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BJSM Online First, published on April 15, 2016 as 10.1136/bjsports-2016-095974

Original article

MRI ndings and return to play in football:

a prospective analysis of 255 hamstring injuries
in the UEFA Elite Club Injury Study
Jan Ekstrand,1,2 Justin C Lee,3 Jeremiah C Healy3
1

Division of Community
Medicine, Department of
Medical and Health Sciences,
Linkping University,
Linkping, Sweden
2
Football Research Group,
Linkping, Sweden
3
Chelsea and Westminster
Hospital, Imperial College,
London, UK
Correspondence to
Professor Jan Ekstrand, Hertig
Karlsgatan 13B, Linkping
S-582 21, Sweden;
jan.ekstrand@telia.com
Received 7 January 2016
Revised 21 March 2016
Accepted 21 March 2016

ABSTRACT
Aim The present study evaluated whether the MRI
parameters of hamstring injuries in male professional
football players correlate with time to return to play
(RTP).
Methods 46 elite European football teams were
followed prospectively for hamstring injuries between
2007 and 2014. Club medical staff recorded individual
player exposure and time-loss after hamstring injury.
MRI parameters were evaluated by two independent
radiologists and correlated with the RTP data.
Results A total of 255 grade 1 and 2 injuries were
evaluated in this study. RTP was longer for grade 2 than
grade 1 injuries (2413, 95% CI 21 to 26 days vs 18
15, 95% CI 16 to 20 days; mean difference: 6, 95%
CI 2 to 9 days, p=0.004, d=0.39). 84% of injuries
affected the biceps femoris (BF) muscle, whereas 12%
and 4% affected the semimembranosus (SM) and
semitendinosus (ST), respectively. No difference in lay-off
time was found for injuries to the three different muscles
(BF 2015 days, SM 1811 days, ST 2314 days;
p=0.83). The recurrence rate was higher for BF injuries
than for SM and ST injuries combined (18% vs 2%,
p=0.009). The size of the oedema weakly correlated
with time to RTP (r2=612%). No correlation was found
between location of injury and time to RTP. The majority
of the intramuscular injuries affected the MT junction
(56% in grade 1 and 2 injuries), but no difference in
lay-off time was found between the different types of
injuries.
Conclusions The radiological grade and size of the
oedema correlate with time to RTP for both, grade 1
and 2 injuries. No correlations were found between time
to RTP and the location and type of injury.

INTRODUCTION

To cite: Ekstrand J, Lee JC,

Healy JC. Br J Sports Med
Published Online First:
[please include Day Month
Year] doi:10.1136/bjsports2016-095974

Hamstring injury is the most common elite football

injury, representing 12% of all injuries. A team
with a 25-player squad typically suffers ve to six
hamstring injuries each season, resulting in 80 football days lost.1 Return to play (RTP) is the key
question from the player, the coach, the media and
agents.2 3 The teams medical staff need as much
information as possible to provide an accurate
response.4 5 The clinical diagnosis is key in predicting RTP.4 6 7 Clinical examination strongly correlates with the time to RTP.6 8 At the elite level,
imaging of muscle injuries conrms clinical diagnosis and may help inform the decision for safe RTP.5
In elite European football, we have previously
shown that 87% of injuries are examined with
MRI or ultrasound.4 However, the additional value

of MRI to patient history and clinical examination

is debatable.7 Several studies have demonstrated the
value of MRI as a prognosticator for lay-off time
after hamstring injury.26 919 Schneider-Kolsky
et al6 showed that both clinical examination and
MRI strongly correlate with RTP, but the correlation between clinical examination and MRI was
only moderate. These ndings indicate that MRI
and clinical examination provide different information that, together, may predict RTP. Recently,
however, Wangensteen et al7 found that the additional predictive value of MRI was negligible compared to baseline patient history and clinical
examinations alone.
The Elite Club Injury Study (ECIS) is an
on-going prospective cohort study supported by
the UEFA and a large source of evidence-based data
(6000 muscle injuries between 2001 and 2014) in
male elite footballers.12 20 We previously reported
a good correlation between radiological grading
and RTP.4 12 The objective of this study was to
analyse whether the correlation between grading
and lay-off time persisted in this extended material
and whether further MRI parameters, such as
muscles involved, location, type or size of hamstring injuries correlate with RTP. Our hypothesis
was that a clear correlation exists between radiological grading of injuries and RTP, and that other
imaging parameters may provide data to assist
those working in professional football in estimating
the time needed to RTP.

