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Consensus statement

Br J Sports Med: first published as 10.1136/bjsports-2021-105371 on 17 January 2023. Downloaded from http://bjsm.bmj.com/ on December 29, 2024 by guest. Protected by copyright.
London International Consensus and Delphi study on
hamstring injuries part 1: classification
Bruce M Paton ‍ ‍,1,2,3 Nick Court,4 Michael Giakoumis,5 Paul Head,6 Babar Kayani,7
Sam Kelly,8 Gino M M J Kerkhoffs,9,10 James Moore,11 Peter Moriarty,7
Simon Murphy,12 Ricci Plastow ‍ ‍,7 Noel Pollock ‍ ‍,1,5 Paul Read,1,3,13 Ben Stirling,14
Laura Tulloch,15 Nicol van Dyk ‍ ‍,16,17 Mathew G Wilson,3,18 David Wood,19
Fares Haddad1,3,7,18

► Additional supplemental ABSTRACT and enhance clinical decision making. We present


material is published online Muscle injury classification systems for hamstring injuries an evidence review to outline our current under-
only. To view, please visit the
journal online (http://​dx.​doi.​ have evolved to use anatomy and imaging information to standing of HSI classification systems and iden-
org/​10.​1136/​bjsports-​2021-​ aid management and prognosis. However, classification tify knowledge gaps, followed by an international
105371). systems lack reliability and validity data and are not expert Delphi study to advance the classification of
specific to individual hamstring muscles, potentially HSI.
For numbered affiliations see
missing parameters vital for sport-­specific and activity-­
end of article.
specific decision making. A narrative evidence review Muscle injury classification systems
Correspondence to was conducted followed by a modified Delphi study There are multiple, differing muscle injury clas-
Dr Bruce M Paton, Institute to build an international consensus on best-­practice sification systems.2–7 Anatomy is key to most
of Sport Exercise and Health, decision-­making for the classification of hamstring systems3 5 7 8 and most use some form of imaging
University College London, injuries. This comprised a digital information gathering
London W1T 7HA, UK;
(particularly MRI and ultrasound (US)).4–6 9 There
survey to a cohort of 46 international hamstring experts is a high incidence of MRI negative HSI, from 17%
​b.​paton@​ucl.​ac.​uk
(sports medicine physicians, physiotherapists, surgeons, to 31%,9–12 and many systems incorporate a grade 0
Accepted 16 November 2022 trainers and sports scientists) who were also invited to for HSI with negative imaging.2–4 6 13 Some classifi-
Published Online First a face-­to-­face consensus group meeting in London . cations use components of subjective and objective
17 January 2023 Fifteen of these expert clinicians attended to synthesise examination or function,11 14–16 which may asso-
and refine statements around the management of ciate with time to return to sport (TRTS) following
hamstring injury. A second digital survey was sent to a HSI.11 17 18 Several reviews on classification systems
wider group of 112 international experts. Acceptance in muscle injury are available.1 19–24 None of these
was set at 70% agreement. Rounds 1 and 2 survey systems are specific to individual hamstring muscles
response rates were 35/46 (76%) and 99/112 (88.4%) but the specific muscles have anatomical and func-
of experts responding. Most commonly, experts used tional differences that are relevant in management.25
the British Athletics Muscle Injury Classification (BAMIC) While early classification systems for muscle injuries
(58%), Munich (12%) and Barcelona (6%) classification traditionally followed a severity of injury approach
systems for hamstring injury. Issues identified to advance (ie, grading system),2 14 15 26 27 they have evolved
imaging classifications systems include: detailing to also consider the anatomical tissue involved (ie,
individual hamstring muscles, establishing optimal use fascia/muscle vs tendon and connective tissue),3 13
of imaging in diagnosis and classification, and testing and the mechanism of injury2 13 (table 1).
the validity and reliability of classification systems. The
most used hamstring injury classification system is the
Limitations of current muscle classification
BAMIC. This consensus panel recommends hamstring
injury classification systems evolve to integrate imaging systems
These classification evolutions have assisted clini-
and clinical parameters around: individual muscles, injury
cians in planning management and prognostica-
mechanism, sporting demand, functional criteria and
tion. Different anatomical tissues have different
patient-­reported outcome measures. More research is
healing time frames and load capacity, resulting in
needed on surgical referral and effectiveness criteria, and
differences in optimal rehabilitation prescription,
validity and reliability of classification systems to guide
progression, readiness to return to sport (RTS),28
management.
and risk of reinjury.29 Current muscle injury classi-
fication systems are generic and do not differentiate
between muscles, even though muscles have different
BACKGROUND anatomy and architecture. Intramuscular connec-
© Author(s) (or their
employer(s)) 2023. No Hamstring injuries (HSIs) continue to cause signif- tive tissue and myotendinous junction (MTJ) archi-
commercial re-­use. See rights icant time lost from high intensity running sports, tecture, for example, differ considerably between
and permissions. Published despite an exponential growth in research on HSI hamstring muscles and within individuals.30 31
by BMJ. prevention and management. The role of HSI classi- The individual hamstring muscles have different
To cite: Paton BM, fication and how this might guide management is of roles,32 even within components of a single move-
Court N, Giakoumis M, interest but currently unclear. The main purpose of ment.33 Clinicians should consider these factors
et al. Br J Sports Med HSI classification systems is to categorise and grade when prescribing rehabilitation as the management
2023;57:254–265. the severity of an injury,1 to aid communication of an injury with the same classification, within a

1 of 14     Paton BM, et al. Br J Sports Med 2023;57:254–265. doi:10.1136/bjsports-2021-105371


Consensus statement

Br J Sports Med: first published as 10.1136/bjsports-2021-105371 on 17 January 2023. Downloaded from http://bjsm.bmj.com/ on December 29, 2024 by guest. Protected by copyright.
Table 1 Classification systems—abbreviated from online supplemental material
Based on Author G0 G1 GII GIII GIV
Clinical Odonoghue No appreciable tissue tear Tissue damage and reduced strength of the Complete tear of the muscle tendon
Signs muscle tendon unit unit and complete loss of function
Ryan Tear of a very small number of Tear of a higher no of fibres, fascia still Greater number of muscle fibres Completed tear of
fibres with Fascia remaining intact remains intact involved. The muscular fascia is at the muscle belly
least partially torn and fascia rupture
Wise Min pain to palpation, localised Substantial TOP, poorly localised, 6–12 Intractable TOP, diffuse, develops in
mm change in circumference, develops 1 hour, >50% loss ROM, severe pain
12–24 hours <50% loss of ROM, pain on on contraction, almost complete loss
contraction, loss of power, disturbed gait of power, unable to WB
Rachun Localised pain, min swelling, Local pain+TOP, moderate bruising+disability, Severe pain+swelling disability,
bruising, minor disability stretching tearing fibres without disruption severe haematoma, loss of function,
palpable defect
Imaging Takebyashi No abnormalities or diffuse Focal fibre rupture—more than 5% of the Complete muscle rupture with
bleeding with or without local muscle involved, with or without fascial retraction, fascial injury is present
fibre rupture (less than 5% of the injury
muscle involved)
Peetrons lack of US Minimal elongation with less Lesions involving from 5% to 50% of the Complete muscle tears with
lesion than 5% of muscle involved— muscle volume or cross-­sectional diameter complete retraction
hypoechoic area
Lee Normal or focal/general areas Discontinuity of muscle fibres in echogenic Complete myotendinous or
of increased echogenicity— perimysal strae. Hypervascularity around tendon-­osseous avulsion, complete
perifascial fluid disrupted muscle fibres. Intramuscular fluid discontinuity of muscle fibres and
collection, partial detachment of adjacent associated haematoma. Bell clapper
fascia or aponeurosis sign
Chan (ISmULT) Normal appearance. Focal or Discontinuous muscle fibres. Disruption site is Complete discontinuity of muscle Proximal MTJ/
general increased echogenicity hyper-­vasculised and altered in echogenicity. fibres. Haematoma and retraction of muscle proximal/
with no architectural distortion No perimysal striation adjacent to the MTJ the muscle ends middle distal/ distal
MTJ+intramuscular
- myotendionous
Schneider- Kolsky <10° ROM deficit 10°–25° ROM deficit >25% ROM deficit
Stoller Hyperintense oedema+/- Hyperintense haemorrhage with tearing Complete tearing+/-muscle
haemorrhage with preservation of of up to 50% of muscle fibres. Interstitial retraction. Hyperintense fluid filled
the muscle morphology. Oedema hyperintensity with focal hyperintensity gap+hyperintense on FSPDFSE+STIR.
pattern=interstitial hyperintensity representing haemorrhage in the muscle Associated adjacent hyperintense
and feathery distribution on belly+/-intramuscular fluid. Hyperintense interstitial muscle changes
FSPD or T2FSE+STIR images focal defect+partial retraction of muscle
hyperintense subcutaneous tissue fibres. associated myotendinous+tendinous
oedema+intermuscular fluid injuries. Hyperintensity+interruption +/-
widening of muscle - tendon Unit
Mixed Cohen Point grading score - Age/muscles/location/ cross sectional area/retraction/ longitudinal axis T2 signal length
Munich Indirect Functional muscle disorder (consider neuromeningeal) - negative imaging findings
Structural muscle injury: Grading on US/MRI classification System
Direct muscle injury
BAMIC Negative <10% cross sectional area 10%–50% cross sectional areas—5–15 cm >50% cross sectional area >15 xm Complete rupture
imaging (tendon >5 cm)
findings
A -Myofascial tear (4 grades) incorporating cranio-­caudal length and cross-­sectional area for grading—small/moderate/extensive/complete
B - Muscle Tendon Junction tear (4 grades) incorporating cranio-­caudal length and cross-­sectional area for grading
C -Intra-­tendinous tear (3–4 grades) incorporating cranio-­caudal length and cross-­sectional area for grading
Barcelona Negative MRI Hyperintense muscle fibre Hyperintense muscle fibre and/or peritendon Any quantifiable gap between
- (MLG-­R) but clinical oedema without intramuscular oedema with minor muscle fibre architectural fibres in craniocaudal or axial
mechanism of suspicion haemorrhage or architectural distortion (fibre blurring and/or pennation planes. Hyperintense focal defect
injury/location distortion (fibre architecture angle distortion) ± minor intermuscular with partial retraction of muscle
- muscle/grade/ and pennation angle preserved). haemorrhage, but no quantifiable gap fibres±intermuscular haemorrhage.
previous injury Oedema pattern: interstitial between fibres. Oedema pattern, same as The gap between fibres at the
hyperintensity with feathery for grade 1 injury’s maximal area in an axial
distribution on FSPD or T2 FSE? plane of the affected muscle belly
STIR images should be documented. The exact
% CSA should be documented as a
subindex to the grade
Mechanism of Direct/indirect/stretch or sprint
injury
Location Location of lesion—proximal/middle/Distal
Extracellular When codifying an intratendon injury or an injury affecting the MTJ or intramuscular tendon showing disruption/retraction or loss of tension
matrix exist (gap), a superscript (r) should be added to the grade
Surgical Wood Proximal hamstring attachment rupture based on MTJ versus Tendon injury/avulsion—bony versus tendon/avulsion—partial versus complete/ retraction
distance/ sciatic nerve involvement
Lampainen No of tendons involved (1–3)/level of athlete(demand)/level of symptoms (pain+function)
BAMIC, British Athletics Muscle Injury Classification; CSA, cross-­sectional area; FSE, fast spin echo; FSPD, fat-­suppressed proton density; MTJ, musculotendinous junction; ROM, range of motion;
STIR, short tau inversion recovery; TOP, tender on palpation; US, ultrasound.

