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The London International Consensus and Delphi study on hamstring injuries emphasizes the need for individualized rehabilitation approaches due to the complexities of hamstring injuries (HSIs) and their recurrence rates. The study involved international experts who reached consensus on key aspects of rehabilitation, including exercise selection, progression criteria, and return to sport guidelines, while highlighting areas where further research is needed. Recommendations include protecting injured tissue in early rehabilitation and focusing on specific muscle roles and demands in later stages to optimize recovery and minimize reinjury risks.

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Consensus statement

London International Consensus and Delphi study on

hamstring injuries part 3: rehabilitation, running and

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Simon Murphy,17 Ricci Plastow ‍ ‍,11 Ben Stirling,18 Laura Tulloch,19 David Wood,20
Fares Haddad1,3,7,11

► Additional supplemental ABSTRACT on aspects of rehabilitation after HSI, suggesting

material is published online Hamstring injuries (HSIs) are the most common athletic rehabilitation prescription should be individualised, but
only. To view, please visit the
journal online (http://dx.doi. injury in running and pivoting sports, but despite large clarified areas where evidence was lacking. Additional
org/10.1136/bjsports-2021- amounts of research, injury rates have not declined in research is required to determine the optimal load
105384). the last 2 decades. HSI often recur and many areas are dose, timing and criteria for HSI rehabilitation and the
lacking evidence and guidance for optimal rehabilitation. monitoring and testing metrics to determine safe rapid
For numbered affiliations see
This study aimed to develop an international expert progression in rehabilitation and safe RTS. Further
end of article.
consensus for the management of HSI. A modified Delphi research would benefit optimising: prescription of
Correspondence to methodology and consensus process was used with an running and sprinting, the application of adjuncts in
Dr Bruce M Paton, Institute international expert panel, involving two rounds of online rehabilitation and treatment of kinetic chain HSI factors.
of Sport Exercise and Health, questionnaires and an intermediate round involving a
University College London, consensus meeting. The initial information gathering
London W1T 7HA, UK;
b.paton@ucl.ac.uk round questionnaire was sent to 46 international
experts, which comprised open-ended questions INTRODUCTION
Accepted 16 November 2022 covering decision-making domains in HSI. Thematic Hamstring injuries (HSIs) remain the most signifi-
Published Online First analysis of responses outlined key domains, which
17 January 2023 cant time loss injury in football and high-intensity
were evaluated by a smaller international subgroup running sports,1 2 with large financial, physical and
(n=15), comprising clinical academic sports medicine emotional costs. Research on prevention strategies
physicians, physiotherapists and orthopaedic surgeons has not been effective in reducing injury incidence
in a consensus meeting. After group discussion around and recurrences have remained constant in elite
each domain, a series of consensus statements were soccer,3 4 whereas the incidence of other injuries
prepared, debated and refined. A round 2 questionnaire has reduced.5
was sent to 112 international hamstring experts to vote Rehabilitation of HSI has evolved to address
on these statements and determine level of agreement. inflammation, promote biological healing and
Consensus threshold was set a priori at 70%. Expert emphasise optimal loading throughout the reha-
response rates were 35/46 (76%) (first round), 15/35 bilitation.6 The individual hamstring muscles have
(attendees/invitees to meeting day) and 99/112 (88.2%) often been treated uniformly as they work in
for final survey round. Statements on rehabilitation conjunction, but evidence has emerged, demon-
reaching consensus centred around: exercise selection strating that they have different functional roles,
and dosage (78.8%–96.3% agreement), impact of capabilities and injury mechanisms,7 based on their
the kinetic chain (95%), criteria to progress exercise anatomy and nerve supply,8 fibre type compo-
(73%–92.7%), running and sprinting (83%–100%) sition9 10 and connective tissue (CT) architec-
in rehabilitation and criteria for return to sport (RTS) ture.8 11 12 Each muscle may therefore require a
(78.3%–98.3%). Benchmarks for flexibility (40%) different rehabilitation approach,11 13 14 influencing
and strength (66.1%) and adjuncts to rehabilitation exercise selection in rehabilitation.15 16 Evidence
(68.9%) did not reach agreement. This consensus panel has emerged to inform exercise prescription in HSI
recommends individualised rehabilitation based on the prevention,17 18 but exercise selection to inform
athlete, sporting demands, involved muscle(s) and injury rehabilitation remains unclear and some consensus
type and severity (89.8%). Early-stage rehab should reviews ignore exercise completely.19
avoid high strain loads and rates. Loading is important The effects of rehabilitation approaches inves-
© Author(s) (or their
employer(s)) 2023. No
but with less consensus on optimum progression and tigating single exercises are common20–22 but few
commercial re-use. See rights dosage. This panel recommends rehabilitation progress studies have examined combined programmes.
and permissions. Published based on capacity and symptoms, with pain thresholds These exist in football, sprinting,23–26 general
by BMJ. dependent on activity, except pain-free criteria supported sports27 and Australian rules football28; however,
To cite: Paton BM, for sprinting (85.5%). Experts focus on the demands they differ significantly, and few rehabilitation
Read P, van Dyk N, and capacity required for match play when deciding protocols investigate higher grade tendon HSIs
et al. Br J Sports Med the rehabilitation end goal and timing of RTS (89.8%). requiring longer rehabilitation and time to return
2023;57:278–291. The expert panellists in this study followed evidence to sport (RTS).29 A 2015 review of rehabilitation

1 of 17 Paton BM, et al. Br J Sports Med 2023;57:278–291. doi:10.1136/bjsports-2021-105384

Consensus statement
The volume of the literature on HSI rehabilitation is
KEY FINDINGS increasing, but current rehabilitation practice does not always
⇒ Differences in hamstring musculotendinous tissue, muscle follow research.42 Less evidence is available in elite sport

Br J Sports Med: first published as 10.1136/bjsports-2021-105384 on 17 January 2023. Downloaded from http://bjsm.bmj.com/ on May 11, 2025 by guest.
anatomy and functional roles should direct the rehabilitation athletes. Research contains small sample sizes, and decision-
prescription for different muscles and myotendinous tissues making draws on clinical expertise. While there are significant
after hamstring injury (HSI). drivers to achieve a faster more robust RTS, multiple stakeholder
⇒ In early-stage rehab, most experts advocate protection of interests frequently result in athletes RTS while still vulnerable
injured tissue from loading at length and elastic loads (ie, to reinjury.43 To more clearly understand current practice, inno-
high strain and strain rate loads). vation and level of expertise pertaining to HSI rehabilitation in
⇒ In early loading, the types of load/contraction considered elite sport settings, a qualitative research approach is required
appropriate, and the order of their application varied greatly to outline assessment and treatment decision-making of global