MATERIALS AND METHODS

This is a substudy of the on-going UEFA ECIS. A
total of 46 teams from 12 countries have been followed over several seasons, from 2007 to 2014,
including a total of 175 club-seasons. The study
design followed the consensus statement on injury
denitions and data collection procedures in football,21 and the general methodology has been
reported elsewhere.22

Inclusion criteria and denitions

All rst team squad players were eligible for inclusion each season. The general operational denitions are provided in table 1. Hamstring injury was
dened as a traumatic distraction or overuse injury
to the hamstring muscle group, including both rsttime and recurrent lesions.1 23 Structural disorders,
such as total and partial muscle ruptures and functional disorders, such as fatigue-induced, spinerelated or neuromuscular muscle disorders, were
included, whereas contusions, haematomas, tendon
ruptures and chronic tendinopathies were

Ekstrand J, et al. Br J Sports Med 2016;0:17. doi:10.1136/bjsports-2016-095974

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Original article
Table 1 Operational definitions used in the study
Training session
Match
Injury

Hamstring injury

Rehabilitation

Lay-off
Early recurrence

Slight/minimal
injury
Mild injury
Moderate injury
Severe injury
Traumatic injury
Overuse injury

Team training that involved physical activity under the

supervision of the coaching staff
Competitive or friendly match against another team
Any physical symptom sustained by a player as a result of a
football match or football training that led to the player
being unable to take full part in future football training or
match play
A traumatic distraction or overuse injury to the hamstring
muscle group (the musculotendinous complex of biceps
femoris, semitendinosus and semimembranosus) including
both first-time and recurrent lesions
A player was considered injured until team medical staff
allowed full participation in training and availability for
match selection
Number of days until the player resumed full team training
Injury of the same type and at the same site as an index
injury occurring within 2 months of returning to full
participation after the index injury
Injury causing 03 days absence
Injury causing 47 days absence
Injury causing 828 days absence
Injury causing >28 days absence
Injury with sudden onset and known cause
Injury with insidious onset and no known trauma

excluded.23 24 Players were considered injured until the club

medical staff allowed full participation in training and availability for match selection.22 Re-injuries were dened according to
the concept of early recurrence.21

Data collection
Baseline player data and consent were collected yearly at the
time of player inclusion. During the season, medical staff registered individual player exposure in minutes during all club and
national team training sessions and matches. Injury cards and
attendance records were sent to the study group once a month.
Each injury was coded according to a modied version of the
Orchard Sports Injury Classication System (OSICS) 2.0.25

Magnetic resonance imaging

Twenty-one of the 46 teams (46%) agreed to provide MRI scans
of thigh muscle injuries. MRI examination was performed
within 2448 h of injury. Minimum inclusion criteria for MRI
included machine <5 years old and eld strength of 1.5 T.
Minimum MR sequences included axial and coronal T1 and T2
with fat saturation/ short inversion recovery sequences. The
MRI Thigh Injury Report Form included the date of imaging,
radiologist, MR sequences, muscles involved and injury severity.
If more than one injured muscle was present, the parameters for
the muscle with the most extensive pathology were recorded.
For severity classication, a modied Peetrons classication26
with the following grading system was used: grade 0negative
MRI without any pathology, grade 1oedema but no architectural distortion, grade 2architectural disruption indicating
partial tear and grade 3total muscle or tendon rupture. The
location of injury within the muscle was dened as proximal,
middle or distal third. The extent of the oedema or tear was
measured in three planes: maximal length, Z (craniocaudal);
width, X (mediolateral); and depth, Y (anteroposterior). Injuries
were classied as follows: MT junction, an injury affecting the
intramuscular myotendinous junction; myofascial, an injury at
the surface of the muscle; muscle, an intramuscular injury away
2

from the intramuscular tendon; or fascial, uid in the intermuscular space but no muscle injury.
Thirteen teams used PACSMail (http://www.sybermedica.com)
to send MRI scans for on-line review by two independent radiologists ( JCH and JCL) blinded to clinical details other than the
clinical diagnosis of hamstring injury. Copies of the 212 scans
and associated reports from the 13 teams using PACSMail were
then sent electronically to the study group. The other eight
teams used paper-based MRI forms (n=95) lled in by the club
consultant radiologist, which were sent to the study group by
mail.

