Return to play after hamstring injuries in football (soccer): a worldwide Delphi procedure regarding definition, medical criteria and decision-making

Abstract

There are three major questions about return to play (RTP) after hamstring injuries: How should RTP be defined? Which medical criteria should support the RTP decision? And who should make the RTP decision? The study aimed to provide a clear RTP definition and medical criteria for RTP and to clarify RTP consultation and responsibilities after hamstring injury. The study used the Delphi procedure. The results of a systematic review were used as a starting point for the Delphi procedure. Fifty-eight experts in the field of hamstring injury management selected by 28 FIFA Medical Centres of Excellence worldwide participated. Each Delphi round consisted of a questionnaire, an analysis and an anonymised feedback report. After four Delphi rounds, with more than 83% response for each round, consensus was achieved that RTP should be defined as 'the moment a player has received criteria-based medical clearance and is mentally ready for full availability for match selection and/or full training'. The experts reached consensus on the following criteria to support the RTP decision: medical staff clearance, absence of pain on palpation, absence of pain during strength and flexibility testing, absence of pain during/after functional testing, similar hamstring flexibility, performance on field testing, and psychological readiness. It was also agreed that RTP decisions should be based on shared decision-making, primarily via consultation with the athlete, sports physician, physiotherapist, fitness trainer and team coach. The consensus regarding aspects of RTP should provide clarity and facilitate the assessment of when RTP is appropriate after hamstring injury, so as to avoid or reduce the risk of injury recurrence because of a premature RTP. IntroductIonHamstring injuries are the most prevalent muscle injury in football, and 12%-33% of athletes with a hamstring injury experience a recurrence within a year after the initial injury.1-5 The burden of hamstring injury is high: for the professional player an average of 18 days and 3 matches missed per season, 5 and for the professional football club an average of 15 matches and 90 days missed per season. 5 The inability to play because of injury, but also because of unnecessary prolonged absence from play during rehabilitation, affects the individual player and team performance. Lower injury burden and higher match availability are significantly associated with a higher final league ranking, points per league match and success in the Union of European Football Association Champions league or Europa League. 6 Reducing the risk of injury recurrence is a key priority after the initial hamstring injury. Recurrent injuries require more extensive rehabilitation than the primary injury, and previous injury is an undisputed risk factor for future injury.3 7-10 Particularly alarming is the observation that recurrence rates have not improved over the last 30 years.11-13 High recurrence rates might be due to inadequate rehabilitation and/or premature return to play (RTP).14 15Of al...

Preventing hamstring injuries in football through enhanced exercise and RTP strategies

“…5 The RTP decision, for example, the clinician’s criteria-based judgement to medically clear a player for full availability for match selection and/or full training, should always be a multidisciplinary decision. Absence of pain, psychological readiness, similar hamstring flexibility and performance on field tests should be assessed for the RTP decision, whereas MRI was not advised to guide RTP clearance.…”

Clinical implications from daily physiotherapy examination of 131 acute hamstring injuries and their association with running speed and rehabilitation progression

“…Commonly, high-speed running is viewed as an important rehabilitation outcome after hamstring injury, and graded exposure to increasing intensity of running is used both therapeutically, and to assess readiness to return to sport 6. If the athlete is progressed too hastily, there is the risk of exacerbation of the injury and presumed lengthening of rehabilitation duration.…”

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“…Resisted shoulder extension strength was used as a measure of function of the affected musculotendinous units, with restoration of at least 90% strength relative to the unaffected side serving as one criterion to progress to return to play. This figure was based on similar values being used in return to play decision-making with other common football-related musculoskeletal injury (Heiderscheit, Sherry, Silder, Chumanov, & Thelen, 2010;Kyritsis, Bahr, Landreau, Miladi, & Witvrouw, 2016;Mendiguchia & Brughelli, 2011;van der Horst, Backx, Goedhart, & Huisstede, 2017). Given the player's dominant throwing arm was affected, which would reasonably be expected to be stronger than his non-dominant arm, it can be argued that this value may have been set too low.…”