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between experts. While experts initially prescribe isometric experts whose aim is to achieve the best outcome for their
exercises, there is evidence of less force development with athletes.
concentric exercise compared with isometric exercise and The London International Hamstring Injury consensus group
consequently less connective tissue strain. was convened in 2020. Our aim was to determine, based on
⇒ Experts considered the key kinetic chain deficits as possible expert consensus, the key aspects in rehabilitation and RTS
contributing factors to (re)injury. decision-making in the assessment and treatment of HSIs.
⇒ Adjuncts such as strength training with blood flow restriction
are increasingly used to allow earlier strength adaptation but
did not achieve global consensus agreement. METHODS
⇒ Experts use an integrated assessment of symptoms, strength
Study design
and response to previous loading as criteria for progressing We used a modified Delphi research design, including an inter-
and dosing exercise and deciding on safety to return to national panel of experts, with the aim of reaching a consensus
running (RTR) and return to sport (RTS). Other criteria such as on best practice for decision-making in rehabilitation and RTS
flexibility and special RTS tests are used less widely. after HSI. The Delphi process is a scientific, iterative, multistage
⇒ On criteria related to pain, experts suggest some activities
process used to achieve expert consensus in a given subject,
should be pain free through rehabilitation (ie, sprinting) but particularly, where a limited literature is available to guide
with other exercise activities, a pain threshold approach can decision-making.44 45 It takes into account expert opinion and
be permitted. expert clinical practice.46 There have been previous Delphi
⇒ In later loading, experts aim to achieve full outer length
studies in prevention47 and RTS after HSI,48 49 but the group
strength and eccentric strength as key criteria for RTR and sought to obtain expert consensus on best-practice rehabilita-
RTS. tion, given current disparate and conflicting approaches.
⇒ In later-stage rehab, experts advocate prescription of running
The methodology followed guidance on Delphi studies44 50 web
and sprinting as key components of HSI rehabilitation and as survey design51 (the Checklist for Reporting Results of Internet
key progression criteria for RTS. E-Surveys51 and the reporting standard for conducting and
⇒ Experts focus on the demands and capacity required for
reporting Delphi studies)50 to avoid bias and is described below
competition when deciding the rehabilitation end goal and and in online supplemental file 1 and methodology in paper 1
timing of RTS. Experts monitor and test athletes through in this series.
rehabilitation and use modalities such as global positioning
system to give sports-specific information on loading/running Expert panel
dosages, speed and RTS readiness. An international representative group of multidisciplinary clini-
cians and researchers were invited to participate, based on their
expertise in assessment and management (including rehabilita-
tion and RTS) of HSI. A purposive, heterogeneous representative
studies was unable to pool the rehabilitation literature due to sample of experts was chosen with a mix of: professional disci-
heterogeneity.30 Interventions included: strength exercises pline (sport and exercise medicine physicians, physiotherapists,
(lengthened vs shortened),24 31 progressive agility and trunk stabil- surgeons, sport and exercise scientists/researchers and athletic
isation,32 progressive running and stretching,33 static stretching34 trainers), international location (or work schedule), gender and
and sacroiliac manipulation.35 Separated meta-analyses of these sporting discipline, in line with Delphi methodology.52
studies found that lengthening exercises reduce time to RTS The criteria for expert inclusion were: a high level of exper-
but none of the other types provided superior results. Reinjury tise assessing, managing, rehabilitating and/or researching HSIs,
rates, when reported, were not significantly different between based on: the number and type of HSI seen per year, years
programmes. These interventions did not follow a clinically worked with athletes who sustain HSI, willingness to complete
reasoned rehabilitation approach. Given this heterogenous small the digital survey and or attend the consensus meeting, sufficient
sample (6 studies with around 386 HSI athletes), there is a need level of written and spoken English and/or peer reviewed publi-
for more robust evidence to inform rehabilitation after HSI. cation (authorship) in hamstring research. Possible experts were
There are guidelines and reviews published on criteria for RTS excluded if they had (1) insufficient experience of assessment or
after HSI,28 36–41 but these are in lower grade injuries. Criteria management of HSI, (2) insufficient time to fully complete the
tests often do not mimic specific sporting loads or functional online survey. Clinicians and non-clinicians were included but
demands,39 40 and do not quantify subsequent reinjury risk.40 asked to answer only those survey questions related to their fields
There is a need to determine if and how current criteria are used of expertise (see online supplemental methodology). Domains of
in practice and if this aligns with the available evidence. There surgery, postsurgical recovery, diagnosis and classification were
may be a need to develop more specific criteria for RTS that link also identified and experts were chosen, with sufficient expertise
more closely with hamstring function in specific sports. in these combined areas, as well as rehabilitation.

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Consensus statement
Coaches and trainers comprised 6% of the experts for the group consensus were retained, with rehabilitation (11), RTR
final survey. While they did not all have experience in diagnosis (8) and RTS (12).
or surgery domains, or early rehabilitation, their expertise in The final Delphi round involved a further online survey to test

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The study was undertaken after a review of decision-making decision-making factors or justifications related to the domain
aspects of the assessment and management and rehabilitation of areas found in the round 1 survey. See tables 1–3 for consensus
HSI. The literature was searched, the evidence discussed and the statements, voting results and typical discussion points or areas
author team led a review of the evidence presented as a narrative of disagreement (open-ended questions).
summary to inform the consensus rationale and knowledge gaps.
The study comprised two rounds of a purposive digital survey Expert panel for final round
interspersed with a face-to-face meeting round. Each round was The final survey, with voting on the consensus statements, was
modified, based on feedback to achieve a consensus among the split into domain sections—classification, surgery, rehabilitation,
international panel of experts. Each Delphi round comprised a RTR/RTS. The expert panel in this survey were asked to complete
digital questionnaire, an analysis and a feedback report. only the domains (sections of the survey) that were within their
Round one involved a digital survey, with open-ended ques- field and scope of expertise. The survey responses were evalu-
tions to a global group of clinicians with expertise in treating ated for completeness. Survey responses in each domain were
HSI. The round one survey (see online supplemental methods evaluated by two steering group members and any incomplete
appendix 1) aimed to gather information, and understand, responses from non- experts in that particular domain were
from the experts’ viewpoint, where are the gaps in the litera- removed from the analysis. Within their expertise areas, panel
ture evidence and clinical practice in HSI rehabilitation, return members were asked to complete sections as carefully as possible
to running (RTR), sprinting and RTS. The initial round 1 survey and provided with response options such as ‘uncertain’. Open-
comprised open-ended qualitative information gathering ques- ended boxes after each consensus statement also allowed them
tions. The survey used a digital institution-based software pack- to comment, and comments and areas of disagreement were
age—Opinio V.7.12 (1998–2020 ObjectPlanet, Oslo, Norway). collated and analysed and grouped by theme.
The responses from the initial survey were collated and anal-
ysed with a thematic and factor analysis53 (see online supple- Steering committee
mental file 1). The expert panel identified four key domains, The surveys were designed by two experienced clinical academic
which included rehabilitation and RTR and RTS. This paper physiotherapists, and a professor of orthopaedic surgery, who
deals with results of rehabilitation and RTS, with previous papers each have greater than 20 years clinical experience treating HSI
covering classification and surgery. The questions were presented and research expertise in HSI, as well as previous experience
for discussion. All the panel members who completed the survey with Delphi research. A structured, iterative process was under-
were invited to the discussion meeting, which comprised a 2-day taken to develop the survey and it was piloted by a mixed group
meeting, alongside an international conference, to allow as many of five sports medicine physicians, five physiotherapists and five
of the participants to join as possible. A nominal group consensus orthopaedic surgeons, and the survey was further refined based
model was followed with a facilitated, structured approach to on their feedback. The expert panel were approached by email
gather qualitative information, from this group.54 This approach located from publicly available correspondence information
has been followed in other consensus projects.55 56 In discus- on organisational web sites or peer reviewed journal articles.
sions, facilitators maintained impartiality and ensured balanced Information was provided prior to participation but actively
discussion to avoid discussions being dominated by the most completing the survey was implied (and stated) as the consent
eminent clinicians/academics (‘eminence’ bias). They aimed to to participate. Any participant who withdrew had data removed.
work toward agreement but not force consensus. Dissenting and
outlier views were considered important, representing differ- RESULTS
ences in practice. This approach aimed to avoid ‘herding’ bias.57 The response rate and participant characteristics for those who
The key consensus statements were synthesised and refined. The participated in each round of the survey are reported in figure 1
rehabilitation sessions were chaired by the steering committee and table 4 below.
author related to their area of specialisation—rehabilitation Round 1 of the survey obtained baseline information from our
(BMP), RTR/RTS (MG). Statements were gradually refined experts on which areas of rehabilitation and RTS required more
through a process of facilitated debate until the entire panel were research. The open-ended responses were grouped and analysed
satisfied and on day 2 were put to the group for anonymous thematically (see tables 5–7).
electronic voting (see online supplemental appendix 4 for the Consensus statements were constructed, refined and agreed
complete list of statements—rehabilitation, RTS/RTR, classifica- after facilitated debate at the face-to-face meeting days. State-
tion and surgery). ments were sent in round 2 of the survey to a wider body of
The consensus steering committee established an a priori global experts and the LOA with statements are represented in
criterion threshold of 70%, with ≥70% agreed/yes responses tables 1, 2 and 7. Those statements reaching 70% agreement or
constituting statement acceptance. Overall, 70% has been used above are highlighted. Typical discussion points are also shown to
successfully by other Delphi studies.58–60 Statements reaching display common responses and disagreement from open-ended

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Consensus statement

Table 1 Consensus statements and percentage agreement for round 2 survey—global expert panel and rehabilitation
Samples of typical responses—discussion points or areas of

Initial and progressive loading of injured hamstring muscles should include exercise 89.8% 8.5% 1.7% Initial loading about neuromuscular stimulation and improving healing/
with different: contraction types, muscle lengths, functional movements, body muscle tension at length not ideal/initial loading isometric to minimise
positions, but the type of exercise will depend on the sports-specific adaptation stress or shearing on tendon/eccentric contractions should be the focus.
required, symptoms and risks of reinjury.
The order and speed of progression of exercises— Adaptation required 96.2% 0.0% 3.8% The level of agreement reflects the importance of the target adaptations
(concentric/isometric/eccentric exercises), hip required as a criterion for prescription.
and knee-based exercises, inner and outer length Symptoms 88.9% 7.4% 3.7% Symptoms were the main criterion used by rehabilitation clinicians to make
exercises and open and closed kinetic chain decisions.
exercises)—will depend on:

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Type of injury 75.0% 15.4% 9.6% Overall, the injury and tissue type were major considerations for clinicians
in deciding on exercise.
Risk of recurrence 60.4% 26.4% 13.2% No comments made? Possibly reflecting the little literature available on
this.
Stage of tissue healing 90.7% 5.6% 3.7% Tissue and stage of healing showed strong agreement—discussions
suggested that it was harder to know at tissue level how healing was
progressing, and symptoms were used as a surrogate to this.
The criteria for progression of exercise should Symptoms pain 90.7% 1.9% 7.4% Symptoms were the main criterion used by rehabilitation clinicians to make
include: decisions.
Strength 92.7% 3.6% 3.6% While strength overall showed good agreement—there was less
agreement on which components of strength were thought to be most
important.
Special tests 62.7% 13.7% 23.5% Lack of agreement on specific tests—but a combination of factors was
thought to be more important.
Functional milestones 87.3% 5.5% 7.3% Function was agreed to be important—but the panel could not agree on
which functional milestones are most important.
Flexibility 67.9% 17.0% 15.1% Flexibility and range of movement (ROM) were thought by the panel to be
less important as a criterion—and comments were that strength exercises
at longer length were sometimes used to build flexibility concurrently with
strength.
The severity of the injury 73.1% 15.4% 11.5% After the initial diagnosis and early treatment stage, the progressions were
led more by the above criteria than the severity of the injury—although
many issued cautions with tendon injuries and higher-grade tendon
injuries due to risk of re rupture.
The dosage of exercise (frequency, intensity, The response to previous loading 96.3% 1.9% 1.9% Graded process of loading and assessing response—both during and after
duration) should be based on: exercise—especially in terms of pain—it was felt this gave the optimum
speed of rehab.
Examination findings 88.2% 9.8% 2.0% High agreement that examination was vital prior to progressions in dosage.
Stage of Healing 86.5% 7.7% 5.8% Appropriate healing level to tolerate applied loads.
Periodisation factors 88.2% 3.9% 7.8% Weekly and seasonal factors affect decisions on dosage and are key
considerations in elite sport environments.
Sporting level 82.7% 15.4% 1.9% These three questions related to knowing the end goal in load capacity for
Current and previous capacity 88.7% 7.5% 3.8% match fitness, which will depend on type and level of sport.

The target adaptations related to 92.3% 3.8% 3.8%

the patient’s goals and or sport
Strength 92.6% 3.7% 3.7% Training principles of overload—ensuring strength loads are progressed
to enable muscle to keep adapting—that is, avoid accommodation to the
equivalent applied loads.
Fitness 78.8% 13.5% 7.7% Cardiovascular fitness may not affect dosage in gym-based work but will
affect running work.
Severity of the injury 84.6% 11.5% 3.8% It may not be appropriate to load some injuries too heavily—as they may
not have symptoms but still be at risk of retear—i.e. biceps femoris and
central tendon involvement.
The whole rehabilitation process should be agreed within the MDT and have athlete 96.8% 1.6% 1.6% MDT and athlete engagement were key—the discussions were around all
engagement. the stakeholders’ potentially conflicting goals and timeframes.
The patient’s sport and previous level of participation will impact the progression of 95.2% 3.2% 1.6% The discussions were like the three questions above.
exercise selection and ultimate return to activity.
It is important to consider the possibility of sciatic nerve/neural symptoms when 90.5% 0.0% 9.5% Strong agreement.
considering a patient’s progression through rehabilitation. Neural mobility could be
considered in treatment but the protection of the repaired or vulnerable tissue should
be maintained.
Adjuncts to rehabilitation, such as blood flow restriction (BFR), electrical stimulation 68.9% 6.6% 24.6% There was less uniform global practice when relating to use of adjuncts
and hydrotherapy should be considered in the early stages to enhance tissue healing such as BFR—this reflects small evidence base only in HSI
and recovery (caution should be used with cuff pressures over repairing tissues when
using BFR training).
Rehabilitation should be monitored with appropriate markers that are progressive 98.4% 0.0% 1.6% Monitoring was agreed but the most common form of monitoring was very
with recovery. varied—most panellists mentioned monitoring with global positioning
system data allowing on field training/match play load data.
Final stage strengthening should aim to achieve adequate symptom free, outer range, 95.2% 1.6% 3.2% Panel had agreement on the types of strength to be achieved by final stage
eccentric and isometric strength in injured and uninjured limb. rehab—with outer length eccentric and isometric strength—in line with
evidence on strength.

Continued

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Consensus statement

Table 1 Continued
Samples of typical responses—discussion points or areas of

It is key during a hamstring rehabilitation to assess, treat and prescribe exercises 90.5% 3.2% 6.3% Panel agreed that biomechanical kinetic chain was important but there
addressing the whole kinetic chain. was less agreement on which were the most important components—
many panellists suggested that it should be individualised and decided
based on thorough subject and objective examination.
MDT, multidisciplinary team.

questions. The order of the statements is based around the associated with early rehabilitation progression,61 but other

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decision-making stages of rehabilitation—early/middle/late/and reviews suggest range of movement (ROM) and flexibility
RTR/RTS stages. are less important.62 63 Motor control and recruitment were
not prioritised by as many experts, possibly reflecting lower
DISCUSSION volumes of evidence and difficulties with measurement. Clin-
This modified Delphi aimed to reach expert consensus on the ical reasoning to inform load prescription using assessment and
rehabilitation of HSI over three rounds, comprising two online specific criteria, rather than time associated prescription, was
surveys separated by a consensus group meeting which estab- preferred. Outer length eccentric and isometric strength capacity
lished consensus statements around: rehabilitation (11), RTR (8) was required by the end stage of rehabilitation, in alignment with
and RTS (12). Further expert voting in the final round online review evidence on prevention of injury17 18 64 and prevention of
survey further refined these statements, with key statements recurrence.65 66 The response to previous loading and strength
reaching the a priori agreed 70% agreement (rehabilitation (92.3% LOA) should be prioritised to decide the dosage of exer-
(11), RTR (8) and RTS (9)). The discussion is ordered around cise/load (LOA 96.2%).
the consensus statements relevant for the stages of rehabilita-
tion—early/middle/late stages. Influence of tissue healing
The stage of healing was important in deciding dosage of loading
Initial and progressive loading: type and dosage of exercise (LOA 86%). Components of muscle tissue (fascia, muscle cells
Exercise prescription should aim to prepare the injured hamstring and tendon) heal and adapt to loading at different rates after
for the sports-specific capacity required (LOA 89.5%). Multiple injury67 and this has implications for time frames of healing,
types of exercise were agreed to be important but there was no loading and recovery.68 69 Rehabilitation should be clinically
agreement on which exercises were best at each rehabilitation reasoned and individualised, based on the type of injured
stage. When deciding on initial loading, pain, athlete confidence tissue, and its speed of healing and adaptation.70–74 Optimising
and classification of injury were important, but flexibility, gait progressive dosage of loading (volume, frequency, intensity and
and strength were ranked low. This is not aligned with evidence, duration) should encompass sufficient overload to promote
suggesting that strength in outer lengths and flexibility are both adaptations but not cause tissue reinjury,75 which may vary for