Statistical analysis
ANOVA was used for between-group comparisons of lay-off
time, oedema size and size of the tear. These variables were presented as meanSD with 95% CI or range. Effect size, using
Cohens d, was calculated using the mean difference of all pairwise comparisons. The association between continuous variables
was measured using Pearsons correlation coefcient (r).
Multiple linear regression with a backward elimination procedure was used to estimate the effects the Z, X and Y planes of
the oedema have on lay-off time. Estimates were expressed as
the days change in lay-off time per millimetre change in the size
of the oedema. In addition, the coefcient of determination (r2)
of the nal models are presented. The association between
categorical variables was measured using Pearsons 2 test or
Fishers exact test.
For the two independent radiologists ( JH and JL), the reliability of the evaluation of grading, muscles involved, location
of injuries and injury types were assessed using statistics. The
reliability of the assessment of the size of the oedema and/or
tear was evaluated using the intraclass correlation coefcient
(ICC(3,1)).
All analyses were two-sided and the signicance level set at
p<0.05. All statistical analyses were performed in SPSS (IBM
SPSS Statistics for Windows, V.22.0. Armonk, New York, USA:
IBM Corp). The study design underwent an ethical review and
was approved by the UEFA Football Development Division and
the Medical Committee.

RESULTS
Examination procedure
Of the 1488 hamstring injuries recorded during the study
period, 917 (62%) were examined by MRI. MRI forms were
received for 307 (33%) of the examinations (gure 1). Since
grade 0 injuries (n=35) have no pathology on MRI, grade 3
injuries (n=9) were too few for robust analyses and data were
missing for eight examinations, only grade 1 (n=173) and grade
2 (n=82) injuries with completed MRI forms were included in
the following results (gure 1).

Reliability of evaluations
An almost perfect agreement between the two independent radiologists was found for the description of radiological grade
( value 0.94, 95% CI 0.85 to 1.00). Substantial agreement was
found for assessing the location of injury ( value 0.71, 95% CI
0.56 to 0.84) and type of injury ( value 0.65, 95% CI 0.49
to 0.80). There was total agreement regarding the muscles
involved. For the measurement of oedema size, the agreement
was substantial to almost perfect (ICC(3,1) 0.88, 95% CI 0.81
to 0.92; 0.80, 95% CI 0.7 to 0.87; 0.76, 95% CI 0.64 to 0.84
for Z, X and Y planes, respectively). For the measurement of
the size of the tear, the agreement was moderate to substantial
(ICC(3,1) 0.69, 95% CI 0.36 to 0.87; 0.45, 95% CI 0.04 to
Ekstrand J, et al. Br J Sports Med 2016;0:17. doi:10.1136/bjsports-2016-095974

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Original article

Figure 1 Flow chart of hamstring muscle injuries in the UEFA Elite Club Injury Study in seasons 2007/2008, 2008/2009, 2009/2010, 2010/2011,
2011/2012, 2012/2013 and 2013/2014.
0.74; 0.70, 95% CI 0.38 to 0.87 for Z, X and Y planes,
respectively).

Grading and lay-off time

The mean lay-off time for all 255 hamstring injuries was 20
15 days (95% CI 18 to 22). A total of 173 injuries (68%)
were grade 1 and 82 (32%) were grade 2. The lay-off time was
signicantly longer for grade 2 injuries than grade 1 injuries (24
13, 95% CI 21 to 26 days vs 1815, 95% CI 16 to 20 days;
mean difference: 6, 95% CI 2 to 9 days, p=0.004, d=0.39).

Muscles involved
Of the 253 injuries for which data on muscle involvement were
available, 212 (84%) affected the biceps femoris (BF) muscle,
30 (12%) in the semimembranosus (SM) muscle and 11 (4%) in
the semitendinosus (ST) muscle. There was no signicant difference in lay-off time for injuries to the three different muscles
(BF 2015, 95% CI 18 to 22 days; SM 1811, 95% CI 14 to
Ekstrand J, et al. Br J Sports Med 2016;0:17. doi:10.1136/bjsports-2016-095974

22 days; ST 2314, 95% CI 13 to 32 days; p=0.68) or in the

lay-off time between the muscles with grade 1 ( p=0.72) or
grade 2 injuries ( p=0.98). However, the association between
recurrence rate and affected muscle was signicant (BF 39/
212=18%; SM and ST combined: 1/41=2%; p=0.009).

