesser extent during early stance
    • Primary suspect for high rate of HSI
    • Terminal swing phase most hazardous as muscle-tendon units at their longest length
    • Muscle length during eccentric contraction reaches 110% for Biceps Femoris, 107.5% for Semimembranosus and 108.2% for Semitendinosus[15]
  • Muscle strain
    • Magnitude of stress or strain on muscle contributes to HSI
    • Unclear if eccentric load or muscle strain is primary etiology, likely mixed
  • Other considerations
    • Unclear if due to accumulated microscopic damage or single event exceeding mechanical limits of the muscle[16]

Pediatric Considerations

  • Ischial apophysis
    • Weakest link in the kinetic chain
    • Ossifies around age 15-17, fuses around age 19-25

Pathoanatomy

  • Hamstrings
    • Composed of Biceps Femoris, Semimembranosus, Semitendinosus
    • Muscle group is biarticular, actions are to flex knee and extend hip
    • SemiM and SemiT provide some internal rotation while the Biceps Femoris provides some lateral rotation
  • The Biceps Femoris is the most commonly injured muscle
    • The myotendinous junction or muscle-tendon junction is the most common site of disruption
    • Undergoes the greatest stretch during terminal swing
  • During gait/ running
    • Normal gait: responsible for hip extension, knee flexion with concentric contraction
    • While running: also assists in deceleration, hip flexion and knee extension with eccentric contraction

Associated Pathology

Risk Factors

  • Non-modifiable risk factors
    • Increasing age[17]
      • Age over 23 has an OR of 2.46[18]
      • A pediatric study found peak incidence at age 17[19]
    • History of previous HSI[20]
    • Ethnicity: Aboriginal[21], Black or Caribbean[2]
    • Leg-length discrepancy
  • Modifiable
    • Weak hamstring muscles[22]
    • Asymmetric hamstring strength[23]
    • Low hamstrings:quadriceps ratio (hamstrings weak relative to quads)[24]
    • Greater knee angle at peak concentric knee flexion[25]
    • Fatigue during a match[26]
    • Inadequate warmup
    • High training volume
  • Lack of flexibility
    • This is controversial
    • Some studies have shown that increased flexibility reduces risk[27]
    • Several prospective studies found no relationship between hamstring flexibility and future HSI[28]
    • In one study of elite Australian Footballers, increased flexibility actually increased risk of HSI[17]
  • Sports
  • Theoretical/ Proposed

Differential Diagnosis

Differential Diagnosis Hip Pain

Differential Diagnosis Thigh Pain

Clinical appearance of diffuse posterior thigh ecchymosis with a proximal myotendinous hamstring injury[36]

Clinical Features

  • History
    • Onset is typically sudden with a sharp pain, patients may endorse a "pop"
    • Pain ranges from minimal to severe depending on degree
    • Pain is posterior, may be worse with sitting
    • Patient may have trouble running or even walking
    • In patients with distal hamstring injuries, athletes can usually report a specific moment when they had knee hyperextension, sense of instability[37]
  • Physical Exam: Physical Exam Hip
    • Examine patient in prone position if possible
    • Goal is to determine location, severity of injury
    • Hip and knee: strength and flexibility are both diminished
    • Athlete should have point tenderness at the site of injury
    • Bruising, swelling may be present with more serve injuries or avulsion injuries
    • Defect or mass may be palpable in the setting of complete tear, typically middle 1/3 posterior thigh
    • Often have "stiff legged" gait due to guarding against hip flexion, knee extension
  • Special Tests

Evaluation

Radiographs

Ultrasound

  • General
    • Excellent diagnostic tool
    • Initial imaging modality of choice
    • Sonopalpation often correlates to pathologic findings
    • Very useful to monitor interval healing
    • As sensitive as MRI for acute hamstring injuries[38]
  • Findings
    • Hyperechoic muscle and tendon
    • May see hypoechoic fluid (blood)
    • May see interruptions in myotendinous architecture
    • Bony avulsion with displacement of hyperechoic bony cortex

