Consensus statements and percentage agreement for round 2 survey—global expert panel and rehabilitation
| Statements related to general rehabilitation | True | False | Undecided | Samples of typical responses—discussion points or areas of disagreement | |
| Initial and progressive loading of injured hamstring muscles should include exercise with different: contraction types, muscle lengths, functional movements, body positions, but the type of exercise will depend on the sports-specific adaptation required, symptoms and risks of reinjury. | 89.8% | 8.5% | 1.7% | Initial loading about neuromuscular stimulation and improving healing/muscle tension at length not ideal/initial loading isometric to minimise stress or shearing on tendon/eccentric contractions should be the focus. | |
| The order and speed of progression of exercises—(concentric/isometric/eccentric exercises), hip and knee-based exercises, inner and outer length exercises and open and closed kinetic chain exercises)—will depend on: | Adaptation required | 96.2% | 0.0% | 3.8% | The level of agreement reflects the importance of the target adaptations required as a criterion for prescription. |
| Symptoms | 88.9% | 7.4% | 3.7% | Symptoms were the main criterion used by rehabilitation clinicians to make decisions. | |
| 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 include: | Symptoms pain | 90.7% | 1.9% | 7.4% | Symptoms were the main criterion used by rehabilitation clinicians to make 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, duration) should be based on: | The response to previous loading | 96.3% | 1.9% | 1.9% | Graded process of loading and assessing response—both during and after 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 match fitness, which will depend on type and level of sport. | |
| Current and previous capacity | 88.7% | 7.5% | 3.8% | ||
| The target adaptations related to the patient’s goals and or sport | 92.3% | 3.8% | 3.8% | ||
| 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 engagement. | 96.8% | 1.6% | 1.6% | MDT and athlete engagement were key—the discussions were around all the stakeholders’ potentially conflicting goals and timeframes. | |
| The patient’s sport and previous level of participation will impact the progression of exercise selection and ultimate return to activity. | 95.2% | 3.2% | 1.6% | The discussions were like the three questions above. | |
| It is important to consider the possibility of sciatic nerve/neural symptoms when 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. | 90.5% | 0.0% | 9.5% | Strong agreement. | |
| Adjuncts to rehabilitation, such as blood flow restriction (BFR), electrical stimulation and hydrotherapy should be considered in the early stages to enhance tissue healing and recovery (caution should be used with cuff pressures over repairing tissues when using BFR training). | 68.9% | 6.6% | 24.6% | There was less uniform global practice when relating to use of adjuncts such as BFR—this reflects small evidence base only in HSI | |
| Rehabilitation should be monitored with appropriate markers that are progressive with recovery. | 98.4% | 0.0% | 1.6% | Monitoring was agreed but the most common form of monitoring was very 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, eccentric and isometric strength in injured and uninjured limb. | 95.2% | 1.6% | 3.2% | Panel had agreement on the types of strength to be achieved by final stage rehab—with outer length eccentric and isometric strength—in line with evidence on strength. | |
| It is key during a hamstring rehabilitation to assess, treat and prescribe exercises addressing the whole kinetic chain. | 90.5% | 3.2% | 6.3% | Panel agreed that biomechanical kinetic chain was important but there 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.