The size of the injury and lay-off time

Size of oedema in grade 1 and 2 injuries
The average length, width and depth of the oedema in grade 1
injuries was 10058 (range 8325) mm, 2917 (range 2124)
mm and 1912 (range 366) mm, respectively. The size of
oedema in grade 2 injuries was larger in the Z, X and Y planes:
13167 (range 5242) mm (mean difference 31, 95% CI 11 to
51 mm, p=0.002, d=0.51), 3924 (range 5108) mm (mean
difference 10, 95% CI 4 to 17 mm, p=0.001, d=0.56) and 32
20 (range 5100) mm (mean difference 14, 95% CI 9 to
19 mm, p<0.001, d=0.93). The correlation between lay-off
time and oedema in the Z, X and Y planes was signicant
3

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Original article
(r=0.26, p<0.001; r=0.26, p<0.001; and r=0.15, p=0.043,
respectively). Linear regression with backward elimination
revealed a 2.0 day (95% CI 1.0 to 3.1 days) change in lay-off
time per 10 mm change in the X plane oedema ( p<0.001)
when modelling all planes of the oedema on lay-off time.
However, as indicated by the coefcient of determination (r2),
the longitudinal length of the oedema only explained 7% of the
variation in lay-off time. No signicant two-way interaction
effects were found between the Z, X and Y planes.

Grade 1
There was a small to medium correlation between lay-off time
and the length and width of the oedema for grade 1 injuries
(r=0.24, p=0.003 and r=0.23, p=0.005, respectively) but no
signicant correlation with the depth of the oedema (r=0.16,
p=0.06). Linear regression for grade 1 injuries revealed a
0.7 day (95% CI 0.2 to 1.1 days) change in lay-off time per
10 mm change in the Z plane of the oedema ( p=0.003,
r2=6%). No signicant two-way interaction effects were found
between the Z, X and Y planes (gure 2).

Grade 2
For grade 2 injuries, there was a medium correlation between
lay-off time and the Z and X planes of the oedema (r=0.31,
p=0.03 and r=0.35, p=0.01, respectively) but no signicant
correlation with the Y plane (r=0.12, p=0.43). Linear regression for grade 2 injuries revealed a 1.8 day (95% CI 0.4 to
3.3 days) change in lay-off time per 10 mm change in the
X plane of the oedema ( p=0.013, r2=12%). No two-way interaction contributed signicantly to the model (gure 2).

Size of the tear in grade 2 injuries

The average length, width and depth of the tear in grade 2
injuries was 4223 (range 3134) mm, 168 (range 334) mm
and 1312 (range 080) mm, respectively. No signicant correlation was found between the size of the tear and lay-off time
in Z (r=0.19, p=0.22), X (r=0.22, p=0.15) or Y (r=0.13,
p=0.40) plane.

Location of injury and lay-off time

Grade 1
Grade 1 injuries were more common in the distal and middle
thirds than in the proximal third (42% and 35% vs 23%). No
signicant difference in lay-off time was found between the different locations (p=0.58). The mean lay-off time for distal third
injuries was 1915 (95% CI 16 to 23) days compared to 17
10 (95% CI 14 to 19) and 1921 (95% CI 13 to 26) days for
middle and proximal third injuries, respectively.

Grade 2
Grade 2 injuries were more common in the middle third than in
the proximal and distal thirds (44% vs 31% and 24%). Grade 2
injuries had a mean 2311 to 15 days of lay-off time independent of location ( p=0.99).

Re-injuries
Re-injuries constituted 16% (41/255) of grade 1 and 2 injuries,
with no signicant difference in rates between the grades
(p=0.95). For grade 1 injuries, the re-injury rates differed signicantly between locations, as they were more common the
more distal the injuries were located ( proximal 5%, middle
14% and distal 21%, p=0.03). Recurrences of grade 2 injuries

Figure 2 Scatterplot and t line for

the correlation between the oedema of
injury as seen by MRI (grade 1 and 2
injuries) and number of days before
return to play (RTP).

Ekstrand J, et al. Br J Sports Med 2016;0:17. doi:10.1136/bjsports-2016-095974

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Original article
were too few (n=13) for robust analyses, but the tendency was
opposite to grade 1 injuries with more recurrences in proximal
injuries (27% vs 13% and 6% for middle and distal locations,
p=0.06).

Type of injury and lay-off time

As shown in table 2, the majority of intramuscular injuries
affected the MT junction (56% of both grade 1 and 2 injuries).
No signicant difference was found in lay-off time between the
different types of injuries (MT junction 2015, 95% CI 18 to
23; muscle: 2010, 95% CI 16 to 25; fascial 156, 95% CI
10 to 20; myofascial 1915, 95% CI 15 to 23; p=0.68). A separate analysis of grade 1 ( p=0.87) and grade 2 ( p=0.21) injuries indicated similar results.