Table 2 Consensus statements and percentage agreement for round 2 survey—global expert panel and return to running
Samples of typical responses—discussion points or
Statements related to return to running True False Undecided areas of disagreement
On pitch/track/field (sport specific) running is a significant part of 98.4% 1.6% 0.0% Levels of agreement for these two questions reflects the
hamstring rehabilitation. importance of running as part of hamstring injury (HSI)
rehabilitation.
Running dosages should be gradually increased to ensure return to full 100.0% 0.0% 0.0% Hamstring muscle function discussed and difference in
sprinting. function at speed was acknowledged.
Sprinting dosage loads should approach game level intensities and 95.2% 4.8% 0.0% Sprinting in games presents injury risk and sprint work is a
volumes to reduce risk of recurrence on return to sport. key component in final phase rehabilitation.
Further research should investigate the specific actions, bias, roles of 84.7% 0.0% 15.3% Differences in muscle roles were discussed and the panel
individual muscles in function of running and sprinting to aid rehab expressed need for more research into how the differences in
exercise prescription. muscle function will then impact rehabilitation.
Further research should investigate types (styles) and dosages of 90.3% 1.6% 8.1% Discussions suggested that running had not been prioritised
running (quantity, speed) that promote adaptations but reduce risk of sufficiently in literature and identified a research need.
recurrence.
Further research should investigate safe time frames to commence 90.3% 1.6% 8.1% Risk of reinjury is high when re-exposing HSI athletes to
running post HSI or surgery. running—and the panel wanted after time frames for
return—and more research into timeframes.
Mild pain with running is permissible in rehabilitating certain HSI, but 83.9% 9.7% 6.5% The panel acknowledged many athletes have pain when
we need to consider the function of the individual, the anatomy, injury, restarting running—there was less agreement on how much
classification and the 24-hour pain pattern (subjective and objective). pain was permissible/deleterious—the stated consideration
factors reached agreement but other factors did not.
In HSI, pain-free running is a criterion for return to sprinting. 85.5% 8.1% 6.5% The panel agreed that pain levels should be reduced prior
to permitting sprinting—the panel acknowledged that the
initial commencement of full sprinting—was a high-risk
period for reinjury.
MDT, multidisciplinary team.

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Consensus statement

Table 3 Consensus statements and percentage agreement for round 2 survey—global expert panel and return to sport
Samples of typical responses—discussion points or areas

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Progression to peak isometric force in mid and outer range, 83.3% 1.7% 15.0% Optimal types of exercise were controversial but consistent
isotonic strength (eccentric only/eccentric and concentric) are all with literature—eccentric or isometric exercises at length were
considerations for RTS. considered important and reached agreement.
Benchmarks for strength should reflect the end goal demands of the 66.1% 10.2% 23.7% The low agreement for this question reflected differences in
athlete but should be within 10% of previous data or population opinion on strength benchmarks.
means.
Athlete subjective apprehension is a consideration for RTS criteria. 98.3% 0.0% 1.7% The strong agreement reflects the importance the panel placed
Athlete self-assessment of their readiness to RTS is a key factor in the 86.7% 5.0% 8.3% on the athletes leading the RTS/return to running process—and
RTS decision-making process. ensuring their opinion was prioritised.
Askling H-test is a useful test in the return to sprinting decision 57.6% 18.6% 23.7% The respondents were divided on use of pain provocation tests.
process. Their usefulness was acknowledged but it was felt that no one
specific test could assess readiness to return to sprinting—and
the tests should form part of an ongoing assessment and
clinical reasoning process.
Endurance capacity testing of the hamstrings should be a 78.3% 6.7% 15.0% Endurance was felt to be important, but it was harder to get
consideration for RTS. agreement on which endurance tests were most important—
running endurance was felt to be important but the panel
suggested that the level of endurance related to the specific
sporting demands.
Pain-free sprinting is a criterion for return to play. 96.7% 1.7% 1.7% The importance of sprinting in match play/competition was
acknowledged, with high agreement. There was less agreement
on the dosage of full sprinting. While some pain was permitted
in running, sprinting in RTS—was expected to be pain free.
Completing full unrestricted training session should be a criterion for 93.3% 6.7% 0.0% Training sessions reached agreement—particularly as this
RTS. assessed the athlete with sports-specific demands and
endurance requirements.
The use of previous GPS metrics can guide the required dosage 83.3% 3.3% 13.3% Many in the panel were using GPS to measure running
of appropriate metrics, that is, volume, sprints, speed, high-speed dosage—and their usefulness was thought to be key—with
running. practice expertise moving faster than research evidence base—
this was thought to be an area requiring greater research.
RTS should be a multidisciplinary process that involves all 98.3% 0.0% 1.7% The importance of a whole MDT and coaching athlete
stakeholders ideally. stakeholder involvement reached hight level of agreement—
but many clinicians acknowledged significant pressure from
stakeholder groups to modify their clinical decision-making.
GPS, global positioning system; MDT, multidisciplinary team.

each myotendinous structure (fascia/muscle/musculotendinous contractions, contraction at long lengths, eccentric contrac-
junction (MTJ)/tendon). This follows evidence of faster time tions and stretch shortening cycle (SSC) contractions (jumping,
frames for healing of myofascial (type a),76 versus MTJ (type plyometrics and running). They disagreed, however, on the
b), which heals via satellite cell induced myogenesis and tendon time frames for protection, with most suggesting that timing
(type c) injuries,77 78 which depend on collagen synthesis and or protection should relate to presence or level of symptoms.
replacement and remodelling.79 80 The type of tissue may influ- Symptoms, however, were thought to provide only a surrogate
ence the amount of early protection required80 and the risk of measure of healing, and in some types of injury, adequate fixed
recurrence, with more protection required and greater risk in tissue healing time may be required (ie, tendon and CT injuries).
type c or tendon type injuries.81 Hamstrings have complex intra- Symptoms may resolve while the healing tissue is still vulner-
muscular tendon architecture and injuries to these structures are able. This represents a conflict between symptom- based and
often poorly recognised,82 with poor rehabilitation outcomes83 time-based rehabilitation approaches and both may be required.
and may require further protection, although this remains
controversial.84 Repaired tendon tissue may not regain preinjury
biomechanical properties, even at 12 months.85 Longer protec- Commencement of loading and exercise prescription
tion may be required, particularly from elastic or strain loads After initial protection, the primary rehabilitation goal is to
like running, sprinting, jumping and other sports-specific move- progressively load recovering tissue to promote its optimal adap-
ments requiring tissue elasticity6 (LOA 92.3%). For HSI, our tation back to full strength, elasticity, capability and function.6
panel suggested early protection may be required from activities The type of muscle contraction prescribed in exercise (eccen-
such as weight-bearing (high-grade injury), stairs and high force tric,35 isometric86 and concentric87) produces different force

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Consensus statement

outputs and loads on muscle tissues, leading to different adapta- at longer lengths may increase fascicle length,92 93 changing the
tion and requiring different periodisation and recovery times.88 89 length tension relationship in muscle and reducing injury risk.94
Early eccentric loading was typically avoided by our experts The hamstring muscle group comprises two joint muscles
due to perceived reinjury risk and loading commences with and muscle function differs depending on the mobile joint, but
isometric contraction at shortened lengths. This follows histor- also whether the mobile segment is fixed (or in a closed kinetic
ical guidance.90 Isometric contractions, however, (depending on chain) or free, in an open kinetic chain. Recruitment will differ
the muscle length and effort) can produce greater tensile force with reversal of the mobile versus fixed attachments.95 96 For
loads within tendinous CT than do eccentric loads.91 Heavy hamstrings, hip versus knee dominant exercises load different
loads may, therefore, be applied too early, but this may inadver- parts of the muscles,97–100 with different training effects. Our
tently allow earlier adaption within CT and speed rehabilitation. panel advocated applying both types, but without agreement on
However, some of our panel and some authors suggest that it which should be first.
may be advantageous to safely expose tissue to paced eccentric Exercise speed and elastic function in rehabilitation prescrip-
loads.28 92 Outer length, eccentric and isometric strength work tion was emphasised by only small numbers in our panels
was certainly an ultimate goal (LOA 95%). Loading hamstring (outlier view), but evidence suggests that adaptations to training

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or jumping.102 Elasticity also works across long fascial slings of
Table 4 Participant characteristics of the expert panels
CT, as well as within individual muscles.103 Deciding when to
Survey Survey final
allow elastic load and SSC activities has importance,102 including

