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London International Consensus and Delphi study on hamstring injuries part 3: rehabilitation, running and return to sport
  1. Bruce M Paton1,2,3,
  2. Paul Read1,3,4,
  3. Nicol van Dyk5,6,
  4. Mathew G Wilson3,7,
  5. Noel Pollock1,8,
  6. Nick Court9,
  7. Michael Giakoumis8,
  8. Paul Head10,
  9. Babar Kayani11,
  10. Sam Kelly12,13,
  11. Gino M M J Kerkhoffs14,15,
  12. James Moore16,
  13. Peter Moriarty11,
  14. Simon Murphy17,
  15. Ricci Plastow11,
  16. Ben Stirling18,
  17. Laura Tulloch19,
  18. David Wood20,
  19. Fares Haddad1,3,7,11
  1. 1Institute of Sport Exercise and Health (ISEH), 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. 4School of Sport and Exercise, University of Gloucestershire, Gloucester, UK
  5. 5High Performance Unit, Irish Rugby Football Union, Dublin, Ireland
  6. 6Section Sports Medicine, University of Pretoria, Pretoria, South Africa
  7. 7Princess Grace Hospital, London, UK
  8. 8British Athletics, London, UK
  9. 9AFC Bournemouth, Bournemouth, UK
  10. 10School of Sport, Health and Applied Science, St. Mary’s University, London, UK
  11. 11Trauma and Orthopaedic Surgery, University College London Hospitals NHS Foundation Trust, London, UK
  12. 12Salford City Football Club, Salford, UK
  13. 13Blackburn Rovers Football Club, Blackburn, UK
  14. 14Orthopaedic Surgery and Sports Medicine, Amsterdam Movement Sciences, Amsterdam University Medical Centers, Amsterdam, The Netherlands
  15. 15Amsterdam Collaboration for Health and Safety in Sports (ACHSS), Amsterdam IOC Research Center, Amsterdam, The Netherlands
  16. 16Sports & Exercise Medicine, Centre for Human Health and Performance, London, UK
  17. 17Medical Services, Arsenal Football Club, London, UK
  18. 18Welsh Rugby Union, Cardiff, Wales, UK
  19. 19Saracen's Rugby Club, London, UK
  20. 20Trauma & 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}


Hamstring injuries (HSIs) are the most common athletic injury in running and pivoting sports, but despite large amounts of research, injury rates have not declined in the last 2 decades. HSI often recur and many areas are lacking evidence and guidance for optimal rehabilitation. This study aimed to develop an international expert consensus for the management of HSI. A modified Delphi methodology and consensus process was used with an international expert panel, involving two rounds of online questionnaires and an intermediate round involving a consensus meeting. The initial information gathering round 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 around 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. Consensus threshold was set a priori at 70%. Expert response rates were 35/46 (76%) (first round), 15/35 (attendees/invitees to meeting day) and 99/112 (88.2%) for final survey round. Statements on rehabilitation reaching consensus centred around: exercise selection and dosage (78.8%–96.3% agreement), impact of the kinetic chain (95%), criteria to progress exercise (73%–92.7%), running and sprinting (83%–100%) in rehabilitation and criteria for return to sport (RTS) (78.3%–98.3%). Benchmarks for flexibility (40%) and strength (66.1%) and adjuncts to rehabilitation (68.9%) did not reach agreement. This consensus panel recommends individualised rehabilitation based on the athlete, sporting demands, involved muscle(s) and injury type and severity (89.8%). Early-stage rehab should avoid high strain loads and rates. Loading is important but with less consensus on optimum progression and dosage. This panel recommends rehabilitation progress based on capacity and symptoms, with pain thresholds dependent on activity, except pain-free criteria supported for sprinting (85.5%). Experts focus on the demands and capacity required for match play when deciding the rehabilitation end goal and timing of RTS (89.8%). The expert panellists in this study followed evidence on aspects of rehabilitation after HSI, suggesting rehabilitation prescription should be individualised, but clarified areas where evidence was lacking. Additional research is required to determine the optimal load dose, timing and criteria for HSI rehabilitation and the monitoring and testing metrics to determine safe rapid progression in rehabilitation and safe RTS. Further research would benefit optimising: prescription of running and sprinting, the application of adjuncts in rehabilitation and treatment of kinetic chain HSI factors.

  • consensus
  • rehabilitation
  • running
  • hamstring muscles
  • hamstring tendons

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  • Contributors This manuscript is the combined effort of the attached authors. 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. BMP, FH and JM were responsible for steering committee, research and survey design and facilitating the consensus meeting days (MG facilitated for running and return to sport).

  • Funding This study was supported by IOC via Academic Centre for Evidence Based Sports Medicine, Amsterdam, the Netherlands and Institute of Sport Exercise and Health.

  • 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.