DISCUSSION
Radiological grading is clearly related to time to RTP
The principal nding of our study of mens professional football
is that radiological grading relates to lay-off duration. In our
analysis of the ECIS material during the seasons in 20072010,
we found that the lay-off time differed signicantly between the
four grades of muscle injury.4 In pairwise comparisons, the differences were signicant between all pairs except between grade
1 and 2 ( p=0.053).4 In the present extended study of seasons
in 20072014, in which we evaluated only grade 1 and 2 injuries, we found signicant differences in lay-off times for these
two grades of injury, indicating that radiological grading of MRI
is a helpful prognosticator for RTP. On average, grade 2 injuries
were associated with 6 additional days to RTP.

Weak correlations between the size of the injury and RTP

The size of the oedema on MRI of the initial injury correlates
slightly with lay-off time in grade 1 and grade 2 injuries.
For grade 1 injuries, the longitudinal length of the oedema
(Z-axis) had the strongest correlation with time to RTP. This
correlation was weak and, as indicated by the coefcient of
determination (r2), the longitudinal length of the oedema only
explains 6% of the variation in lay-off time. For grade 2 injuries, the linear regression showed that the width of the oedema
(X-axis) had the strongest correlation with time to RTP
(explaining 12% of the variation in RTP). We found no

Table 2 Days of absence after different types of hamstring muscle

injuries
Grade 1

Grade 2

Injury type

Frequency

Per
cent

Absence
(days)

MT junction
Muscle
Fascial
Myofascial
Total
Missing data

96
11
10
45
162
11

56
6
6
26
94
6

1816
176
156
1916

Frequency
46
11
0
14
71

Per
cent

Absence
(days)

56
13
0
17
97
13

2413
2412
179

Injuries were classified as one of four different types according to the involvement of
intramuscular tissue: MT junction (injury affecting the myotendinous junction),
Myofascial (injury at the surface of the muscle), Muscle (injury away from the
intramuscular tendon), or Fascial (fluid in the intermuscular space but no injury to the
muscle).
Radiological grades were classified according to modified Peetrons: Grade 1=oedema
but no architectural distortion, grade 2=architectural disruption indicating partial tear.
Absence expressed as meanSD.

Ekstrand J, et al. Br J Sports Med 2016;0:17. doi:10.1136/bjsports-2016-095974

correlation between the cross-sectional area of the injury (XY

plane) and RTP.
Conicting results concerning the correlation between
oedema size and RTP have been reported. Three studies using
multivariate analyses reported a moderate or strong correlation
between both the longitudinal length and the cross-sectional
area of the oedema and RTP,2 3 6 27 whereas others have found
no correlation.8 28 The size of the tear (architectural distortion)
did not correlate with lay-off time, which seems counterintuitive. Oedema size was more signicant, suggesting local
reactive changes to insult may be more important than the
primary injury.

No correlation between location of injury and RTP

The location of grade 1 and 2 injuries did not correlate with
lay-off time. Conicting results have previously been reported,
suggesting that the distance from the muscle origin to the injury
is associated with prolonged time to RTP.19 29 30 In a study of
18 sprinters, Askling et al8 reported that the closer the lesion is
to the ischial tuberosity, the longer the interval to full activity. In
contrast, our present data and the report from Slavotinek et al15
regarding Australian football revealed no such correlation. This
difference probably reects differences in patients. The time to
RTP in Asklings paper was a median 16 weeks (112 days), indicating hospital-based material with severe injuries. The median
absence was 34 weeks (27 days) in the Australian football study
and 2 weeks (14 days) in the present study, indicating eld-based
material with less severe injuries. We conclude that, in elite football, the location of the injury (proximal, midsubstance or
distal) in grade 1 and 2 hamstring injuries has no predictive
value for RTP.

Is typing the injury meaningful?