Paton BM, et al. Br J Sports Med 2023;57:254–265. doi:10.1136/bjsports-2021-105371 2 of 14


Consensus statement

Br J Sports Med: first published as 10.1136/bjsports-2021-105371 on 17 January 2023. Downloaded from http://bjsm.bmj.com/ on December 29, 2024 by guest. Protected by copyright.
different hamstring muscle, may require individualised manage- have a 95% chance of returning to sport anywhere between 3.9
ment to optimise outcome. Anatomical architectural consider- and 57.5 days. In this study, for MRI positive injuries (87% of
ations, including loss of tension, anatomical displacement and this cohort), the grading systems and the BAMIC anatomical site
sciatic nerve involvement may also be important in surgical deci- accounted for only 7.6%–11.9% of total variance in TRTS.
sion making. HSI classification systems may benefit from consid- These studies suggest that anatomical site and severity grading
ering muscle-­specific differences in anatomy, function or injury are likely to be helpful, but not fully sufficient to explain TRTS.
pattern when assessing validity, outcomes and in the further There is likely to be a role for clinical findings and reasoning
evolution of classification systems.19 22 and other individual athlete and sporting factors alongside clas-
sification systems to enhance prognostication. Considering all
of these contributors is the role of the expert clinician in sport.
Reliability and validity of classification systems Some authors suggest difficulty in grouping all three hamstring
Many classification systems do not have validity or reliability muscles together when classifying these injuries and suggest that
evaluation, often because it is difficult to assess pathophysiology each muscle should be classified separately, to consider differences
and healing outcomes at a tissue level. Surrogate measures of in connective tissue, fascia, and tendon architecture that produce
healing and recovery are typically used. Clinical assessment and/ different injury types, healing rates and prognoses.19 20 22 The
or imaging findings correlating with HSI severity, prognosis and BAMIC classification paper comments that the specific injured
outcomes are most pragmatically useful and are often used to hamstring muscle should be named with the associated classifi-
validate systems.17 34 Most use TRTS,35 but time to return to full cation, but outcome papers are challenging with this approach
training (TRFT),10 reinjury rates29 and performance metrics36 due to small numbers in the subsequent classification groups.
have also been studied. The complete resolution of HSI signs on Differences in rates of healing or prognosis between hamstring
imaging is unlikely to be necessary for successful RTS.37 There muscles, or locations such as the T junction injury, are not
is a high incidence of MRI negative injuries9–12 but this may not consistent and subclassification may not be required,10 although
impact reliability or validity of classification systems as many these studies contain small numbers. Many systems make no
systems incorporate a grade 0 and these HSI generally have a differentiation between tendon injuries in the proximal, distal or
better prognosis.10 38 Online supplemental material 2 describes intramuscular tendons, which may have different healing rates
current HSI classification systems and available validity reli-
and reinjury risk, requiring modifications to rehabilitation and
ability data)
possible surgical consideration.40–42 Most authors have found
The British Athletics Muscle Injury Classification (BAMIC)
differences in rehabilitation outcomes or reinjury risk with intra-
group have investigated the prognostic validity of their system,28
tendon injuries,43 but not all.35 Further discrimination of class
and they, and others, have also demonstrated good intra and inter-­
c injuries to include the distance of retraction and categorisa-
rater reliability of the BAMIC system.12 39 In a study of 44 track
tion between the intramuscular tendon and free tendon may be
and field athletes with 65 HSI,29 they observed that increased
helpful with respect to surgical decision making.44
TRFT and injury recurrence was associated with injuries that
Classifications that use a scoring system (examination, history
involved hamstring tendon tissue (‘c’ classification). TRFT was
and imaging findings carrying different weight) produce a
also significantly associated with grading severity (less in grade
combined score, such as that of Cohen et al,6 who observed that
0 (10±4.7 days) but higher in grade 3c (84±49.4 days)). In
a combined score of >10 corresponded to a worse prognosis
that study there was no significant difference in TRFT between
(games missed) and demonstrated that the percentage of muscle
myofascial (A) and myotendinous (B) injuries or between grade
1 and grade 2 injuries. The study did not include direct or contu- tendon involvement, the number of muscles, and the amount
sion muscle injuries, described in the Munich system, as these are of retraction were significant predictors of TRTS, but age and
rare in track and field. The BAMIC group have also outlined a location were not. Conversely, Hamilton et al observed that this
rehabilitation approach, informed by the athlete’s BAMIC clas- combined score did not provide a clinically useful prognosis for
sification28 and completed a further 4-­year follow-­up study after RTS, reflecting the challenges of attempting to accurately deter-
implementation of this rehabilitation approach.10 This did note a mine RTS duration.45 This is due to rarity of severe injuries and
significant difference in TRFT between grade 1 and grade 2 HSI therefore studies contain insufficient numbers of these injuries to
classified by BAMIC and again a significant difference in TRTS validate classification.
for injuries that involved the tendon (‘c’ classification). The rein-
jury rates in this 4-­year study were very low at 2.9% overall and
0% in the ‘c’ classification. Classification systems for surgical decision making
Wangensteen et al compared the level of agreement between Surgery may be required for some HSI, although these tears only
BAMIC, Chan, and modified Peetrons classifications using a probably represent 0%–5% of HSI in certain athlete groups.
mixed sport cohort comprising 176 HSI with MRI images,12 While many bony injury classification systems assist with reha-
reporting ‘substantial’ to ‘almost perfect’ intrarater and inter-­ bilitation and orthopaedic surgical decision making,46 classifica-
rater reliability when scored by experienced radiologists. For tion systems for muscles, have historically not included surgical
BAMIC, there was an association between TRTS for grades 0 considerations as part of their system, due to the lack of evidence
and 2 and 1 and 3. For HSI location, there was no association in to inform surgical indications.44 Two classification systems have
TRTS between types a and b and a and c, but there was between attempted to describe different types of proximal hamstring
b and c. The Chan system demonstrated no associations between tendon injuries and consideration of surgical repair. Wood et
anatomical site related to proximity, but differences were found al described five types of injury, detailing amount of displace-
on anatomical site within the muscle (2a–e). The Chan authors ment, sciatic nerve involvement and location.8 Lempainen et
reported difficulties with association due to the low frequency of al have attempted to separate each tendon proximally to allow
injury in many of the categories (3a, 4b and 4c categorised just 1, surgical consideration even in partial injuries such as semimem-
2, 2 injuries, respectively). Many categories had large individual branosus.47 Treating these proximal free tendon injuries non
TRTS, which means an individual with a HSI 3c injury would operatively can cause significant morbidity and failure to RTS.48

3 of 14 Paton BM, et al. Br J Sports Med 2023;57:254–265. doi:10.1136/bjsports-2021-105371


Consensus statement

Br J Sports Med: first published as 10.1136/bjsports-2021-105371 on 17 January 2023. Downloaded from http://bjsm.bmj.com/ on December 29, 2024 by guest. Protected by copyright.
Unfortunately, there are no reliability data for these surgical clinical expertise, a consensus with international Delphi process
systems. Prognostic information using a cohort of 72 operations was conducted to aid progress in this area of significant interest.
provides incidence and outcomes for the subtypes in the Wood
System.8 44 Several recently validated patient-­reported outcome Aims
measures (PROMs) may help,49 50 although these scores relate to 1. To determine the current global practice of classifying HSI.
proximal hamstring ruptures, and there may other types of HSI 2. To determine the key aspects of decision making in the clas-
where surgery may be indicated. As knowledge advances on key sification of HSI.
indications for surgery, HSI classification systems should evolve 3. To provide best practice for decision making in the classifi-
to optimise decision making around the role of surgery. cation of HSI.