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Clinician+researcher 30 (85.7%) 15 (100%) 62 (63%)
Neither clinician nor researcher 0 1 (1%)
the amount of negative work106 and force107 all increase. Typi-
Hamstring cases/year None 0 5 (5%) cally, our experts reported not exposing injured tissue to running
0–5 1 (2.9%) 6 (6%) early, but in certain injury types, in controlled situations, this
5–9 6 (17.1%) 25 (24%) loading, may allow earlier tissue adaptation.
10–14 7 (20%) 12 (12%) We did not reach consensus around neural activation and
15–19 10 (28.6%) 13 (13%) motor control, which were only highlighted by small numbers on
20 or more 11 (31.4%) 38 (38%) our panel (outlier viewpoint), reflecting some evidence finding
Healthcare profession Sports medicine physician 4 (10%) 1 (7%) 21 (18 %)
neuromuscular deficits and inhibition after HSI.108–110 Many
Orthopaedic surgeon 8 (21%) 5 (35%) 18 (17 %)
clinicians include exercise for muscle activation, to address this
inhibition and control,111 and different hamstring exercises acti-
Physical therapist 22 (55%) 10 (64%) 43 (40 %)
Sports scientist 1 (3%) 25 (24 %)
vate muscles very differently,112–114 with implications for neural
Athletic trainer/strength and 2 (5%) 7 (6 %)
conditioning coach components to strength. Reinjury risk can be higher with lower
Other 2 (5%) 2 (2%) levels of muscle activation in warm up.115 Neural movement may
Country of practice North America 4 (11%) 10 (10%) be important, with neuromeningeal mechanisms to some HSI
Europe 26 (66%) 12 (80%) (UK,
Neth, Ir)
65 (64%) proposed,116 and assessment and treatment of neurodynamics
Middle East/Africa 4 (11%) 1 (7%) SAf 12 (12%)
can have significant effects on symptoms and flexibility.117–119
Southeast Asia 1 (1%)
South America 1 (1%)
Flexibility
Australasia/pacific 5 (13%) 2 (13%) (Aust) 10 (10%)
The commencement of flexibility work recommended after HSI
Sports Football 31 (29%) 4 (27%) 79 (80%)
Athletics 19 (19%) 2 (13%) 59 (60%)
is varied and we did not reach consensus. Lack of hamstring flex-
Rugby codes 13 (12%) 4 (27%) 40 (40%)
ibility is a possible risk factor for HSI and reinjury120 but can be
NFL (North American football) 5 (5%) 9 (9%) present after injury.121 Some authors advocate flexibility work
AFL (Australian Rules football) 3 (3%) 9 (9%) after HSI34 122 but other evidence suggests flexibility may not be
Basketball 9 (9%) 30 (30%) a risk factor for reinjury.63
Volleyball 4 (4%) 1 (1%)
Skiing and winter sports 9 (9%) 21 (21%)
Hockey 3 (3%) 1 (7%) 22 (21%)
Monitoring and progression of exercise
Judo/martial arts/wrestling 2 (2%) 24 (24%)
Progression of exercise maintains ongoing adaptation to
Cricket 15 (15%) training.123 There was strong agreement for monitoring through
Ice hockey 12 (12%) rehabilitation (LOA 98.4%). Exercise progressions should ideally
Acrobatics/gymnastics/dance 17 (17%) be made based on criteria. Having specific adaptation goals
Gaelic football 7 (7%) (LOA 96.1%), considering tissue healing (90.4%), or the type of
Racquet sports 17 (17%) injury (75%), and using symptoms (88.5%), such as pain, were
Handball 20 (20%) considered important criteria for progression. There was less
Other 9 (8%) 4 (27%) 6 (6%)
agreement on recurrence risk (60.4%) affected decision-making.
Years working with 0–4 5 (14.3%) 17 (17%)
hamstring injury Risk of recurrence did not reach consensus. This may reflect the
5-9 8 (22.9%) 13 (13%)
pathology lack of research into what types or speeds of progression affect
10-14 9 (25.7%) 22 (21%)
15–20 4 (11.4%) 23 (23%)
reinjury risk. Strength, rather than pain, was the most important
More than 20 9 (25.7%) 24 (24%)
criterion for progression, indicating that some clinicians prefer
Highest academic Bachelor/diploma 14 (14%) to tolerate some level of pain (pain threshold), although, a high
achievement
Masters 35 (35%) proportion of the panel wanted tissue to be pain free prior to
PhD 34 (35%) progression.28 92
Clinical doctorate 15 (15%) We did not achieve consensus on the optimal order of exer-
Had hamstring injury Hamstring problem 38 (38%) cise progression but did agree that this should be individualised
personally
Not applicable 61 (62%) based on the level and type of sport and required capacity (LOA
Aust, Australia ; IR, Ireland; Neth, Netherlands; SAf, South Africa.
95%). Rehabilitation should be commenced and progressed
with a sport-specific end target goal/capacity (LOA 96.2%) and
that loading of the injured muscle(s) should follow the muscle
are influenced by contraction speed and elastic function. Muscle actions, demands roles in the athlete’s sport and level of play.
CT is an elastic energy store and tendon strain and elastic/spring Injury patterns in some sports relate to slow speed stretch type
behaviour are vital to hamstring muscle function, but involve forces with contracting muscles.124 Sports such as rugby or
high tensile loads on the tendon and muscle CT.101 This elastic/ American football see different HSI mechanisms with high load
spring behaviour must be restored for activities such as running slow stretch injury, typically involving the semimembranosus and

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Consensus statement

Table 5 Round 1 survey: what are the key questions that you would like answered regarding the early phase of rehabilitation after hamstring
injury (HSI)?

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Modalities for inflammation/healing (RICE, Meds) 5 Does prolonged use of ice, compression or medication positively or negatively affect
hamstring healing rates?
Timescales (start and progress load) 4 How early can we safely prescribe eccentric/long length exercises?
Flexibility/range of movement 3 Is there a role for knee flexibility work?
Immobilisation and bracing (optimum, effects) 3 Does initial immobilisation positively or negatively affect hamstring healing rates?
Neural factors, inhibition and activation 3 What are the outcomes of return to run process, early versus delayed versus criteria based,
versus early introduction of eccentrics—any effect on neuromuscular inhibition?
Optimum dosing (frequency, intensity, duration) 2 What exercise dosages are optimal for loading early phase after hamstring injury?
Safety of early loading 1 Does early mobilisation/rehab including stretching and activation of the hamstring speed
or limit recovery?
Tissue strain load/exercise 1 What is the strain placed on muscle/tendon by different rehab exercises?
Weight-bearing 1 When does initial reduction in weight-bearing help or hinder healing?
Early strength 1 What are the outcomes of early introduction of eccentric exercises?
Total 50
EMS, electromagnetic stimulation; RICE, rest, ice, compression, elevation; STM, soft tissue massage.

fascia, with extremes of hip flexion and knee extension.124 125 protocols, and when to commence them, is less clear in reha-
Sports involving jumping, pivoting or kicking126 differ again in bilitation. Hamstring contractions in high-speed running (HSR),
hamstring and lower limb kinetic chain function.127 Rehabilita- however, involve controlling concurrent knee and hip high-
tion exercise should, therefore, be chosen, adapted and targeted speed single leg angular motions128 and it may be appropriate to
specifically to the functional requirements of the injured consider biarticular single leg exercise.
muscle98 111 in the sport and its injury risk movements.
It is historically suggested that knee-based exercise be intro-
duced prior to hip- based exercise. Hip-based protocols such Subjective and objective longitudinal monitoring throughout
as the L Protocol require the hamstrings to function at longer rehabilitation
muscle lengths and are effective in elite sprinters23 and footbal- Progression of rehabilitation should be reasoned and based on
lers24 for HSI prevention. The advantage of hip over knee-based ongoing assessment including both subjective and objective

Table 6 What questions would you most like answered on exercise prescription in hamstring injury (HSI) rehabilitation?
Domain area (theme) Responses Typical responses
Progression of exercise 8 What is optimum order of progression of exercise? inner to outer? short length to long concentric to eccentric to
isometric? open kinetic chain versus closed kinetic chain? knee to hip based?
Dosage 5 What is the optimum dosage of strength exercise?
Contraction types 5 What type of contraction should be emphasised during hamstring injury rehabilitation?
Running/sprinting 4 What is a safe but stimulating dosage of pitch-based running?
Exercise choice 4 what are the optimal exercises for hamstring injury prevention?
Importance of symptoms 3 How effective is early introduction of eccentrics and pain threshold training?
Safety versus effectiveness balance 3 What is a safe but stimulating dosage of strength exercise?
Tissue healing stage 2 What modes of exercise should be carried out at certain healing stages?
Timing 2 When should certain exercise types, isometric, concentric, eccentric, stretch shortening cycle be implemented
throughout rehabilitation?
Insufficient evidence 2 Can we get more insights to the specific mechanisms of HSI at a contraction mode, neural and structural level to aid
prevention and rehabilitation exercise choices?
Flexibility 1 What are the effects of flexibility exercises?
Strength 1 What types of strength are crucial?
Which muscles 1 How best do we target loading the biceps femoris long or short head and do we need to?
Functional exercise 1 More randomised controlled trials (analogous to those employing the Nordic) exploring the functional effectiveness
of different exercises.
Neural factors 1 Which exercises promote optimal hamstring activation?
Total 43