A new grading system for muscle injuries was proposed recently
(British Athletics Muscle Injury Classication).30 31 This classication dened injury according to the intramuscular site: myotendinous (termed MT junction in the present study), myofascial,
perifascial (termed fascial in the present study) and intramuscular
(termed muscle in the present). The classication also takes into
account whether the tendon itself is involved. The authors
suggest injury to the MT junction, and especially injury to the
tendon, may be associated with prolonged time to RTP.32
However, this grading system is currently expert opinion and
awaits validation.7 31 32
In our study, we found that the majority of grade 1 and 2
injuries affect the intramuscular myotendinous junction,
whereas injuries affecting the myofascial tissue and not involving the tendon are less frequent. Pure muscle or fascial injuries
were rare. Our data suggest that typing injuries according to
location does not correlate with lay-off times and its utility is
questionable. The results of our study agree with data from
Connell et al.2

No difference in lay-off days between specic muscles but a

higher re-injury rate for BF injuries
We found that the majority of injuries involved the BF muscle.
Injuries to the SM and ST are much less common, which is in
agreement with other studies.24 33 34 Furthermore, our study
shows that the specic muscle involved does not correlate with
the time to RTP, which is in agreement with earlier studies.3 15 34
However, we found that the recurrence rate was substantially
higher for injuries affecting the BF compared to those affecting
the SM and ST, but larger data sets are needed to validate this
5

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Original article
statement, as injuries to ST and SM are less frequent than BF
injuries.

taking in important matches or due to external pressure inuences RTP decisions.7

Strengths of the study

Acknowledgements The authors wish to thank all the participating clubs,

including coaches, players and medical staff. Biostatistician Henrik Magnusson is
acknowledged for his assistance with the statistical analyses.

The main strength of this study is the prospective data set

with 255 injuries from a homogenous group of male professional footballers. We used standardised methodology that
complies with international consensus agreements on procedures for epidemiological studies including RTP in football
injuries.21 22 Furthermore, our classication and measurements
have excellent interobserver agreement and reliability. The
radiologists were blinded to clinical ndings and performed
their analysis independent of each other but achieved excellent
agreement for radiological grading ( value 0.94). Similar
excellent interobserver and intraobserver reliability for grading
and prognostic MRI parameters in acute hamstring injuries
were previously reported by Hamilton et al.35 Thus, the
scoring of hamstring injuries by experienced radiologists is
reproducible.35

Limitations of the study

The medical teams in the clubs who made the RTP decisions
were not blinded to imaging results; they were blinded to the
grading of the study radiologists but were informed of the MRI
evaluations by their own radiologists. There were no specic criteria for RTP due to the lack of consensus regarding optimal
treatment or uniform guidelines for RTP in hamstring injuries
in football players.7 In addition, we did not investigate how risk

Contributors JE, JCL and JCH were responsible for the conception and design of
the study. All the authors were involved in data collection over the study period. JE
conducted the analyses with the biostatistician (HM). All the authors contributed to
interpreting the ndings. JE wrote the rst draft of the paper, which was critically
revised by JCL and JCH. The nal manuscript was approved by all the authors. JE is
the study guarantor.
Funding The Football Research Group was established in Linkping, Sweden, in
collaboration with Linkping University and through grants from the Union of
European Football Associations, the Swedish Football Association, the Football
Association Premier League Limited and the Swedish National Centre for Research
in Sports.
Competing interests None declared.
Ethics approval The study design was approved by the UEFA Medical Committee
and the UEFA Football Development Division.
Provenance and peer review Not commissioned; externally peer reviewed.

REFERENCES
1
2

What are the ndings?

The radiological grade correlates with time to return to play
(RTP) for both, grade 1 and 2 injuries.
The size of the oedema only weakly correlates with time to
RTP.
For grade 1 and 2 hamstring injuries, the proximity to the
ischial tuberosity has no predictive value for RTP in elite
football.
There is no difference in lay-off days between specic
hamstring muscles involved, but biceps femoris (BF) injuries
have a higher re-injury rate.
The typing of muscle injuries according to intramuscular site
can be questioned.

10

11

12
13

How might it impact on clinical practice in the future?

For practitioners working on the football eld and frequently
using imaging, information about MRI parameters that are
and are not correlated with RTP will be of interest.
The difference in recurrence rates between injuries to BF
compared to semimembranosus (SM) and semitendinosus
(ST) could guide practitioners to be more conservative with
BF injuries due to the high recurrence rate (better safe than
quick) and to be more aggressive in the rehabilitation of
injuries to the SM and ST muscles because re-injuries to
these muscles are rare.
6

14
15

16

17

18

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MRI findings and return to play in football: a

prospective analysis of 255 hamstring
injuries in the UEFA Elite Club Injury Study
Jan Ekstrand, Justin C Lee and Jeremiah C Healy
Br J Sports Med published online April 15, 2016

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