METHODS
Classification for high-grade intramuscular tendon or MTJ
Study design
injuries
A modified Delphi study design was used, including an interna-
There are some intramuscular HSI for which surgical interven-
tional panel of experts, with the aim of reaching a consensus on
tion has been considered. These include injuries at the ‘T junc-
best practice for classification after HSI. In the situation where
tion’ of the biceps long head, proximal biceps MTJ, conjoint
clinicians must make assessment and treatment decisions based
intramuscular tendon and semimembranosus separation inju-
on incomplete, weak and poor-­quality evidence, clinical exper-
ries.51–53 Injuries at these sites are classified within the constructs
tise and experience become vital. A research approach to gain
of existing classification systems rather than as defined entities.
insight from practitioners’ expertise is useful. Single experts can
Further work is required to clarify clinical outcomes and surgical
be useful but a scientific approach that aims for a consensus/
indications for injuries at these sites and to establish whether
agreement among a group of experts can provide more optimal
existing classification systems should be adapted to incorporate
recommendations.59 The London 2020 international hamstring
further understanding of these injuries and to assist with decision
consensus group was established as a multidisciplinary collabo-
making.
ration to advance the assessment and management of HSI. The
Delphi methodology was thought to present a systematic and
Summary scientific approach to capture the decision-­making experience
and expertise of global experts to identify and investigate areas in
There are a number of classification systems available for use
HSI where new decision making approaches could be developed.
by clinicians, but no single system allows optimal treatment
planning or prognostication. Current classification systems are There have been previous Delphi consensus studies in muscle
nonspecific for the individual hamstring muscle injured, despite injuries,2 60 injury prevention61 and aspects of management of
each muscle having different anatomy, innervation, functional HSI, such as return to play62 63 but other aspects of hamstring
roles and injury patterns.54 Apart from direct contusion inju- assessment and treatment may also benefit from this approach
ries, the mechanism of injury has been largely overlooked in such as classification systems, decision making in rehabilitation
classification systems, but different mechanisms of injury may and the justification for surgery, particularly given the disparate
cause specific injuries such as slow stretch versus high intensity and conflicting approaches used currently.22 64
running HSI.55–57 Pattern recognition, however, is complex as a The description of our modified Delphi methods is described
single mechanism of injury (eg, high speed running) may cause below, following guidance on Delphi studies65 66 and web survey
multiple different types of HSI.10 design,67 but can also be found in online supplemental file 1.
Management of HSI must consider the demands of the partic-
ular sport, such as the differences in injury patterns for sprint Participants: expert panel
versus pivot type sports, or those with and without physical Identifying appropriate experts is vital to the Delphi process68
contact. Elite level sports require a higher performance demand and an international, representative, multidisciplinary group
and often aim to reduce TRTS. The management decisions in of expert clinicians and researchers were invited to participate
elite sport may be different depending on sporting demand, time in this study, based on their expertise in the assessment and
of season, patient goals and many other contextual factors.58 management of HSI. A purposive, heterogeneous representative
Different sporting levels are currently not considered in classifi- sample of experts was chosen to ensure a mix of—professional
cation systems. discipline (sport and exercise medicine physicians, physiothera-
Clinicians managing high-­ grade injuries may benefit from pists, surgeons, sport and exercise scientists/researchers, strength
classification systems that aid rehabilitation or surgical decision and conditioning specialists and athletic trainers), international
making. Furthermore, while some classifications consider prox- experience, sex and sporting discipline in line with Delphi
imal HSI avulsions, further evidence is required regarding the methodology.69
optimal management of intramuscular tendon injuries that may The criteria for expert inclusion were— a high level of exper-
help inform rehabilitation guidelines and surgical indications. tise assessing, managing and/or researching HSI, based on—the
Finally, the testing of reliability and validity of HSI classification number of injuries seen; years worked managing HSI; peer-­
is a priority. No current classifications are able to predict TRTS reviewed publication (authorship) in hamstring research; willing-
or the risk of reinjury. ness to complete the digital survey and or attend the consensus
In view of these classification gaps and lack of robust evidence, meeting and sufficient level of written and spoken English.
we undertook a consensus process, including an international Possible experts were excluded if they had (1) insufficient
Delphi Study, seeking expert opinion to enhance decision experience of assessment or management of HSI, (2) insuffi-
making in the classification of HSI in order to inform clinical cient time to fully complete the online survey. Clinicians and
management for athletes presenting with HSI. non-­clinicians were included but asked to answer only those
Due to the limitations of small athlete numbers in studies that survey questions related to their fields of expertise. (see meth-
evaluate muscle injury classifications, and the vital importance of odology supplement). Domains of surgery, postsurgical recovery

Paton BM, et al. Br J Sports Med 2023;57:254–265. doi:10.1136/bjsports-2021-105371 4 of 14


Consensus statement

Br J Sports Med: first published as 10.1136/bjsports-2021-105371 on 17 January 2023. Downloaded from http://bjsm.bmj.com/ on December 29, 2024 by guest. Protected by copyright.
and rehabilitation were also identified and experts were chosen, After discussions, the key consensus statements were synthe-
with sufficient expertise in these combined areas as well as sised and refined. These sessions were chaired by each steering
classification. committee author related to their area of specialisation—clas-
Coaches and trainers comprised 6% of the experts for the sification (JM), Rehabilitation (BMP), RTR/RTS (MG) and
final survey. Athletes were not included; however, we would surgery (FH). Statements were gradually refined through a
acknowledge their voices as vital. Many of our experts have also process of facilitated debate until the entire panel were satisfied
been athletes and 38% of the final survey expert respondents and on day 2 were put to the group for anonymous electronic
reported a personal history of HSI. voting. See online supplemental appendix 4 for the list of state-
There is no guideline for number of experts to be involved ments—rehabilitation, RTS/RTR, classification and surgery.
in a consensus,69 but the sample size was set at 30 for the initial The consensus steering committee (established an a priori
survey to ensure a full international and multidisciplinary sport/ criterion threshold of 70%, with ≥70% agreed/yes responses
profession mix. A possible drop-­out and non-­response rate was constituting statement acceptance. 70% has been used success-
predicted. The study aimed to follow research recommendations fully by other Delphi studies.77–79 Eighteen statements on the
with opinion-­based research questions.65 70 diagnosis and classification of HSI reached sufficient group
agreement.
The final Delphi round involved a further online survey was
Modified Delphi process developed, to test these statements with this survey to a wider
The study comprised two rounds of a purposive digital survey global international group of experts who met the previous inclu-
interspersed with a face-­to-­face meeting round. Each round was sion/exclusion criteria. The participants voted on the statements
modified, based on feedback, to achieve a consensus among the with yes, no, uncertain (‘forced choice’) responses. This made
international panel of experts. Each Delphi round comprised a the final survey shorter and less onerous for participants, but
digital questionnaire, an analysis, and a feedback report. The some further Likert or factor ranking questions determined level
study was undertaken after a review of decision-­making aspects of agreement. (See examples within methodology supplement).
of the assessment and management of HSI. The literature These experts voted on statements and ranked their key
was searched, the evidence discussed and the author team led decision-­making factors or justifications related to the domain
a review of the evidence presented as a narrative summary to areas found in the round 1 survey.
inform the consensus rationale and knowledge gaps (see online
supplemental file 2).
Expert panel for final round
Round 1 involved a digital survey, with open-­ended questions
The final survey with voting on the consensus statements, was
to a global group of clinicians and researchers with expertise in
split into domain sections—classification, surgery, rehabil-
HSI. The round 1 survey (see online supplemental appendix 1)
itation, RTR/RTS. Participants were asked to complete only
aimed to gather information, and understand, from the experts’
the domains (sections of the survey) that were within their
viewpoint, where are the gaps in the literature evidence and clin-
field and scope of expertise. The survey responses were evalu-
ical practice in HSI decision making. The initial round 1 survey
ated for completeness. Survey responses in each domain were
comprised open-­ended qualitative information gathering ques-
evaluated by two steering group members and any incom-
tions and some quantitative data questions using Likert scales
plete responses from non-­experts in that particular domain
to determine level of agreement. The survey used a digital
were removed from the analysis. Within their expertise areas,
institution-­based software package—Opinio V.7.12 (copyright
panel members were asked to complete sections as care-
1998–2020 ObjectPlanet, Oslo Norway). The surveys in this
fully as possible and provided with response options such as
study followed the Checklist for Reporting Results of Internet
‘uncertain’. Open-­ended boxes after each consensus statement
E-­Surveys67 and the reporting standard for conducting and
also allowed them to comment, and comments and areas of
reporting Delphi studies66 to avoid bias.
disagreement were collated and analysed.
The responses from the initial survey were collated and anal-
ysed with a thematic and factor analysis71 (see online supple-
mental table 1). The expert panel identified four key domains Steering committee
classification and diagnosis, surgery, rehabilitation and return to The surveys were designed by two experienced clinical academic
running (RTR) and sport) (and key questions for these domains physiotherapists, and a professor of orthopaedic surgery, who
(see tables in online supplemental appendix 3). This paper deals each have greater than 20 years clinical experience treating HSI
with results of classification and diagnosis, with subsequent papers and research expertise in HSI, as well as previous experience
covering surgery and rehabilitation. The questions on diagnosis with Delphi research. A structured, iterative process was under-
and classification were outlined and presented for discussion. All taken to develop the survey and it was piloted by a mixed group
the panel members who completed the survey were invited to of five sports medicine physicians, five physiotherapists and five
the discussion meeting. The discussion took place via a group orthopaedic surgeons, and the survey was further refined based
consensus 2-­ day meeting, alongside an international confer- on their feedback. The expert panel were approached by email
ence, to allow as many of the participants to join as possible. A located from publicly available correspondence information on
nominal group consensus model was followed with a facilitated, peer reviewed journal articles. Information was provided prior
structured approach to gather qualitative information, from this to participation but actively completing the survey was implied
group.72 This approach has been followed in other consensus (and stated) as the consent to participate. Any participant who
projects.73 74 In discussions, facilitators maintained impartiality withdrew had data removed.
and ensured balanced discussion to avoid ‘eminence bias’.65
They aimed to work towards agreement but not force consensus. RESULTS
Dissenting and outlier views were considered important, repre- Respondents
senting differences in practice. This approach aimed to avoid The volume of responses made reporting in one single paper
‘herding bias’.75 76 difficult. For this reason, three papers are presented with