MRI

  • General
    • Often reserved for more severe injuries where rupture is suspected
    • In chronic cases, used to evaluate sciatic nerve as well
  • Findings
    • Increased signal intensity (T2 weighted)
    • May show avulsion of ischial tuberosity
  • May be superior to US in the following cases
    • Evaluating injuries to deep portions of the muscles[39]
    • When a previous hamstring injury is present, as residual scarring can be misinterpreted on an US image as an acute injury[40]
    • Better quantifying the size of injury (length, cross sectional area)

Classification

  • Grade I
    • Mild
    • Damage: minimal
    • MRI: T2 hyperintense signal about a tendon or muscle without fiber disruption
  • Grade II
    • Moderate
    • Damage:
    • MRI: T2 hyperintense signal around and within a tendon/muscle with fiber disruption less than half the tendon/muscle width
  • Grade III
    • Severe
    • Damage: complete tear or rupture
    • MRI: Tendon/muscle fiber disruption greater than half its tendon/muscle width

Management

  • Goals
    • Return athlete to his or her prior level of function
    • Minimize risk for reinjury

Prevention

  • Nordic Hamstring Exercise (NHE)
    • Description: athlete in kneeling position, gradually lowers upper body toward ground with extension at knee with eccentric contraction of hamstrings to slow decent
    • Shown to increase hamstring torque, shift torque-joint angle to longer muscle lengths[41]
    • Two studies with low compliance among amateur Australian Footballers[42], and professional soccer players[43] failed to reduce the risk
    • Elite soccer players who incorporated NHE into pre- and per-season conditioning demonstrated a 65% reduction in rates of HSI and decreased severity of HSI[44]
  • Flywheel Training Ergometer
    • Designed to augment eccentric torque during leg curl
    • Shown to increase eccentric hamstring strength, reduce HSI rates[45]
    • Small RCT also showed reduction of HSI[46]
  • Strength Imbalance Correction
    • Large cohort study (n=462) showed risk reduction of HSI by detecting and correcting isokinetic strength imbalances[47]
  • Flexibility
    • When compared to controls, prescribing contract-relax flexibility training during warm up did not reduce rate of HSI[48]
    • An unsupervised 16 week warm-up and cool-down stretching program among recreational runners did not reduce the risk of HSI compared to control[49]

Nonoperative

  • Approach of choice in most cases including
    • Single tendon tears
    • Multi-tendon tears with <2 cm retraction
    • Rupture at myotendinous junction
    • Individuals with low activity levels, significant comorbidities
  • Relative rest
  • Medications
  • Physical Therapy
    • See: protocolized rehabilitation below
  • Corticosteroid Injection
    • Controversial, not currently recommended, data lacking on proven benefit
    • Corticosteroids known to be myotoxic and tenotoxic[50]
    • Levine et al found no determinantal effects, may accelerate recovery time for return to play[51]
  • Platelet Rich Plasma
    • Limited retrospective studies show faster healing, less swelling[52]
    • Rossi showed a 5 day faster RTP with PRP but no difference in rate of recurrence[53]
    • Sheth performed a systematic review of PRP on muscle injuries and found 6 day decrease in RTP across all injuries, however no difference for hamstring injuries[54]
  • Consider the follow soft tissue therapies to consider, no evidence to recommend for or against
    • Electrophysical agents
  • Evidence shows no benefit
  • Conflicting Evidence
    • Massage Therapy has mixed evidence on hamstring muscle activity and flexibility, no evidence regarding any effect on healing or recovery[56]

Operative

  • Indications[57]
    • Proximal avulsion ruptures
    • Partial avulsion that has failed nonoperative management for 6 months (persistent symptoms)
    • 2 tendons with at least > 2 cm retraction in young, active patients
    • 3 tendon tears
  • Technique
    • Tendon repair
    • ORIF if significant displacement of bony avulsion (>2 cm)

Rehab and Return to Play

Rehabilitation

  • Goals
    • Focus on remodeling with eccentric strength training
    • Increased range of motion, flexibility

