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London International Consensus and Delphi study on hamstring injuries part 1: classification
  1. Bruce M Paton1,2,3,
  2. Nick Court4,
  3. Michael Giakoumis5,
  4. Paul Head6,
  5. Babar Kayani7,
  6. Sam Kelly8,
  7. Gino M M J Kerkhoffs9,10,
  8. James Moore11,
  9. Peter Moriarty7,
  10. Simon Murphy12,
  11. Ricci Plastow7,
  12. Noel Pollock1,5,
  13. Paul Read1,3,13,
  14. Ben Stirling14,
  15. Laura Tulloch15,
  16. Nicol van Dyk16,17,
  17. Mathew G Wilson3,18,
  18. David Wood19,
  19. Fares Haddad1,3,7,18
  1. 1Institute of Sport Exercise and Health, University College London, London, UK
  2. 2Physiotherapy Department, University College London Hospitals NHS Foundation Trust, London, UK
  3. 3Division of Surgery and Intervention Science, University College London, London, UK
  4. 4AFC Bournemouth, Bournemouth, UK
  5. 5British Athletics, London, UK
  6. 6School of Sport, Health and Applied Science, St. Mary’s University, London, UK
  7. 7Trauma and Orthopaedics, University College London Hospitals NHS Foundation Trust, London, UK
  8. 8Rochdale FC, Rochdale, UK
  9. 9Orthopaedic Surgery and Sports Medicine, Amsterdam Movement Sciences, Amsterdam University Medical Centers, Amsterdam, The Netherlands
  10. 10Amsterdam Collaboration for Health and Safety in Sports (ACHSS), Amsterdam IOC Research Center, Amsterdam, The Netherlands
  11. 11Centre for Human Health and Performance, London, UK
  12. 12Arsenal Football Club, London, UK
  13. 13School of Sport and Exercise, University of Goucester, Gloucester, UK
  14. 14Welsh Rugby Union, Cardiff, Wales, UK
  15. 15Saracen's Rugby Club, London, UK
  16. 16High Performance Unit, Irish Rugby Football Union, Dublin, Ireland
  17. 17Section Sports Medicine, University of Pretoria, Pretoria, South Africa
  18. 18Princess Grace Hospital, London, UK
  19. 19Trauma & Orthopaedic Surgery, North Sydney Orthopaedic and Sports Medicine Centre, Sydney, New South Wales, Australia
  1. Correspondence to Dr Bruce M Paton, Institute of Sport Exercise and Health, University College London, London W1T 7HA, UK; b.paton{at}


Muscle injury classification systems for hamstring injuries have evolved to use anatomy and imaging information to aid management and prognosis. However, classification systems lack reliability and validity data and are not specific to individual hamstring muscles, potentially missing parameters vital for sport-specific and activity-specific decision making. A narrative evidence review was conducted followed by a modified Delphi study to build an international consensus on best-practice decision-making for the classification of hamstring injuries. This comprised a digital information gathering survey to a cohort of 46 international hamstring experts (sports medicine physicians, physiotherapists, surgeons, trainers and sports scientists) who were also invited to a face-to-face consensus group meeting in London . Fifteen of these expert clinicians attended to synthesise and refine statements around the management of hamstring injury. A second digital survey was sent to a wider group of 112 international experts. Acceptance was set at 70% agreement. Rounds 1 and 2 survey response rates were 35/46 (76%) and 99/112 (88.4%) of experts responding. Most commonly, experts used the British Athletics Muscle Injury Classification (BAMIC) (58%), Munich (12%) and Barcelona (6%) classification systems for hamstring injury. Issues identified to advance imaging classifications systems include: detailing individual hamstring muscles, establishing optimal use of imaging in diagnosis and classification, and testing the validity and reliability of classification systems. The most used hamstring injury classification system is the BAMIC. This consensus panel recommends hamstring injury classification systems evolve to integrate imaging and clinical parameters around: individual muscles, injury mechanism, sporting demand, functional criteria and patient-reported outcome measures. More research is needed on surgical referral and effectiveness criteria, and validity and reliability of classification systems to guide management.

  • consensus
  • hamstring muscles
  • rehabilitation
  • surgical procedures, operative
  • diagnosis

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

  • Collaborators This group of Authors forms part of the London International Consensus and Delphi study group on hamstring injuries, but we wanted to permit each member to take an authorship with these papers if possible.

  • Contributors This manuscript is the combined effort of the attached authors. BMP drafted the initial manuscript. NP, NvD and MW contributed significant drafting comments and edits. Other authors were responsible for minor edits. BMP, FH and JM were responsible for research and survey design and facilitating the consensus meeting days.

  • 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, NL. The consensus and the launch of PHAROS were partly made possible by a grant from the International Olympic Committee (IOC).

  • 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.