5 of 14 Paton BM, et al. Br J Sports Med 2023;57:254–265. doi:10.1136/bjsports-2021-105371


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Br J Sports Med: first published as 10.1136/bjsports-2021-105371 on 17 January 2023. Downloaded from http://bjsm.bmj.com/ on December 29, 2024 by guest. Protected by copyright.
DISCUSSION
This paper presents the results of a modified Delphi study and
consensus in the decision making of classification of HSI. The
final Delphi round comprised a digital survey determining
the level of agreement (LOA) from global HSI experts on the
consensus statements from the London 2020 international
Hamstring consensus group meeting.

Areas of agreement/disagreement
We observed that clinicians use multiple sources of informa-
tion in their decision making to inform diagnosis, classification,
management and prognosis of HSI. Both imaging and clinical
examination findings were considered essential and informed
each other when making decisions on treatment of HSI

Justification for imaging


► Imaging is vital in the classification system (LOA 70.5%).
► Anatomical (radiological) classification is essential in the
diagnostic process (LOA 62.0%).
Imaging was deemed vital for classification; however, the
survey respondents did not agree that imaging was vital for
diagnosis. Survey respondents and our consensus meeting panel
noted that a proportion of HSI present without positive imaging
findings, and the failure of MRI to accurately predict TRTS.17 80
Clinicians expressed that they prioritised loss of range of motion
(ROM)/loss of tension and symptom levels to decide on imaging,
with some external factors considered important such as the type
Figure 1 Flow diagram of expert participants and response rates
or level of sport and cost or patient expectations.81
(RR).
While these findings are similar to the literature on the
justification of imaging in HSI, there are few specific MRI or
US guidelines for HSI.82–85 These are often incorporated into
decision-­making domain areas of—classification, surgery and general guidelines for musculoskeletal imaging.83 86 The low
rehabilitation and RTS. range of clinical justifications may leave out some significant
The response rates and the inclusion and exclusions for each imaging justifications—and knowing examination features that
survey round are given in the flow chart in figure 1. The compo- trigger early investigation may save time and enable an athlete to
sitions and characteristics of the expert panel for each round receive appropriate and targeted rehabilitation.56 87 88 Although
survey and the face-­to-­face meeting are reported below in table 2. minor and low grade HSI may not require imaging,11 intramus-
cular tendon injuries cannot be easily diagnosed solely with clin-
ical examination features89 and if this is an important potential
Preferred HSI classification system diagnosis for that athlete, imaging should be obtained. In the
Table 3 presents the participants preferred HSI classification second-­ round survey, (table 7) respondents commented that
system. For both surveys 1 and 2, BAMIC, Munich and Barce- imaging and anatomy were important, but their votes showed
lona ranks 1, 2 and 3, respectively. lower levels of agreement for imaging being essential for clas-
In the initial survey, we asked participants what questions sification (70.3%) but not for diagnosis (56.6%) and stronger
need answering in HSI classification. The initial survey results agreement on preference for clinical examination, functional
are presented in tables 4–6. Top three questions are: (1) are markers and history findings to be considered.
there different clinical presentations for fascial/muscular/Iintra-
muscular tendon and free tendon injuries, (2) which HSI clas-
sification system most effectively guides management and (3) Clinical features
does the classification of injury relate to recovery time (return ► Immediate physical examination signs including bruising,
to performance)? loss of muscle tension, palpable defects and/or significant
When considering the key factors that influence clinician’s weakness and excessive/no response on provoking activities
decisions for requesting imaging, the top three answers were (1) warrant further investigation (LOA 92.6%).
loss of range of motion and/or strength and/or tension and/or In the area of clinical investigation to aid diagnosis or assess-
integrity on examination, (2) symptoms and (3) injury mecha- ment of severity, our consensus panel and survey respondents
nism. Tables 5 and 6 (initial survey) deal with the key factors put great weight on clinical assessment findings to help diag-
in referral for imaging and key examination considerations for nose and classify HSI. Immediate physical examination signs like
diagnosis. bruising, loss of muscle tension, palpable defects and/or signifi-
Table 7 reports the consensus statements from our meeting cant weakness and excessive/no response on provoking activities
days and reports the results of round 2 digital survey from the showed strong agreement as justifications for ordering imaging.
99 respondents. The levels of agreement for each of these state- Many clinicians suggested these could be diagnostic and put
ments is reported and those that achieved more than 70% are most emphasis on loss of tension or muscle/strength function to
highlighted. aid diagnosis. Second to this were symptoms and the mechanism

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Table 2 Participant charactreristics of the expert panels
Survey round 1 Meeting Survey final Round
Characteristic Categories N=35 N=15 N=99
Sex (M: F) 33:2 14:1 81:18
Age (years) 27–36 11 (31.4%) 6 32 (31.6%)
37–46 13 (37.1%) 4 33 (33.7%)
47–56 9 (25.7%) 4 20 (20.4%)
57–70 2(5.7%) 1 14 (14.3%)
Role clinician Clinician only 3 (5.7%) 26 (25%)
Researcher/scientist only 2 (8.6%) 11 (11 %)
Clinician+researcher 30 (85.7%) 15 (100%) 62 (63%)
Neither clinician nor researcher 0 1 (1%)
Hamstring cases/year None 0 5 (5%)
0–4 1 (2.9%) 6 (6%)
5–9 6 (17.1%) 25 (24%)
10–14 7 (20%) 12 (12%)
15–19 10 (28.6%) 13 (13%)
20 or more 11 (31.4%) 38 (38%)
Healthcare profession Sports medicine physician 4 (10%) 1 (7%) 21 (18 %)
Orthopaedic surgeon 8 (21%) 5 (35%) 18 (17 %)
Physical therapist 22 (55%) 10 (64%) 43 (40 %)
Sports scientist 1 (3%) 25 (24 %)
Athletic trainer/strength and conditioning coach 2 (5%) 7 (6 %)
Other 2 (5%) 2 (2%)
Country of practice North America 4 (11%) 10 (10%)
Europe 26 (66%) 12 (80%) (UK, Neth, Ir) 65 (64%)
Middle East/Africa 4 (11%) 1 (7%) SAf 12 (12%)
Southeast Asia 1 (1%)
South America 1 (1%)
Australasia/pacific 5 (13%) 2 (13%) (Aust) 10 (10%)
Sports football 31 (29%) 4 (27%) 79 (80%)
athletics 19 (19%) 2 (13%) 59 (60%)
Rugby codes 13 (12%) 4 (27%) 40 (40%)
NFL (North American football) 5 (5%) 9 (9%)
AFL (Australian Rules football) 3 (3%) 9 (9%)
Basketball 9 (9%) 30 (30%)
Volleyball 4 (4%) 1 (1%)
Skiing and winter sports 9 (9%) 21 (21%)
Hockey 3 (3%) 1 (7%) 22 (21%)
Judo/martial arts/wrestling 2 (2%) 24 (24%)
Cricket 15 (15%)
Ice hockey 12 (12%)
Acrobatics/gymnastics/dance 17 (17%)
Gaelic football 7 (7%)
Racquet sports 17 (17%)
Handball 20 (20%)
Other 9 (8%) 4 (27%) 6 (6%)
Years working with HSI pathology 0–4 5 (14.3%) 17 (17%)
5-­9 8 (22.9%) 13 (13%)
10-­14 9 (25.7%) 22 (21%)
15–20 4 (11.4%) 23 (23%)
More than 20 9 (25.7%) 24 (24%)
Highest academic achievement Bachelor/diploma 14 (14%)
Masters 35 (35%)
PhD 34 (35%)
Clinical doctorate 15 (15%)
Had hamstring injury personally Hamstring problem 38 (38%)
Not applicable 61 (62%)
Aust, Australia ; HSI, hamstring injuries; IR, Ireland; Neth, Netherlands; SAf, South Africa.