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Table 7 What are the questions you would like answered on return to running and sport after hamstring injury?
Domain area (theme) Responses Typical responses

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Timing 4 How early is it safe to sprint?
Total 30

measures,129 as well as evidenced-based criteria. Many of the tests such as handheld dynamometry (HHD) are more reliable,
criteria that clinicians use to progress load are investigated only but still show questionable validity and reliability.146 Tests such
in subsets of the HSI population61 or not at all.28 as prone knee bend testing at 15° with HHD26 or knee flexion in
supine with hip flexed, which test outer length hamstring func-
Imaging tion, can better mimic sporting or injury risk situations. Other
None of our expert panel recommended using imaging findings measurement devices such as the Nordbord147 have been used as
as criteria for progression, and this was not added as a consensus a criterion for RTS and progression, citing evidence of Nordic
statement. MRI findings show poor significance at RTP130 131 and hamstring exercise (NHE) to prevent HSI148 but a recent meta-
our outcomes align with another consensus statement in football, analysis reported inconclusive evidence of NHE preventing
where medical imaging was not recommended to inform RTS HSI.149
decisions.49 While imaging is used for classification and grading Other muscle strength tests, such as hand held dynamom-
of injury, which assists rehabilitation prescription in practice,16 29 etry and isokinetic dynamometry,150 and the derived hamstring
imaging could not be used to determine restoration of muscle to quadriceps151 or concentric to eccentric121 152 153 ratios may
and CT architecture and load capacity. be beneficial,28 although other evidence suggest less utility to
predict risk of reinjury154 155 or RTS.156 Tests, however, cannot
Clinical examination findings/assessment isolate/quantify individual hamstring or posterior chain muscle
Many studies use clinical examination components as the main contribution157 and other knee and hip muscles, such as gastroc-
decision-makers for progressions as they show greater predic- nemius or adductor magnus, may compensate for hamstring
tive value than imaging modalities such as MRI.132 133 Several muscle deficits. The different sport- specific body positions,
studies have investigated the most important examination functional roles and speeds of the individual hamstring muscles
findings.134–137 in sporting tasks (ie, sprinting) are difficult to assess with these
Pain was the most important criterion for rehabilitation tests and our experts reported combining these tests to measure
progression (LOA 90.4%). Traditionally, the absence of pain was multiple parameters of strength.158 More valid/sports- specific
the criterion for progression,40 although some pain is accept- tests to aid progression in strength prescription in rehabilitation
able28 49 and rehabilitation with a permitted pain threshold has are needed.
been found to be beneficial.65 138 139 Slower pain-free progres- Some of our experts used surface electromyography (sEMG),
sion is advocated in high-grade or tendinous HSIs.16 140 141 Pain measuring the contribution of each posterior chain (hamstring)
threshold rehabilitation may not accelerate time to RTS, but muscle in exercises and detect neuromuscular inhibition108;
may accelerate restoration of isometric knee flexor strength and however, other authors highlight poor validity and reliability of
maintain biceps femoris long head fascicle length, compared sEMG.159 Further research is warranted, as some central nervous
with pain-free rehabilitation.92 system changes are present after HSI110 and may be implicated
ROM/muscle flexibility scored highly with our experts as in recurrence.
progression criteria (LOA 67.9%) but did not quite reach
consensus threshold. Some evidence suggests that flexibility
and ROM tests, however, may correlate with time to return to Adjuncts
sport.61 Tests such as Maximal Hip Flexion Active Knee Exten- Adjuncts to strengthening which enhance muscle adaptation, but
sion (MHFAKE)142 and straight leg raise120 may be useful. Clini- with lower tissue joint loads are frequently used in early reha-
cians may also consider the use of modified Thomas Test143 or a bilitation. Examples include muscle stimulation and strength
slump test for neurodynamic assessment.118 119 training with blood flow restriction (BFR), which allow earlier
Muscle strength was scored highly by our panel as a key exam- commencement of strength training, at lower levels of load.
ination progression criterion (LOA 92.5%), following evidence Their utility did not reach consensus in the final round (LOA
of strength tests correlating closely with clinical progression 67.8%), although BFR was used by all the rehab clinicians in our
and running effort.61 132 We did not have consensus on the consensus meeting panel, reflecting differences in global clinical
most important types of strength or optimum measurement practice. Few studies have examined their use after HSI. There
methods but agreed that outer length and eccentric strength is growing evidence for effectiveness in other conditions such
were key (LOA 95%). This follows evidence that outer length as anterior cruciate ligament reconstruction,160 and our panel
tests correlated more with progression than mid or inner range reported adapting protocols for HSI.
strength tests.61 132 Quick convenient tests, such as manual The use of EMS and hydrotherapy was identified as being
muscle tests show low validity and reliability.144 145 Instrumented part of current practice,161 162 particularly in the early phase of

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Consensus statement
rehabilitation,26 although the optimal use of these modalities activity.185 Some pain is expected, and they agreed mild pain may
remain unknown. be acceptable (LOA83.1%) but did not agree on a tolerated pain
threshold. They suggested a tolerated threshold level of pain

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RTS (LOA 77.6%). The statement around sciatic nerve showed
strong agreement (90.5%), reflecting its proximity and frequent on hamstring functional demands in running and rehabilitation
involvement in high-grade HSI, where the nerve can be trac- programmes.23 24
tioned or tethered. Associated symptoms warrant investigation The panel identified flexibility and ROM factors as important
and possible surgical consideration. prior to RTR, with tests such as MHFAKE,61 although the
Some of our experts suggested hip and pelvis biome- literature suggests flexibility is not a risk factor for reinjury.63
chanics influence HSI risk. Sacroiliac joint mobility and force Large differences were present in their choice of special tests
closure163 164 and ilial asymmetry both affect the pelvis and for RTR, with examination type tests or jump/hop testing was
ischial tuberosity position, altering length tension relationships also used,186 in line with evidence on reactive strength index187
in the hamstrings. Pelvic control and gluteal muscle activation as a risk factor for injury but these tests also lacked agreement,
associates with HSI in running.165 Gluteal versus hamstring reflecting conflicting evidence on evaluating HSI risk using
contribution in hip extension,166 femoroacetabular impinge- power and plyometric testing.63
ment,167 168 lack of hip flexion,169 lumbar spine L5/S1 nerve root
pathology170 and trunk strength with altered EMG activity171 Criteria for sprinting
have all been implicated in HSI risk. Other studies, however, do No consensus was reached on criteria for safe return to sprinting,
not implicate proximal kinetic chain muscles after HSI and the reflecting the lack of evidence quantifying sprint loads and
picture may be more complicated.172 Our panel advocated for a risk of reinjury. There was 100% agreement that loads should
kinetic chain approach that individualises assessment and clinical be increased to full sprinting prior to RTS. This reflects their
reasoning for each athlete. awareness of the hamstrings functional role in full sprinting and
the increased tissue strain rates with elevated running speeds.188
Return to running Progressing running too rapidly in rehabilitation may risk retear
Running and sprinting were identified as a key components of but altered running kinematics63 and even insufficient running
rehabilitation after HSI (LOA98.4%) (table 6). This reflected conditioning189 190 may also increase risk of reinjury. More
literature suggesting HSR exposure173 174 and poor prescrip- research into optimum dosages of running to prevent reinjury
tion of running64 are risk factors for HSI and reinjury. The risk is needed (LOA 90%).
hamstrings are integral to running and sprinting,175 176 particu- There was some difference in criteria that our panel used
larly in end swing and early stance phases177 when large forces to permit return to sprinting, with higher speeds emphasised
and rates/amounts of strain178 are present within the hamstring in strength testing. Few of our panel mentioned power or rate
CT.101 104 179 In running, the three hamstring muscles show of force development testing, and clinicians disagreed on the
different activation, at different lengths178 and velocities,12 180 required threshold of strength, often using only the percentage
and with different force outputs.98 111 175 In sprinting, semiten- of strength of the uninjured limb—the limb symmetry index
dinosus undergoes the largest lengthening velocity, with semi- (%LSI) to quantify, but with strong acknowledgement that the
membranosus, functioning with the greatest force production unaffected limb was rarely normal. Special tests as criteria for
and biceps femoris undergoing the largest strain,11 175 with sprinting (such as the Askling H- Test185) did not reach high
some studies suggesting thatBiceps Femoris long head can reach levels of agreement (56.1%), but there was strong agreement
112% of its resting length179 181 (possibly the reason why this on completion of submaximal running phases as a criterion for
muscle is more frequently injured in HSR mechanism31 182 183). returning to sprinting, although the panel disagreed on threshold
The muscles may also function differently based on the levels of volumes, intensities or speeds. This reflects the lack of evidence
acceleration.184 This may mean each muscle requires a different around the dosages of running required to reduce injury risk,
rehabilitation prescription for RTR. and our panel showed high LOA on the need for future running
Strong agreement between our experts highlighted that research into muscle roles (84.2%)/types of running (90%) and
different hamstring muscles play different roles in running, safe time frames (90%). Many of our panel prioritised global
which affects rehabilitation prescription (LOA 84.2%) and safe positioning system (GPS) data to benchmark, grade and target
time frames to progress running (LOA 90%). running loads, and evaluated on symptom response (pain
tightness) to graded running loads. They agreed that pain-free
running was a criterion for sprinting (LOA 85.5%). In the situ-
Criteria for RTR
ation of sprinting, where injury risk is higher, pain-free versus
Consensus was reached on a criteria-based approach rather than
pain threshold criteria were preferred.
time frames for RTR but differed on their preferred criteria.
Clinicians indicated their use of criteria related to pain, strength
and flexibility, but assessed running specific muscle functions Return to sport
and capacities.17 We acknowledged that the RTS phase was a reinjury risk period
Pain level was the main criterion chosen by the panel for RTR, and safe management was vital (table 7). Many athletes demon-
either on examination (palpation)65 or with a specific test or strate deficits in function, despite being cleared to RTS.122 147 The