Proposed Program

  • General
    • From Heiderscheit et al[58]
    • Targeting Grade I and II hamstring injuries
    • See reference for better description of individual exercises
  • Phase 1
    • Duration 1-5 days immediately post injury
    • Protection: avoid excessive stretching, pain can define ROM
    • Analgesia: Ice, NSAIDS, consider crutches
    • Exercise: promote neuromuscular control within a protected range of motion, thereby minimizing the risk of damage to the remodeling muscle
    • Progression criteria
      • 1: normal walking stride without pain
      • 2: very low-speed jogging without pain
      • 3: Pain-free isometric contraction against submaximal (50%-70%) resistance during prone knee flexion (90°) manual strength test
  • Phase 2
    • Protection: return to full range of motion unless weakness is present
    • Analgesia: continue ice after therapy, discontinue NSAIDs if possible
    • Exercise: promote a gradual increase in hamstring lengthening
    • Progression criteria
      • 1: full strength (5/5) without pain during a 1-repetition maximum effort isometric manual muscle test
      • 2: forward and backward jogging at 50% maximum speed without pain
  • Phase 3
    • Protection: No restriction to ROM, sprinting and explosiveness avoided until RTP criteria met
    • Analgesia: Ice after rehabilitation
    • Exercise: agility, and sport-specific drills should be emphasized that involve quick direction changes and technique training, respectively
    • Return to Sport Criteria:
      • Remains challenging and important area of future research
      • Athlete must be able perform full ROM, strength, and functional abilities without complaints of pain or stiffness
      • Strength: 4 consecutive reps of max effort manual strength test

Return to Play

  • Contributors to re-injury risk[59]
    • Persistent weakness in the injured muscle
    • Reduced extensibility of the musculotendon unit due to residual scar tissue
    • (Mal)adaptive changes in the biomechanics and motor patterns of sporting movements following the original injury

Complications Prognosis

Prognosis

  • Physical Exam
    • For injuries involving the intramuscular tendon, clinical exam is as predictable of rehabilitation duration as findings on MRI[60], however this same study found this was not true for proximal tendon
  • MRI Findings predicting longer recovery
    • Injury involving a proximal free tendon
    • Proximity of the injury to the ischial tuberosity
    • Increased length, cross-sectional area of injury
    • Useful to estimate time away from sport, but not risk of re-injury[58]
  • Location
    • Shorter recovery time at the intramuscular tendon, despite more pain, when compared to the longer recovery more proximal to ischial tuberosity[61]
  • Consequences
    • Associated with significant time lost from training, competition[62]
    • May result in financial losses among professional athletes[2]
    • Diminished athletic performance[3]
    • Performance is reduced upon return following HSI

Complications

  • Recurrent hamstring strain
  • Peroneal Nerve Injury
  • Sciatic Nerve Injury
  • Hamstring Syndrome
  • Ischial Tuberosity Nonunion
  • Chronic pain
  • Inability to return to sport