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Table 3 Survey results round 1—ranking of classification systems Table 5 Key factors triggering referral for imaging
Survey 1 vote Meeting vote Survey 2 No of
Classification system (%) (%) vote (%) Factors responses % of total
British Athletics Muscle injury 17 (40) 15 (35) 56 (58) Loss of range of motion/ strength/ tension or integrity 14 16
Munich 9 (21) 10 (24) 11 (12) on examination
Barcelona M Injury 5 (12) 6 (14) 6 (6) Symptom levels 12 14
Modified Peetrons US/MRI 6 (14) 3 (7) 9 (9) Injury mechanism or sound (pop) 8 9
Chan 2 (5) 1 (2) 1 (1) Failure to improve 7 8
Cohen 0 (0) 2 (5) 3 (3) Severity 6 7
Wood 1 (3) 4 (10) 5 (5) Diagnosis 6 7
Takebayashi 0 1 (2) 1 (1) Prognosis Questions (need for surgery) 4 5
Nil used 2 (5) 0 2 (2) Suspected tissue type 5 6
Totals 43 42 96 Particular muscle 3 3
US, ultrasound. Athlete level 3 3
Player or coach expectation 3 3
Bleeding bruising 5 6
of injury. The failure of the athlete to improve also triggered Availability of imaging modalities 2 2
further investigation (see table 5).
Timing 3 3
Local protocol 1 1
Types of imaging Cost 1 1
► MRI is the preferred imaging for diagnosis and classification
Red flag 1 1
(LOA 89.5%).
Scientific evidence 1 1
MRI was the investigation of choice over US. This is consis-
Athlete susceptibility (including previous HSI) 1 1
tent with literature which focuses on MRI based classification
Total 86 100
systems. Koulouris and Connell compared the use of US to MRI
for the diagnosis of acute HSI, finding MRI detected proximal HSI, hamstring injuries.
hamstring avulsion injuries in 100% of cases compared with
only 58.3% of cases with US scan.90
MRI side to side differences were felt to be less important and guidelines on the use of US.83 84 86 US has some advantages
(LOA 49.5%) due to negative MRI findings in a high proportion for imaging muscle including evaluation of fluid/haematoma and
of HSI,11 but also financial reasons and the degree of contralateral scar, as well as real time movement and opportunity to support
incidental pathology often found on MRI. The consensus group intervention. It can be used in conjunction with MRI,92 but the
and survey respondents were also discriminating in their use and panel was in agreement that MRI was the most helpful imaging
timing of US, with use in the early stage (pitch side)—within the modality.
first 48 hours (LOA 14.8%) or even for primary diagnosis—after
the first 48 hours (LOA 21.8%) was not practiced. There was
more agreement on its use in the rehabilitation phase, possibly HSI classification systems
to monitor healing stages (LOA 61.8%), however, this did not ► Classification systems should have agreed Terminology
reach our threshold LOA. This finding agrees with literature91 (LOA 91.8%).

Table 4 Questions requiring answers in hamstring injury classification systems


Category of question Responses % of total Typical responses
Classification versus anatomy 17 24 Difference in clinical presentation between fascial/muscular/tendon/intramuscular tendon
Classification versus treatment planning 8 11 Which classification system most effectively guides management?
Classification versus prognosis/recovery 8 11 Does the classification of injury relate to recovery time (RT performance)?
Subclassification 6 8 Are we missing any important subcategories with current classification systems?
System of choice 5 7 Which classification system most closely predicts improvement, recovery and duration?
Classification versus clinical examination 5 7 Can we use a simplified system that uses clinical examination outcomes?
Classification versus mechanism of Injury 5 7 What is the association between injury type and outcome (return to play and reinjury) without
too much outcome in overlap between groups?
Muscle group specific system 5 7 Do we need to develop a classification system that is muscle (group)-­specific? Do we need to
consider different muscles, in grading systems?
Classification versus imaging 4 6 Are we basing rehab outcome timeframes mainly on MRI? can we develop holistic criteria
including athlete history, mechanism, presentation, clinical testing?
Classification versus surgery 3 4 Can systems encompass surgical criteria? Is surgery indicated—early vs late surgery?
Multivariable system 2 3 Is there a combination of radiological findings, functional characteristics (biomechanics, speed,
strength, range of motion) that can be added to create a composite score?
Classification versus function 2 3 Is there a combination of functional characteristics (biomechanics, speed, strength, range of
motion) that can be added to create a composite score?
Sport specific system 1 1 Can we develop a classification system that is sport-­specific?
Validity/reliability of systems 1 1 Are classification systems reliable and valid prior to implementation?
Total 72 100

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suggested muscle specific classification was required while others
Table 6 Key factors to make HSI diagnosis
suggested that sports specific classification should be considered.
Examination aspects No of responses There are also anatomical differences within individuals, making
Strength 18 specific classification more challenging.54
Palpation findings 13 The panel acknowledged the importance of clinical history
Function 8 and examination findings in classification. They suggested a
Pain 4 place in the classification systems for mechanism of injury and
Examination 4 functional criteria. Surgical criteria were rated as important, but
Neural findings 3 this statement did not reach consensus, reflecting differences in
Haematoma/swelling 2
opinion on the role of surgery. HSIs that need surgical consid-
n/a 2
eration are uncommon but ideally would be highlighted early to
prevent delays in treatment and risk of reinjury, longer recovery
History 1
and complications.93 However, further evidence on the indica-
Tone 0
tions for surgery is required to enable subsequent clear classifi-
Flexibility 0
cation and identification of these injuries so rare injuries are not
Total 55
misdiagnosed by clinicians who may not deal with these types
HSI, hamstring injuries; n/a, not available. of injury regularly.42 Finally, many suggested a multicomponent,
multivariable classification system was important, and clini-
cians voted highly on the inclusion of functional criteria such
► There is a need for one main classification system (agreed as walking and running/sprinting in classification systems. They
terminology and nomenclature) (LOA 84.8%). also wanted more effective PROMs that have received much
Most of the survey respondents use the BAMIC system attention, validation and reliability work in other injury types.94
(57%), although they concurrently use Munich and the Barce-
lona systems, but less commonly used US or earlier grades 1–3
systems. While they wanted a single classification system with Are HSI registries relevant?
agreed nomenclature and terminology, they indicated that none ► There is a need for a registry for HSI (LOA 68.7%).
of the classification systems were perfect, and all had areas Clinicians came close to agreement on the need for HSI regis-
that required improvement. Clinicians wanted a classification tries. Some clinicians operated in countries where registries are
to help with prognosis and outcome information and provide common for high volume injuries, such as anterior cruciate liga-
guidance for treatment decisions, as well as allowing them to ment injuries. These registries, however, have been set up under
grade severity. While they acknowledged that no one classifi- an orthopaedic framework. In HSI, the percentage of patients
cation system may be able to meet all these requirements, there requiring surgery is small. In elite sports, such as football,
was strong agreement that terminology should be consistent and registries may already exist in some form, and it may be more
agreed. appropriate for the most impacted sports to use an international
sporting framework (ie, PHAROS, UEFA, FIFA).
Areas where classifications must evolve
► We should differentiate between muscles in the classification Limitations
(LOA 88.9%). The panels for our three Delphi rounds were international, The
► Classification needs clear parameters such as (but not limited London international hamstring consensus meeting face-­ to-­
to): face group comprised 15 out of 35 respondents (43%) to the
– Free tendon versus central tendon (LOA 86.1%). initial digital survey. This may set up a bias, however, the panel
– Anatomical, radiological classification (LOA 95.1%). attending were heterogenous, with a multidisciplinary mix of
– Should evolve to include surgical criteria (LOA 51.2%). profession, location, sport, age and domain expertise in treat-
► Mechanism of injury should be commented alongside the ment of HSI. They comprised clinicians from Australia, Nether-
classification (where appropriate/known) (LOA 82.0%). lands, Ireland, the Middle East but the majority of the face-­to-­face
► Beyond anatomical classification, there is a need to have: meeting panel were UK based. We sought and invited experts
– Functional criteria running alongside (LOA 90%). from Asia, Africa and South America, however, there were less
– PROMs running alongside (LOA 80.4%) identifiable experts (clinical or published) from these locations,
While the survey respondents acknowledged that imaging and and they could not attend due to pandemic travel restrictions.
the involved anatomical tissue were important, many expressed This may mean their HSI management practices are not repre-
the need to individualise muscles—in part, due to the differing sented, possibly introducing bias. However, our meeting panel
architecture and functional roles between the hamstring muscles. all worked in elite sport with work schedules that included the
This is reflected in the types of injuries, with the muscles differing management of international patient/athlete cohorts . Most did
in their injury patterns. Our panel agreed that it was likely to be not train professionally in the UK and their work experience
important to consider individual muscle factors such as function and current work schedules comprised USA, Africa, Middle
and anatomy.19 22 Muscle architecture was also a factor in the East, Australia and Asia. They reported that many of their
agreement on free tendon versus the intramuscular tendon. athletes trained internationally, and with international coaches,
Some comments suggested a gap in the current classifica- reflecting the current international nature of elite and Olympic
tion systems in classifying intramuscular tendon injuries, for sport. To further reinforce the integrity of the consensus, and
example, the BF central tendon40 or the connective tissue T junc- provide more international perspective, authors were included
tion between BF long and short head.41 These pathologies have with significant Middle East hamstring work experience.
typical injury patterns within the BF. Some clinicians reported Our group of experts had multiple domains of exper-
that the implications of these injury pattens may differ between tise and scope of practice. This consensus project involved
sports. This may be one significant reason why some respondents disparate domains of—surgery, postsurgical and non-­ surgical