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Consensus statement
highest risk period for reinjury after RTS is the first month,191 Performance tests and sports-specific/position-specific testing
with risks raised for the first year136 and competition running On-field tests of performance have also been used alongside
levels can remain suppressed even after RTS.43 running tests for return to play. These include hop and jump

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criteria, correlating with performance. It should be noted that Athlete confidence
a decision to RTS is a shared decision and the clinician’s role Athlete confidence and apprehension ranked highly in criteria
may be to provide information regarding risk rather than strict for RTS (LOA 98.6%). Player self- assessment, psychological
criteria to RTS.192 However, completion of full unrestricted readiness and confidence were seen as vital for RTS (86.7%),
training sessions was crucial (LOA 93.3%), as well as pain-free with negative emotions such as anxiety and fear avoidance detri-
sprinting (96.7%), with volume, speed and intensity at (and mental to performance and pain.200 201 Athlete confidence is the
preferably beyond) competition levels. This reflects evidence most significant predictor of return to full performance in some
showing ongoing deficits in force production and power in conditions such as ACL reconstruction.202 However, in HSI,
running—even at RTS,193 although appropriate prescription some athletes may present with few symptoms until sprinting,
and progression of loads can reduce reinjury risk.189 It should or SSC activity and athletes may feel ready to RTS but are still
also be recognised that in some sports, players can RTS but at risk of reinjury.
adjust their exposure to HSR loads.43 Monitoring external Our panel reported decision- making pressure from other
running workload using GPS allows more quantifiable, on-field non-medical factors203–207 and players can RTS in spite of
sports-specific (position-specific) loads, speeds as part of expert poor test results.208 They strongly agreed that decision-making
rehabilitation. The clinicians also recommended using histor- should include members of the medical/rehabilitation team, the
ical training and match play GPS baseline data as a benchmark coaches, other stakeholders and especially athletes themselves
(LOA 83.3%). Running load metrics include: speed, accel- (LOA 98.3%)192 209.
erations, distance, direction changes and number of sprints
efforts.49 194
Limitations
We agreed that endurance was a consideration (LOA 78.3%)
There are many potential weaknesses of the Delphi and
but there was less agreement on what type of endurance. It
consensus research methodology. Bias is possible with inade-
should be sports specific, relating to the sport’s volume of high-
quate stakeholder/expert inclusion/exclusion or with inade-
speed running. This follows evidence suggesting increased risk of
quate design of surveys or meetings. 210 In spite of invitation,
injury with lack of fitness195 and fatigue.196
many international round 1 expert panel respondents were
Factors such as ROM and flexibility, traditionally rated as
unable to attend our face-to-f ace meeting days, The London
important, failed to reach threshold agreement (45%). This may
2020 international Delphi and hamstring consensus meeting
reflect evidence on flexibility and static stretching causing some group comprised 15 out of 35 respondents/experts (43%)
detriment to elastic function and performance197 and review to the initial survey. This could result in inclusion bias;
evidence suggesting flexibility and ROM were less important as however, the panel attending were heterogenous, with a mix
reinjury risk factors.63 Few in the panel suggested imaging was of profession, sport, age and domain expertise in treatment
useful for RTS decision-making, in line with current evidence.63 of HSI. They comprised clinicians from Australia, Neth-
erlands, Ireland, the Middle East, but the majority of the
meeting panel were UK based. We sought and invited experts
Strength from Asia, Africa and South America; however, there were
Strength as a criterion for RTS reached consensus but the group less identifiable experts (clinical or published), and they
disagreed on which strength components were key. Mid and could not attend due to pandemic travel restrictions. This
outer length isometric and eccentric strength was agreed on may mean their HSI management practices are not repre-
(LOA 83.3%) in line with evidence on types of strength defi- sented, possibly introducing a further bias. Our meeting
cits posing injury risk.65 66 The quantity of strength required is panel all worked in elite sport in international jobs with
not clear, particularly in relation to the uninjured side (including work schedules with international patient/athlete cohorts.
the frequent benchmark of <10% deficit) (LOA 66.1%). This Many did not train professionally in the UK and their work
reflects a movement away from %LSI as a strength measure due experience and current work schedules comprised the USA,
to loss of unaffected leg strength post injury. Preseason bench- Africa, Middle East, Australia and Asia. They reported that
mark screening on variables such as strength/fitness, flexibility many of their athletes trained internationally, reflecting the
did not have a high LOA (64.9%) on which screening data to current international nature of elite and Olympic sport. To
prioritise and what % difference was permissible. General popu- further reinforce the integrity of the consensus, and provide
lation data were thought to be too non-specific. Sports differed more international perspective, authors were included with
in priority benchmark screening data and the %LSI consid- significant Middle East hamstring work experience.
ered acceptable. The panel suggested less correlation between Our group had multiple domains of expertise. These included
strength components and the ability to run and more research surgery, postsurgical and conservative rehabilitation, classifi-
may be required to understand if running criteria should be cation, diagnosis, running and RTS. It was harder to evaluate
prioritised over strength criteria for RTS (90.3%). expertise in rehabilitation and RTS, and the criteria chosen for

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Consensus statement
expertise were harder to establish for rehabilitation. Academic They recommend criteria of symptoms, strength and
criteria were thought to be important, but very few rehabilitation response to previous loading as criteria for progressing and
specialists had published. Clinical criteria were therefore deemed dosing exercise and deciding on safety to RTR and RTS.

Br J Sports Med: first published as 10.1136/bjsports-2021-105384 on 17 January 2023. Downloaded from http://bjsm.bmj.com/ on May 11, 2025 by guest.
important. For clinical experience, the number of patients seen Other criteria such as flexibility and special RTS tests are
annually with his by the expert was chosen (ie, quantity of expe- used less widely. On criteria related to pain, experts suggest
rience), but it was difficult to determine the range of injury types some activities should be pain free through rehabilitation
or severity and gauge the quality of rehabilitation experience. (sprinting), but with other exercise activities a pain threshold
Choosing criteria for expertise is difficult for any Delphi study approach can be permitted. In later loading, experts aim to
and represents one weakness of this methodology.211 While we achieve full outer length strength and eccentric strength as a
trusted the survey respondents to complete only those fields that key criterion for RTR and RTS.
encompassed their expertise (the reason for lack of full response In later-s tage rehab, experts advocate prescription of