See Also

References

  1. ↑ Brooks JH, Fuller CW, Kemp SP, Reddin DB. Incidence, risk, and prevention of hamstring muscle injuries in professional rugby union. Am J Sports Med. 2006;34:1297-1306
  2. ↑ 2.0 2.1 2.2 Woods C, Hawkins R, Hulse M, et al. The Football Association Medical Research Programme: an audit of injuries in professional football-analysis of preseason injuries. Br J Sports Med 2002 Dec; 36 (6): 436–41
  3. ↑ 3.0 3.1 Verrall GM, Kalairajah Y, Slavotinek JP, et al. Assessment of player performance following return to sport after hamstring muscle strain injury. J Sci Med Sport 2006 May; 9 (1-2): 87–90
  4. ↑ Ahmad, Christopher S., et al. "Evaluation and management of hamstring injuries." The American journal of sports medicine 41.12 (2013): 2933-2947.
  5. ↑ Drezner J, Ulager J, Sennett MD. Hamstring muscle injuries in track and field athletes: a 3-year study at the Penn Relay Carnival abstract. Clin J Sport Med 2005; 15 (5): 386
  6. ↑ Hawkins RD, Hulse MA, Wilkinson C, et al. The association football medical research programme: an audit of injuries in professional football. Br J Sports Med 2001 Feb; 35 (1): 43–7
  7. ↑ Feeley BT, Kennelly S, Barnes RP, et al. Epidemiology of National Football League training camp injuries from 1998 to 2007. Am J Sports Med 2008 Aug; 36 (8): 1597–603
  8. ↑ Brooks JH, Fuller CW, Kemp SP, et al. Epidemiology of injuries in English professional rugby union: part 2 training injuries. Br J Sports Med 2005 Oct; 39 (10): 767–75Return to ref 12 in article
  9. ↑ Feeley BT, Kennelly S, Barnes RP, et al. Epidemiology of National Football League training camp injuries from 1998 to 2007. Am J Sports Med. 2008;36:1597-1603.
  10. ↑ 1. Orchard J, Best TM. The management of muscle strain injuries: an early return versus the risk of recurrence. Clin J Sport Med. 2002;12:3-5.
  11. ↑ 11.0 11.1 Orchard J, Seward H. Epidemiology of injuries in the Australian Football League, seasons 1997–2000. Br J Sports Med 2002 Feb; 36 (1): 39–44
  12. ↑ Opar, David, Morgan Williams, and Anthony Shield. "Hamstring strain injuries: Factors that lead to injury and re-injury [accepted manuscript]." (2012).
  13. ↑ 13.0 13.1 Brooks JH, Fuller CW, Kemp SP, et al. Incidence, risk, and prevention of hamstring muscle injuries in professional rugby union. Am J Sports Med 2006 Aug; 34 (8): 1297–306
  14. ↑ Yu B, Queen RM, Abbey AN, et al. Hamstring muscle kinematics and activation during overground sprinting. J Biomech 2008 Nov 14; 41 (15): 3121–6
  15. ↑ Thelen DG, Chumanov ES, Hoerth DM, et al. Hamstring muscle kinematics during treadmill sprinting. Med Sci Sports Exerc 2005 Jan; 37 (1): 108–14
  16. ↑ Verrall GM, Slavotinek JP, Barnes PG. The effect of sports specific training on reducing the incidence of hamstring injuries in professional Australian Rules football players. Br J Sports Med 2005 Jun; 39 (6): 363–8
  17. ↑ 17.0 17.1 Gabbe BJ, Bennell KL, Finch CF. Why are older Australian football players at greater risk of hamstring injury? J Sci Med Sport 2006 Aug; 9 (4): 327–33
  18. ↑ Freckleton, Grant, and Tania Pizzari. "Risk factors for hamstring muscle strain injury in sport: a systematic review and meta-analysis." British journal of sports medicine 47.6 (2013): 351-358.
  19. ↑ Cohen, Steven, and James Bradley. "Acute proximal hamstring rupture." JAAOS-Journal of the American Academy of Orthopaedic Surgeons 15.6 (2007): 350-355.
  20. ↑ Orchard JW. Intrinsic and extrinsic risk factors for muscle strains in Australian football. Am J Sports Med 2001 May; 29 (3): 300–3
  21. ↑ Verrall GM, Slavotinek JP, Barnes PG, et al. Clinical risk factors for hamstring muscle strain injury: a prospective study with correlation of injury by magnetic resonance imaging. Br J Sports Med 2001 Dec; 35 (6): 435–9