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Table 7 Consensus statements and percentage agreement for round 2 survey—global expert panel (n=99)—classification
Consensus statements related to
classification True False Undecided Samples of typical responses—discussion points or areas of disagreement
Anatomical (radiological) classification is 62.0% 22.0% 16.0% It is essential in the higher-­grade hamstrings to determine the tendon involvement
essential in the diagnostic process however with smaller strains radiology is non-­essential.
There is a need for One main classification 84.8% 2.0% 13.1% A 'one-­size-­fits all' may not be appropriate. Different sports have different
system (agreed terminology and mechanisms of injury, demands and therefore RTP times, and re injury rates.
nomenclature). Seems logical that what may work for track and field doesn't necessarily hold true for
football. Difficult to fit everything into one main classification anatomy, function, and
prognostication.
Classification needs Anatomical, 95.9% 0.0% 4.1% It appears research remains undecided for the influence of anatomical location and
clear parameters such radiological free vs central tendon involvement in classification systems.
as (but not limited classification
to):- Free Tendon versus 86.9% 6.1% 7.1% Again, the evidence is limited in the classification of tendon versus MTJ injuries (as
Central Tendon an example). No evidence suggests central tendon involved injuries are better off
with surgical intervention or not.
The only evidence we do have is that treating without the MRI and using clinical
markers to guide progression is the only consistent approach, whether central tendon
is involved or not.
Should evolve to 52.1% 19.8% 28.1% Surgical criteria would be useful for practitioners deciding on prognosis and
include surgical criteria management.
Classification systems should have agreed 91.8% 2.0% 6.1% Diagnostic classification system should be clear in reports and research. Only for
terminology consistency’s sake from both a scientific and clinical perspective.
There is a need for a registry for hamstring 68.7% 10.1% 21.2% more data is useful, but I fear people will bias their interpretation of it (eg, all central
injuries tendon injuries take longer to rehab than MTJ—but this is because you treated
them based on the MRI which showed central tendon and you were conservative
as a result). This bias is tough to avoid in these registry datasets and people will
misconstrue the data. Would be difficult with so many sports. Maybe intrasport
registry.
Mechanism of injury should be commented 82.0% 11.0% 7.0% This always allows for a clearer prognosis/ This is more useful than the classification
alongside the classification (where system. Affects anatomical involvement, prognosis, and rehab decisions.
appropriate/known)
We should differentiate between muscles in 88.9% 4.0% 7.1% Obvious/different muscles have different functions so a classification that guides
the classification? rehab is desirable hamstrings have different structure and therefore function which
needs to be clearly stated to understand if certain muscles are at greater reinjury
risk or require longer/requires a very demanding system that may be too difficult to
adhere to.
Beyond anatomical Functional criteria 90.0% 6.0% 4.0% Time to walk pain free/Confidence to Sprint/ patient expected time to return to sport.
classification, there is running beside
a need to have: - PROMs running beside 80.4% 10.3% 9.3% Current PROMs for hamstring injury may not be particularly useful/ PHAT LEFS/ Marx
score/ FASH.
Imaging is vital in the classification system 70.5% 14.7% 14.7% To decide between conservative or surgery, not otherwise/ Would prefer that
classification would guide us to ask for imaging. Not that imaging is always essential
especially in low grade injury/ in professional sport, imaging is more often required
than not, however does not always change management.
Immediate physical examination signs like 92.6% 2.1% 5.3% In this presentation you are suspecting a free tendon or complete rupture which may
bruising, loss of muscle tension, palpable require surgery/pain level and mechanism (suggesting a complete tear, avulsion, or
defects and/or significant weakness and anything else that might require a surgical opinion.
excessive/no response on provoking activities
warrant further investigation
MRI is the preferred imaging for diagnosis and 89.5% 4.2% 6.3% If used, I prefer MRI/ultrasound imaging can be very useful if conducted by a
classification physician/ sonographer with lots of training. Ultrasound is also very suited to
examine the damaged muscle- connective tissue area under movement. Ultrasound
can also be a good cheaper alternative.
MRI side to side comparison is ideal for 49.5% 25.3% 25.3% This does not happen that often due to financial restrictions. Enough information can
classification likely be gained from a unilateral MRI to give an accurate diagnosis. /Contralateral
side is not always a 'healthy' side/Should be used together with US/I prefer a correct
protocolised MRI only of the affected side.
When is ultrasound Primary imaging after 14.8% 58.0% 27.3% Ultrasound is not particularly useful when there is a lot of oedema, in the early post-­
most useful/relevant injury preE 48 hours injury period.
as Primary imaging after 25.8% 42.7% 31.5% 4 day deadline is best to see well the haematic collection.
injury post 48 hours
In the rehabilitation 61.8% 16.9% 21.3% It depends in what aspect. Architecture—yes. Lesion tracking—no.
phase
Highlighted values indicate LOA >70%/ large uncertain or false values are given in italics/ bold.
MTJ, myotendinous junction; PROMs, patient-­reported outcome measures; RTP, return to play.

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Box 1 Recommendations from consensus Box 1 Continued

1. Imaging is important for outlining the anatomical muscle, 8. Development of key functional components and best
location and tissue involved in the injury. MRI is the methods of measurement for classification will be important,
investigation of choice and should be performed 24–48 as are the development of adequate patient reported
hours postinjury. US can be used as an adjunct, as it is less outcome measure.
useful for diagnosis but could be useful in rehabilitation 9. The systems should be sports specific, again acknowledging
to assess healing. Imaging should assist grading, using— the different loads, risk situations, and injury patterns in
volume, cross sectional area, length of lesions, as well as any different sports.
discontinuity in tendon or connective tissue, which may be 10. Very few classification systems have validation studies to
predictive of, slower/poorer outcomes and/or recurrence. ascertain their ability to accurately prognosticate and guide
2. A thorough history and physical examination are vital. treatment decisions. Outcomes should include time to return
Clinicians identified key history and examination findings to running, sprinting and full performance, as well as risk of
that trigger imaging referral. These include loss of—ROM, recurrence. The type of numbers required for these studies
tension or contraction capability, pain, presence and pattern may only be reached by large scale injury registries.
of bruising, swelling, the mechanism of injury and the sound
(popping) or feeling (tearing/instability) at the time of injury,
failure to progress in rehabilitation, and athlete factors such rehabilitation, classification, diagnosis, running and RTS. It
as previous injury, sporting type and level. was harder to evaluate expertise in classification and diagnosis
3. Classification systems need to perform multiple functions, and the criteria chosen for expertise were harder to establish,
including grading of severity and anatomical description academic criteria were thought to be important, but very few
and need to have agreed terminology to be pragmatically experts had published on classification, although they used clas-
useful. Currently, British Athletics Muscle Injury Classification sification systems. Many trainers and coaches had less expertise
(BAMIC) is the most widely used classification system in the diagnosis and classification domain and were not included
for hamstring injuries (HSI), with Munich and Barcelona as experts, although in some countries, trainers will have this
systems also used. Some clinicians use multiple systems, expertise. Choosing criteria for expertise is difficult for any
as they acknowledge strengths and weaknesses with each Delphi study and this represents one weakness of this method-
system. Systems are based on imaging and anatomy but ology.76 Our classification section received the most responses.
have evolved to encompass mechanism of injury. Our expert While we trusted the survey respondents to complete only those
clinicians preferred a single classification system to aid in fields that encompassed their expertise, it may be possible that
decision making around treatment and prognosis. some respondents completed sections outside their domain and
4. Classification and grading systems may evolve to include level of expertise or scope of practice. This was the reason for
multiple components that combine—imaging findings— lack of full response rate for every section. Open-­ended ques-
MRI / US, clinical presentation on history and examination, tions in the first round meant that we only took information
mechanism of injury data and athlete susceptibility data
such as previous injuries and age. Hamstring function may
have a place in classification, particularly running and Key points
sprinting, although this may relate more to a management
outcome than a component of classification. Classification ⇒ While classification systems exist for hamstring injuries
systems should also evolve or have the capacity to deal (HSIs) and encompass anatomical and imaging criteria,
with muscles individually, due to their different architecture, current classification systems are not specific to individual
functional roles and injury patterns. (hamstring) muscles.
5. Intramuscular tendon injuries are recognised in the BAMIC ⇒ Classification systems have evolved to include the specific
system and appear to have an increased risk of recurrence anatomical tissue (ie, muscle, myotendinous, tendon) as
or delay returning to sport. Loss of tension and cross-­ well as severity of injury gradings, and some include the
sectional area of tendon injury appear to be prognostic mechanism of injury and athlete factors.
variables.43 Further work is required to determine optimal ⇒ Clinicians most commonly use the British Athletics Muscle
management pathways and further develop classification of Injury Classification (BAMIC) system, with Munich and
the intramuscular tendon injury. Barcelona systems also used for the classification of HSI.
6. Further information in classification systems, such as ⇒ This expert panel recommends MRI as the imaging of choice
inclusion of individual muscles, mechanism of injury, patient for diagnosis with few panellists prioritising diagnostic
demands may aid treatment and prognostication for these ultrasound. Neither modality is recommended as a means
injuries. High level research is needed assess if outcomes of monitoring rehab progression or deciding on readiness to
such as return to sport or injury recurrence improve by using return to sport.
this information. ⇒ Experts agree classification systems for HSI should evolve to
7. The smaller cohort of higher-­grade HSI that commonly include parameters around: individual hamstring muscles,
recur, are harder to manage, and may benefit frodetailed intramuscular injuries, mechanism of injury, sporting demand,
classification with criteria to aid decision making around functional criteria and patient-­reported outcome measures.
surgical management. This lacks global agreement and there ⇒ There is a need for more research into criteria that determine
are only two classification systems with surgical criteria, the need for surgical intervention.
both focussing on proximal hamstring free tendon tears. ⇒ There is a need for more research into the effectiveness of
classification systems to prognosticate and guide treatment
Continued
decision making.