Protected by copyright, including for uses related to text and data mining, AI training, and similar technologies.
rate for every section), it may be possible that some respondents running and sprinting as a key component of HSI rehabil-
completed sections that were outside their domain and level of itation and as a key progression criterion for RTS. Experts
expertise or scope of practice. Open-ended questions in the first focus on the demands and capacity required for match play
round meant that only the information that clinicians submitted when deciding the rehabilitation end goal and RTS—they
was used and adapted for the basis of subsequent rounds. continuously monitor and test athletes through rehabili-
The perspectives of some groups may be under-represented tation and are using modalities such as GPS to give more
in this work, with coaches and athletes comprising a smaller sports-s pecific on-f ield information on loading and running
proportion of our panel, and, their view is vital, 212 although dosages and RTS readiness and would like more research
38% of the panel in the final survey had undergone HSI, into optimising these testing modalities.
possibly contributing to the ‘patient/athlete’ voice.
While we attempted to be inclusive, the representation Author affiliations
1
of women is low in our panels, (2/39, 1/15 and 18/99). Institute of Sport Exercise and Health (ISEH), University College London, London, UK
2
Physiotherapy Department, University College London Hospitals NHS Foundation
We found the response rates lower for the women experts
Trust, London, UK
we surveyed and invited to our meeting. It was found that 3
Division of Surgery and Intervention Science, University College London, London, UK
female rates of publication are lower in HSI, with less 4
School of Sport and Exercise, University of Gloucestershire, Gloucester, UK
5
publicly available information on expertise. This also holds 6
High Performance Unit, Irish Rugby Football Union, Dublin, Ireland
for experts from low-to-m iddle income countries, and other Section Sports Medicine, University of Pretoria, Pretoria, South Africa
7
Princess Grace Hospital, London, UK
deserving groups with lower publication rates, or fewer 8
British Athletics, London, UK
English language publications, and less publicly available 9
AFC Bournemouth, Bournemouth, UK
information on expertise. This has been a weakness in other 10
School of Sport, Health and Applied Science, St. Mary’s University, London, UK
11
consensus research and the voices of these groups are also Trauma and Orthopaedic Surgery, University College London Hospitals NHS
vital. Foundation Trust, London, UK
12
Salford City Football Club, Salford, UK
13
Blackburn Rovers Football Club, Blackburn, UK
14
Orthopaedic Surgery and Sports Medicine, Amsterdam Movement Sciences,
Recommendations for future research Amsterdam University Medical Centers, Amsterdam, The Netherlands
15
The consensus panel members suggested the following area Amsterdam Collaboration for Health and Safety in Sports (ACHSS), Amsterdam IOC
Research Center, Amsterdam, The Netherlands
of HSI rehabilitation areas of future research: tolerability of 16
Sports & Exercise Medicine, Centre for Human Health and Performance, London,
tissue for early loading and the greatest injury risk loads or UK
dosages, which order of progression of exercise was optimal, 17
Medical Services, Arsenal Football Club, London, UK
18
neuromuscular control of running, muscle tendon interac- 19
Welsh Rugby Union, Cardiff, UK
tion/sling function and elasticity and optimum methods to Saracen’s Rugby Club, London, UK
20
Trauma & Orthopaedic Surgery, North Sydney Orthopaedic and Sports Medicine
measure and train these, and finally, the optimal and minimal Centre, Sydney, New South Wales, Australia
effective doses of running exposure to reduce reinjury risk.
Twitter Bruce M Paton @bpatphys, Nicol van Dyk @NicolvanDyk, Noel Pollock
@drnoelpollock, Michael Giakoumis @MickGiakoumis, Paul Head @PHphysio,
CONCLUSION AND RECOMMENDATIONS Sam Kelly @skelly_2, James Moore @JMoorePhysio and Simon Murphy
Our Delphi study and expert panel suggest that rehabilitation @simonmurphy23
prescription after HSI should be individualised, based on the Acknowledgements We would like to thank the large number of hamstring
athlete’s sports-specific hamstring demands, the nature of the experts who contributed their valuable time, effort and expertise in completing our
surveys. The consensus process and meeting were cocreated and funded by the
injury and required capacities. Decision-making should consider Institute of Sport Exercise and Health, London, UK and the Academic Centre for
differences in hamstring musculotendinous tissue, individual Evidence Based Sports Medicine, Amsterdam, the Netherlands. The consensus and
muscle anatomy and functional roles. This should direct reha- the launch of PHAROS were partly made possible by a grant from the International
bilitation prescription for different muscles and myotendinous Olympic Committee. We would like to thank also to Naomi Shah PT (India) and
tissues after HSI. In early- stage rehabilitation, most experts Magnus Hilmarsson PT (Iceland) who assisted with meeting days.
advocate protection of injured tissue from elastic load or stretch Contributors This manuscript is the combined effort of the attached authors.
shortening (high strain amount and rate loads), but the types of BMP drafted the initial manuscript. PR, MW, NvD, NP and JM contributed significant
drafting comments and edits. Other authors were all responsible for minor edits.
load/contraction and the order of their application varied greatly BMP, FH and JM were responsible for steering committee, research and survey design
between our experts. and facilitating the consensus meeting days (MG facilitated for running and return
Experts recommend addressing dysfunctions in the whole to sport).
lower limb and kinetic chain related to hamstring function. Funding This study was supported by IOC via Academic Centre for Evidence Based
While not reaching consensus, many experts are increasingly Sports Medicine, Amsterdam, the Netherlands and Institute of Sport Exercise and
using adjuncts such as BFR training to achieve early strength Health.
gains with lower tissue loads. Competing interests None declared.

13 of 17 Paton BM, et al. Br J Sports Med 2023;57:278–291. doi:10.1136/bjsports-2021-105384

Consensus statement
Patient consent for publication Consent obtained directly from patient(s). 21 Macdonald B, OʼNeill J, Pollock N, et al. Single-Leg Roman chair hold is more
effective than the Nordic hamstring curl in improving hamstring Strength-
Ethics approval This study involves human participants and was approved by UCL
Endurance in Gaelic footballers with previous hamstring injury. J Strength Cond Res
Research Ethics Committee Office for The Vice Provost Research, approved project

Br J Sports Med: first published as 10.1136/bjsports-2021-105384 on 17 January 2023. Downloaded from http://bjsm.bmj.com/ on May 11, 2025 by guest.
2019;33:3302–8.
ID: 5938/002 - http://ethics.grad.ucl.ac.uk. Participants gave informed consent to
22 Oliver GD, Dougherty CP. The razor curl: a functional approach to hamstring training.
participate in the study before taking part.
J Strength Cond Res 2009;23:401–5.
Provenance and peer review Not commissioned; externally peer reviewed. 23 Askling CM, Tengvar M, Tarassova O, et al. Acute hamstring injuries in Swedish elite
Supplemental material This content has been supplied by the author(s). sprinters and jumpers: a prospective randomised controlled clinical trial comparing
It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not two rehabilitation protocols. Br J Sports Med 2014;48:532–9.
have been peer-reviewed. Any opinions or recommendations discussed are 24 Askling CM, Tengvar M, Thorstensson A. Acute hamstring injuries in Swedish
solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all elite football: a prospective randomised controlled clinical trial comparing two
liability and responsibility arising from any reliance placed on the content. rehabilitation protocols. Br J Sports Med 2013;47:953–9.
Where the content includes any translated material, BMJ does not warrant the 25 Mendiguchia J, Martinez-Ruiz E, Edouard P, et al. A multifactorial, Criteria-based

Protected by copyright, including for uses related to text and data mining, AI training, and similar technologies.
accuracy and reliability of the translations (including but not limited to local progressive algorithm for hamstring injury treatment. Med Sci Sports Exerc
regulations, clinical guidelines, terminology, drug names and drug dosages), and 2017;49:1482–92.
is not responsible for any error and/or omissions arising from translation and 26 Mendiguchia J, Brughelli M. A return-to-sport algorithm for acute hamstring injuries.
adaptation or otherwise. Phys Ther Sport 2011;12:2–14.
27 Sherry MA, Johnston TS, Heiderscheit BC. Rehabilitation of acute hamstring strain
ORCID iDs injuries. Clin Sports Med 2015;34:263–84.
Bruce M Paton http://orcid.org/0000-0002-2581-599X 28 Hickey JT, Timmins RG, Maniar N, et al. Criteria for progressing rehabilitation and
Nicol van Dyk http://orcid.org/0000-0002-0724-5997 determining Return-to-Play clearance following hamstring strain injury: a systematic
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Ricci Plastow http://orcid.org/0000-0003-4820-8831 29 Pollock N, Kelly S, Lee J, et al. A 4-year study of hamstring injury outcomes in elite
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Consensus statement

London International Consensus and Delphi study on

► Additional supplemental ABSTRACT on aspects of rehabilitation after HSI, suggesting

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The target adaptations related to 92.3% 3.8% 3.8%

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