  22. ↑ Garrett Jr WE, Safran MR, Seaber AV, et al. Biomechanical comparison of stimulated and nonstimulated skeletal muscle pulled to failure. Am J Sports Med 1987 Sep; 15 (5): 448–54
  23. ↑ Zakas A. Bilateral isokinetic peak torque of quadriceps and hamstring muscles in professional soccer players with dominance on one or both two sides. J Sports Med Phys Fitness 2006; 46 (1): 28–35
  24. ↑ Aagaard P, Simonsen EB, Magnusson SP, et al. A new concept for isokinetic hamstring: quadriceps muscle strength ratio. Am J Sports Med 1998 Mar; 26 (2): 231–7
  25. ↑ Brockett CL, Morgan DL, Proske U. Predicting hamstring strain injury in elite athletes. Med Sci Sports Exerc 2004 Mar; 36 (3): 379–87
  26. ↑ Garrett Jr WE. Muscle strain injuries. Am J Sports Med 1996; 24 (6 Suppl.): 2–8
  27. ↑ Witvrouw E, Danneels L, Asselman P, et al. Muscle flexibility as a risk factor for developing muscle injuries in male professional soccer players: a prospective study. Am J Sports Med 2003 Jan; 31 (1): 41–6
  28. ↑ Burkett LN. Causative factors in hamstring strains. Med Sci Sports 1970; 2 (1): 39–42
  29. ↑ Feeley BT, Kennelly S, Barnes RP, et al. Epidemiology of National Football League training camp injuries from 1998 to 2007. Am J Sports Med 2008 Aug; 36 (8): 1597–603
  30. ↑ Ekstrand J, Hagglund M, Waldén M. Injury incidence and injury patterns in professional football: the UEFA injury study. Br J Sports Med. Epub 2010 May 29
  31. ↑ Bennell KL, Crossley K. Musculoskeletal injuries in track and field: incidence, distribution and risk factors. Aust J Sci Med Sport 1996 Sep; 28 (3): 69–75
  32. ↑ Heiser TM, Weber J, Sullivan G, et al. Prophylaxis and management of hamstring muscle injuries in intercollegiate football players. Am J Sports Med 1984 Sep; 12 (5): 368–70
  33. ↑ Garrett Jr WE, Califf JC, Bassett 3rd FH. Histochemical correlates of hamstring injuries. Am J Sports Med 1984 Mar; 12 (2): 98–103
  34. ↑ Woodley SJ, Mercer SR. Hamstring muscles: architecture and innervation. Cells Tissues Organs 2005; 179 (3): 125–41
  35. ↑ Abebe E, Moorman C, Garrett Jr W. Proximal hamstring avulsion injuries: injury mechanism, diagnosis and disease course. Oper Tech Sports Med 2009; 17 0(4): 205–9
  36. ↑ Ahmad, Christopher S., et al. "Evaluation and management of hamstring injuries." The American journal of sports medicine 41.12 (2013): 2933-2947.
  37. ↑ Ropiak, Christopher R., and Joseph A. Bosco. "Hamstring injuries." Bulletin of the NYU hospital for joint diseases 70.1 (2012): 41.
  38. ↑ Connell, David A., et al. "Longitudinal study comparing sonographic and MRI assessments of acute and healing hamstring injuries." American Journal of Roentgenology 183.4 (2004): 975-984.
  39. ↑ Koulouris G, Connell D. Hamstring muscle complex: an imaging review. Radiographics. 2005;25:571-586
  40. ↑ . Connell DA, Schneider-Kolsky ME, Hoving JL, et al. Longitudinal study comparing sonographic and MRI assessments of acute and healing hamstring injuries. AJR Am J Roentgenol. 2004;183:975-984.
  41. ↑ Mjølsnes R, Arnason A, østhagen T, et al. A 10-week randomized trial comparing eccentric vs. concentric hamstring strength training in well-trained soccer players. Scand J Med Sci Sports 2004 Oct; 14 (5): 311–7
  42. ↑ Gabbe BJ, Branson R, Bennell KL. A pilot randomised controlled trial of eccentric exercise to prevent hamstring injuries in community level Australian Football. J Sci Med Sport 2006 May; 9 (1-2): 103–9
  43. ↑ Engebretsen AH, Myklebust G, Holme I, et al. Prevention of injuries among male soccer players: a prospective, randomized intervention study targeting players with previous injuries or reduced function. Am J Sports Med 2008 Jun; 36 (6): 1052–60