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9
that our experts submitted, which was used and adapted for the Orthopaedic Surgery and Sports Medicine, Amsterdam Movement Sciences,
basis of subsequent rounds. We did not include athletes/patients Amsterdam University Medical Centers, Amsterdam, The Netherlands
10
Amsterdam Collaboration for Health and Safety in Sports (ACHSS), Amsterdam IOC
in these surveys, as domain-­specific professional knowledge was
Research Center, Amsterdam, The Netherlands
required, but statements suggesting athletes should lead and guide 11
Centre for Human Health and Performance, London, UK
decision making in their own treatment received high (unani- 12
Arsenal Football Club, London, UK
13
mous) LOA. Also 38% of respondents to our survey reported School of Sport and Exercise, University of Goucester, Gloucester, UK
14
had undergone HSI, possibly contributing to the patient/thlete Welsh Rugby Union, Cardiff, UK
15
Saracen’s Rugby Club, London, UK
voice. Further work would ideally include athletes, coaches and 16
High Performance Unit, Irish Rugby Football Union, Dublin, Ireland
other sport stakeholders, whose perspective is vital. 17
Section Sports Medicine, University of Pretoria, Pretoria, South Africa
While we attempted to be inclusive, the representation of 18
Princess Grace Hospital, London, UK
19
women is low in our panels, (2/39, 1/15 and 18/99). We found Trauma & Orthopaedic Surgery, North Sydney Orthopaedic and Sports Medicine
less publicly available information directing to women experts, Centre, Sydney, New South Wales, Australia
and it was found that female rates of publication are lower in
HSI, with less publicly available information on expertise. Twitter Bruce M Paton @bpatphys, Michael Giakoumis @MickGiakoumis, Paul Head
@PHphysio, Sam Kelly @skelly_2, James Moore @JMoorePhysio, Simon Murphy
Although we attempted to invite these clinicians/researchers, the @simonmurphy23, Noel Pollock @drnoelpollock and Nicol van Dyk @NicolvanDyk
response rates lower for the women we surveyed and invited
Acknowledgements We would like to thank the large number of hamstring
to our meeting. This has been a weakness in other consensus experts who contributed their time and effort in completing our surveys, Thanks also
research. We recognise this as a significant limitation of our to Naomi Shah PT (India) and Magnus Hilmarsson PT (Iceland) who assisted with
consensus and recommend that future work specifically prior- meeting days.
itises endeavours to enhance representation of women within Collaborators This group of Authors forms part of the London International
consensus and Delphi group methodology as their voice is also Consensus and Delphi study group on hamstring injuries, but we wanted to permit
vital. each member to take an authorship with these papers if possible.
Where possible we aimed to include equity-­deserving groups Contributors This manuscript is the combined effort of the attached authors. BMP
while maintaining our expertise criteria for inclusion and further drafted the initial manuscript. NP, NvD and MW contributed significant drafting
work should aim to include these groups. Balancing inclusion 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
and expertise can be challenging but should be prioritised in any
meeting days.
Delphi study.
Funding The consensus process and meeting were cocreated and funded by the
Recommendations from Consensus on diagnosis, classifica-
Institute of Sport Exercise and Health, London, UK and the Academic Centre for
tion and grading of HSI (box 1). 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).
CONCLUSION Competing interests None declared.
A narrative review of classification in HSI showed that systems
Patient consent for publication Consent obtained directly from patient(s).
have evolved from clinical signs only, to imaging-­based systems.
Ethics approval Ethical approval for the study was sought and obtained from the
They have evolved to include injury mechanisms, and the anatom-
institutional ethical review board (Project ID 5938/002). Participants were informed
ical tissue and site, as well as the grading of injury severity. The prior to commencing the surveys, with completion implying consent.
relationship between imaging findings, grading/severity, rein-
Provenance and peer review Not commissioned; externally peer reviewed.
jury risk and prognosis, however, is still not fully clear. While
many clinicians would like to use classification systems to allow 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
prescription of rehabilitation and an accurate prognosis, there have been peer-­reviewed. Any opinions or recommendations discussed are
are very few studies that have investigated this. Our consensus solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all
group and Delphi survey rounds suggest that, in order of use, liability and responsibility arising from any reliance placed on the content.
expert clinicians most frequently use BAMIC, then Munich, Where the content includes any translated material, BMJ does not warrant the
then Barcelona muscle injury classification systems for HSI, for accuracy and reliability of the translations (including but not limited to local
regulations, clinical guidelines, terminology, drug names and drug dosages), and
the reasons of utility and simplicity. They have highlighted the is not responsible for any error and/or omissions arising from translation and
need to differentiate between the three hamstring muscles and adaptation or otherwise.
exact anatomical location to help classify these injuries. They
acknowledge limitations of any classification system but suggest ORCID iDs
Bruce M Paton http://orcid.org/0000-0002-2581-599X
they could evolve to consider additional information (functional
Ricci Plastow http://orcid.org/0000-0003-4820-8831
parameters, injury mechanisms, athletic sporting demands, Noel Pollock http://orcid.org/0000-0003-4660-2835
surgical indications and PROMs) to more optimally treat HSI. Nicol van Dyk http://orcid.org/0000-0002-0724-5997
Using the current systems along with this additional data may
allow more tailored and effective rehabilitation for each specific REFERENCES
injury. 1 Hamilton B, Valle X, Rodas G, et al. Classification and grading of muscle injuries: a
narrative review. Br J Sports Med 2015;49:306.
Author affiliations 2 Mueller-­Wohlfahrt H-­W, Haensel L, Mithoefer K, et al. Terminology and classification
1
Institute of Sport Exercise and Health, University College London, London, UK of muscle injuries in sport: the Munich consensus statement. Br J Sports Med
2
Physiotherapy Department, University College London Hospitals NHS Foundation 2013;47:342–50.
Trust, London, UK 3 Pollock N, James SLJ, Lee JC, et al. British athletics muscle injury classification: a new
3 grading system. Br J Sports Med 2014;48:1347–51.
Division of Surgery and Intervention Science, University College London, London, UK
4 4 Peetrons P. Ultrasound of muscles. Eur Radiol 2002;12:35–43.
AFC Bournemouth, Bournemouth, UK
5 5 Chan O, Del Buono A, Best TM, et al. Acute muscle strain injuries: a proposed new
British Athletics, London, UK
6 classification system. Knee Surg Sports Traumatol Arthrosc 2012;20:2356–62.
School of Sport, Health and Applied Science, St. Mary’s University, London, UK
7
Trauma and Orthopaedics, University College London Hospitals NHS Foundation 6 Cohen SB, Towers JD, Zoga A, et al. Hamstring injuries in professional football
Trust, London, UK players: magnetic resonance imaging correlation with return to play. Sports Health
8
Rochdale FC, Rochdale, UK 2011;3:423–30.

Paton BM, et al. Br J Sports Med 2023;57:254–265. doi:10.1136/bjsports-2021-105371 12 of 14


