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London International Consensus and Delphi study on hamstring injuries part 2: operative management
  1. Ricci Plastow1,
  2. Gino M M J Kerkhoffs2,3,
  3. David Wood4,
  4. Bruce M Paton5,6,
  5. Babar Kayani7,
  6. Noel Pollock8,9,
  7. Nick Court10,
  8. Michael Giakoumis11,
  9. Paul Head12,
  10. Sam Kelly13,14,
  11. James Moore15,
  12. Peter Moriarty7,
  13. Simon Murphy16,
  14. Paul Read17,18,
  15. Ben Stirling19,
  16. Laura Tulloch20,
  17. Nicol van Dyk21,22,
  18. Mathew Wilson18,23,
  19. Fares Haddad1,17
  1. 1 Trauma & Orthopaedic Surgery, University College London Hospitals NHS Foundation Trust, London, UK
  2. 2 Department of Orthopedic Surgery and Sports Medicin, Amsterdam Movement Sciences, Amsterdam University Medical Centers, Amsterdam, The Netherlands
  3. 3 Amsterdam Collaboration for Health and Safety in Sports (ACHSS), Amsterdam IOC Research Center, Amsterdam, The Netherlands
  4. 4 Trauma & Orthopaedic Surgery, North Sydney Orthopaedic and Sports Medicine Centre, Sydney, New South Wales, Australia
  5. 5 Division of Medicine, Institute of Sport Exercise Health, University College London, London, UK
  6. 6 Physiotherapy, University College London Hospitals NHS Foundation Trust, London, UK
  7. 7 Division of Surgery and Interventional Science, University College London, London, UK
  8. 8 British Athletics Medical Team, London, UK
  9. 9 Sports Medicine, Institute of Sport Exercise and Health, London, UK
  10. 10 AFC Bournemouth, Bournemouth, UK
  11. 11 Medical, British Athletics, London, UK
  12. 12 School of Sport, Health and Applied Science, St. Mary’s University, London, UK
  13. 13 Salford City Football Club, Salford, UK
  14. 14 Blackburn Rovers FC, Blackburn, Lancashire, UK
  15. 15 Sports & Exercise Medicine, Centre for Human Health and Performance, London, UK
  16. 16 Sports Medicine, Arsenal Football Club, London, UK
  17. 17 Institute of Sport Exercise & Health, London, UK
  18. 18 Princess Grace Hospital, London, London, UK
  19. 19 Welsh Rugby Union, Cardiff, UK
  20. 20 Saracen's Rugby Club, London, UK
  21. 21 High Performance Unit, Irish Rugby Football Union, Dublin, Ireland
  22. 22 Section Sports Medicine, University of Pretoria, Pretoria, South Africa
  23. 23 Targeted Intervention, University College London, London, UK
  1. Correspondence to Dr Ricci Plastow, Trauma & Orthopaedic Surgery, University College London Hospitals NHS Foundation Trust, London, London, UK; ricci.plastow{at}


The key indications for surgical repair of hamstring injuries (HSIs) remain unclear in the literature due to a lack of high-level evidence and expert knowledge. The 2020 London International Hamstring Consensus meeting aimed to highlight clear surgical indications and to create a foundation for future research. A literature review was conducted followed by a modified Delphi process, with an international expert panel. Purposive sampling was used with two rounds of online questionnaires and an intermediate round involving a consensus meeting. The initial information gathering (round 1) questionnaire was sent to 46 international experts, which comprised open-ended questions covering decision-making domains in HSI. Thematic analysis of responses outlined key domains, which were evaluated by a smaller international subgroup (n=15) comprising clinical academic sports medicine physicians, physiotherapists and orthopaedic surgeons in a consensus meeting. After group discussion of each domain, a series of consensus statements were prepared, debated and refined. A round 2 questionnaire was sent to 112 international hamstring experts to vote on these statements and determine level of agreement. The consensus threshold was set a priori at 70% agreement. Rounds 1 and 2 survey respondents were 35/46 (76%) and 99/112 (88.4%), respectively. The consensus group agreed that the indications for operative intervention included: gapping at the zone of tendinous injury (87.2% agreement) and loss of tension (70.7%); symptomatic displaced bony avulsions (72.8%); and proximal free tendon injuries with functional compromise refractory to non-operative treatment (72.2%). Other important considerations for operative intervention included: the demands of the athlete/patient and the expected functional outcome (87.1%) based on the anatomy of the injury; the risk of functional loss/performance deficit with non-operative management (72.2%); and the capacity to restore anatomy and function (87.1%). Further research is needed to determine whether surgery can reduce the risk of reinjury as consensus was not reached within the whole group (48.2%) but was agreed by surgeons (70%) in the cohort. The consensus group did not support the use of corticosteroids or endoscopic surgery without further evidence. These guidelines will help standardise treatment of HSIs, specifically the indications and decision-making for surgical intervention.

  • consensus
  • hamstring tendons
  • hamstring muscles
  • surgical procedures, operative
  • orthopedics

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  • Twitter @bpatphys, @drnoelpollock, @MickGiakoumis, @PHphysio, @skelly_2, @JMoorePhysio, @simonmurphy23, @NicolvanDyk

  • Correction notice This article has been corrected since it published Online First. A second affiliation has been added for the author Nicol van Dyk.

  • Contributors RP drafted the initial manuscript for surgery. BK, FH, BMP and NP contributed significant drafting comments and edits. Other authors were all responsible for minor edits. BMP, FH and JM were responsible for research and survey design, Delphi steering committee and facilitating the consensus meeting days. With GMMJK, DW and FH facilitating discussion.

  • Funding The consensus process and meeting were cocreated and funded by the Institute of Sport Exercise and Health, London, UK and the Academic Centre for Evidence Based Sports Medicine, Amsterdam, Netherlands. The consensus and the launch of PHAROS were partly made possible by a grant from the International Olympic Committee.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.