  44. ↑ Arnason A, Andersen TE, Holme I, et al. Prevention of hamstring strains in elite soccer: an intervention study. Scand J Med Sci Sports 2008 Feb; 18 (1): 40–8
  45. ↑ Askling C, Karlsson J, Thorstensson A. Hamstring injury occurrence in elite soccer players after preseason strength training with eccentric overload. Scand J Med Sci Sports 2003 Aug; 13 (4): 244–50
  46. ↑ Goldman EF, Jones DE. Interventions for preventing hamstring injuries. Cochrane Database Syst Rev 2010; (1): CD006782
  47. ↑ Croisier JL, Ganteaume S, Binet J, et al. Strength imbalances and prevention of hamstring injury in profes-sional soccer players: a prospective study. Am J Sports Med 2008 Aug; 36 (8): 1469–75
  48. ↑ Arnason A, Andersen TE, Holme I, et al. Prevention of hamstring strains in elite soccer: an intervention study. Scand J Med Sci Sports 2008 Feb; 18 (1): 40–8Return to ref 56 in article
  49. ↑ van Mechelen W, Hlobil H, Kemper HC, et al. Prevention of running injuries by warm-up, cool-down, and stretching exercises. Am J Sports Med 1993 Sep; 21 (5): 711–9
  50. ↑ Scutt, Nanette, Christer G. Rolf, and Andrew Scutt. "Glucocorticoids inhibit tenocyte proliferation and tendon progenitor cell recruitment." Journal of orthopaedic research 24.2 (2006): 173-182.
  51. ↑ Levine, William N., et al. "Intramuscular corticosteroid injection for hamstring injuries: a 13-year experience in the National Football League." The American journal of sports medicine 28.3 (2000): 297-300.
  52. ↑ Setayesh, Kian, et al. "Treatment of muscle injuries with platelet-rich plasma: a review of the literature." Current reviews in musculoskeletal medicine 11.4 (2018): 635-642.
  53. ↑ Rossi, Luciano Andrés, et al. "Does platelet-rich plasma decrease time to return to sports in acute muscle tear? A randomized controlled trial." Knee Surgery, Sports Traumatology, Arthroscopy 25.10 (2017): 3319-3325.
  54. ↑ Sheth, Ujash, et al. "Does platelet-rich plasma lead to earlier return to sport when compared with conservative treatment in acute muscle injuries? A systematic review and meta-analysis." Arthroscopy: The Journal of Arthroscopic & Related Surgery 34.1 (2018): 281-288.
  55. ↑ Rantanen J, Thorsson O, Wollmer P, Hurme T, Kalimo H. Effects of therapeutic ultrasound on the regeneration of skeletal myofibers after experimental muscle injury. Am J Sports Med. 1999;27:54-59.
  56. ↑ Hoskins W, Pollard H. Hamstring injury management--Part 2: Treatment. Man Ther. 2005;10:180-190.
  57. ↑ https://www.orthobullets.com/knee-and-sports/3102/hamstring-injuries
  58. ↑ 58.0 58.1 Heiderscheit, Bryan C., et al. "Hamstring strain injuries: recommendations for diagnosis, rehabilitation, and injury prevention." journal of orthopaedic & sports physical therapy 40.2 (2010): 67-81.
  59. ↑ . Orchard J, Best TM. The management of muscle strain injuries: an early return versus the risk of recurrence. Clin J Sport Med. 2002;12:3-5.
  60. ↑ Schneider-Kolsky ME, Hoving JL, Warren P, Connell DA. A comparison between clinical assessment and magnetic resonance imaging of acute hamstring injuries. Am J Sports Med. 2006;34:1008-1015.
  61. ↑ Askling C, Saartok T, Thorstensson A. Type of acute hamstring strain affects flexibility, strength, and time to return to preinjury level. Br J Sports Med. 2006;40:40-44
  62. ↑ Engebretsen AH, Myklebust G, Holme I, et al. Intrinsic risk factors for hamstring injuries among male soccer players: a prospective cohort study. Am J Sports Med 2010 Jun; 38 (6): 1147–53
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