Consensus statement

Br J Sports Med: first published as 10.1136/bjsports-2021-105371 on 17 January 2023. Downloaded from http://bjsm.bmj.com/ on December 29, 2024 by guest. Protected by copyright.
7 Valle X, Alentorn-­Geli E, Tol JL, et al. Muscle injuries in sports: a new evidence-­ 38 Ekstrand J, Askling C, Magnusson H, et al. Return to play after thigh muscle injury
informed and expert consensus-­based classification with clinical application. Sports in elite football players: implementation and validation of the Munich muscle injury
Med 2017;47:1241–53. classification. Br J Sports Med 2013;47:769–74.
8 Wood DG, Packham I, Trikha SP, et al. Avulsion of the proximal hamstring origin. J 39 Patel A, Chakraverty J, Pollock N, et al. British athletics muscle injury classification: a
Bone Joint Surg Am 2008;90:2365–74. reliability study for a new grading system. Clin Radiol 2015;70:1414–20.
9 Wangensteen A, Guermazi A, Tol JL, et al. New MRI muscle classification systems and 40 Comin J, Malliaras P, Baquie P, et al. Return to competitive play after hamstring
associations with return to sport after acute hamstring injuries: a prospective study. injuries involving disruption of the central tendon. Am J Sports Med 2013;41:111–5.
Eur Radiol 2018;28:3532–41. 41 Entwisle T, Ling Y, Splatt A, et al. Distal Musculotendinous T junction
10 Pollock N, Kelly S, Lee J, et al. A 4-­year study of hamstring injury outcomes in elite injuries of the biceps femoris: an MRI case review. Orthop J Sports Med
track and field using the British athletics rehabilitation approach. Br J Sports Med 2017;5:2325967117714998.
2022;56:257–63. 42 van der Made AD, Tol JL, Reurink G, et al. Potential hamstring injury blind spot: we
11 Schneider-­Kolsky ME, Hoving JL, Warren P, et al. A comparison between clinical need to raise awareness of proximal hamstring tendon avulsion injuries. Br J Sports
assessment and magnetic resonance imaging of acute hamstring injuries. Am J Sports Med 2019;53:390–2.
Med 2006;34:1008–15. 43 Eggleston L, McMeniman M, Engstrom C. High-­Grade intramuscular tendon disruption
12 Wangensteen A, Tol JL, Roemer FW, et al. Intra- and interrater reliability of three in acute hamstring injury and return to play in Australian football players. Scand J
different MRI grading and classification systems after acute hamstring injuries. Eur J Med Sci Sports 2020;30:1073–82.
Radiol 2017;89:182–90. 44 Wood D, French SR, Munir S, et al. The surgical repair of proximal hamstring avulsions.
13 Valle X, Mechó S, Pruna R, et al. The MLG-­R muscle injury classification for hamstrings. Bone Joint J 2020;102-­B:1419–27.
examples and guidelines for its use. Apunts. Medicina de l'Esport 2019;54:73–9. 45 Hamilton B, Wangensteen A, Whiteley R, et al. Cohen’s MRI scoring system has
14 O’Donoghue DH. Treatment of injuries to athletes. Philadelphia, 1962. limited value in predicting return to play. Knee Surg Sports Traumatol Arthrosc
15 Rachun A. Standard Nomenclature of athletic injuries. 1st edn. Chicago Il, 1966. 2018;26:1288–94.
16 Wise DD. Physiotherapeutic treatment of athletic injuries to the muscle--tendon 46 Bryson WN, Fischer EJ, Jennings JW, et al. Three-­column classification system for
complex of the leg. Can Med Assoc J 1977;117:635–9. tibial plateau fractures: what the orthopedic surgeon wants to know. Radiographics
17 Wangensteen A, Almusa E, Boukarroum S, et al. Mri does not add value over and 2021;41:144–55.
above patient history and clinical examination in predicting time to return to sport 47 Lempainen L, Banke IJ, Johansson K, et al. Clinical principles in the management of
after acute hamstring injuries: a prospective cohort of 180 male athletes. Br J Sports hamstring injuries. Knee Surg Sports Traumatol Arthrosc 2015;23:2449–56.
Med 2015;49:1579–87. 48 Chang JS, Kayani B, Plastow R, et al. Management of hamstring injuries: current
18 Whiteley R, van Dyk N, Wangensteen A, et al. Clinical implications from daily concepts review. Bone Joint J 2020;102-­B:1281–8.
physiotherapy examination of 131 acute hamstring injuries and their association with 49 Blakeney WG, Zilko SR, Edmonston SJ, et al. Proximal hamstring tendon avulsion
running speed and rehabilitation progression. Br J Sports Med 2018;52:303–10. surgery: evaluation of the Perth hamstring assessment tool. Knee Surg Sports
19 Balius R, Pedret C, Kassarjian A. Muscle madness and making a case for muscle-­ Traumatol Arthrosc 2017;25:1936–42.
specific classification systems: a leap from tissue injury to organ injury and system 50 French SR, Kaila R, Munir S, et al. Validation of the Sydney hamstring origin rupture
dysfunction. Sports Med 2021;51:193–7. evaluation (shore). Bone Joint J 2020;102-­B:388–93.
20 Bisciotti GN, Balzarini L, Volpi P. The classification of muscle injuries: a critical review. 51 Ayuob A, Kayani B, Haddad FS. Acute surgical repair of complete, Nonavulsion
Medicina Dello Sport 2015;68:165–77. proximal semimembranosus injuries in professional athletes. Am J Sports Med
21 Hamilton B. Hamstring muscle strain injuries: what can we learn from history? Br J 2020;48:2170–7.
Sports Med 2012;46:900–3. 52 Ayuob A, Kayani B, Haddad FS. Musculotendinous junction injuries of the proximal
22 Hamilton B, Alonso J-­M, Best TM. Time for a paradigm shift in the classification of biceps femoris: a prospective study of 64 patients treated surgically. Am J Sports Med
muscle injuries. J Sport Health Sci 2017;6:255–61. 2020;48:1974–82.
23 Tol JL, Hamilton B, Best TM. Palpating muscles, massaging the evidence? An editorial 53 Kayani B, Ayuob A, Begum F, et al. Surgical repair of distal Musculotendinous T
relating to ’Terminology and classification of muscle injuries in sport: The Munich junction injuries of the biceps femoris. Am J Sports Med 2020;48:2456–64.
consensus statement’. Br J Sports Med 2013;47:340–1. 54 Afonso J, Rocha-­Rodrigues S, Clemente FM, et al. The Hamstrings: anatomic and
24 Tscholl P, Meynard T, Le Thanh N, et al. Diagnostics and classification of muscle physiologic variations and their potential relationships with injury risk. Front Physiol
injuries in sports. Swiss Sports and Exercise Medicine 2018;66:8–15. 2021;12:694604.
25 Kellis E. Intra- and Inter-­Muscular Variations in Hamstring Architecture and Mechanics 55 Askling CM, Heiderscheit BC. Acute hamstring muscle injury: Types, rehabilitation, and
and Their Implications for Injury: A Narrative Review. Sports Med 2018;48:2271–83. return to sports. In: Sports injuries: prevention, diagnosis, treatment and rehabilitation.
26 Smart M, Rowley Bristow W. The treatment of muscular and joint injuries by Second Edition, 2015: 2137–47.
graduated contraction. The Lancet 1912;179:1189–91. 56 Askling CM, Tengvar M, Saartok T, et al. Acute first-­time hamstring strains during
27 Gilcreest EL. Rupture of muscles and tendons. J Am Med Assoc 1925;84:1819–22. slow-­speed stretching: clinical, magnetic resonance imaging, and recovery
28 Macdonald B, McAleer S, Kelly S, et al. Hamstring rehabilitation in elite track and field characteristics. Am J Sports Med 2007;35:1716–24.
athletes: applying the British athletics muscle injury classification in clinical practice. 57 Askling CM, Tengvar M, Saartok T, et al. Acute first-­time hamstring strains during
Br J Sports Med 2019;53:1464–73. high-­speed running: a longitudinal study including clinical and magnetic resonance
29 Pollock N, Patel A, Chakraverty J, et al. Time to return to full training is delayed imaging findings. Am J Sports Med 2007;35:197–206.
and recurrence rate is higher in intratendinous (’c’) acute hamstring injury in elite 58 Dijkstra HP, Pollock N, Chakraverty R, et al. Return to play in elite sport: a shared
track and field athletes: clinical application of the British Athletics Muscle Injury decision-­making process. Br J Sports Med 2017;51:419–20.
Classification. Br J Sports Med 2016;50:305–10. 59 Minas H, Jorm AF. Where there is no evidence: use of expert consensus methods to fill
30 Kellis E, Galanis N, Kapetanos G, et al. Architectural differences between the the evidence gap in low-­income countries and cultural minorities. Int J Ment Health
hamstring muscles. J Electromyogr Kinesiol 2012;22:520–6. Syst 2010;4:33.
31 Woodley SJ, Mercer SR. Hamstring muscles: architecture and innervation. Cells Tissues 60 McCall A, Pruna R, Van der Horst N, et al. Exercise-­Based strategies to prevent
Organs 2005;179:125–41. muscle injury in male elite footballers: an Expert-­Led Delphi survey of 21
32 Higashihara A, Ono T, Kubota J, et al. Differences in the electromyographic activity practitioners belonging to 18 teams from the Big-­5 European Leagues. Sports Med
of the hamstring muscles during maximal eccentric knee flexion. Eur J Appl Physiol 2020;50:1667–81.
2010;108:355–62. 61 Donaldson A, Cook J, Gabbe B, et al. Bridging the gap between content and context:
33 Higashihara A, Nagano Y, Ono T, et al. Differences in hamstring activation establishing expert consensus on the content of an exercise training program to
characteristics between the acceleration and maximum-­speed phases of sprinting. J prevent lower-­limb injuries. Clin J Sport Med 2015;25:221–9.
Sports Sci 2018;36:1313–8. 62 van der Horst N, Backx F, Goedhart EA, et al. Return to play after hamstring injuries in
34 Petersen J, Thorborg K, Nielsen MB, et al. The diagnostic and prognostic value of football (soccer): a worldwide Delphi procedure regarding definition, medical criteria
ultrasonography in soccer players with acute hamstring injuries. Am J Sports Med and decision-­making. Br J Sports Med 2017;51:1583–91.
2014;42:399–404. 63 Zambaldi M, Beasley I, Rushton A. Return to play criteria after hamstring muscle injury
35 van der Made AD, Almusa E, Reurink G, et al. Intramuscular tendon injury is not in professional football: a Delphi consensus study. Br J Sports Med 2017;51:1221–6.
associated with an increased hamstring reinjury rate within 12 months after return to 64 Lightsey HM, Kantrowitz DE, Swindell HW, et al. Variability of United States online
play. Br J Sports Med 2018;52:1261–6. rehabilitation protocols for proximal hamstring tendon repair. Orthop J Sports Med
36 Whiteley R, Massey A, Gabbett T, et al. Match high-­speed running distances are often 2018;6:2325967118755116.
suppressed after return from hamstring strain injury in professional footballers. Sports 65 Hasson F, Keeney S, McKenna H. Research guidelines for the Delphi survey technique.
Health 2021;13:290–5. J Adv Nurs 2000;32:1008–15.
37 Vermeulen R, Almusa E, Buckens S, et al. Complete resolution of a hamstring 66 Jünger S, Payne SA, Brine J, et al. Guidance on conducting and reporting Delphi
intramuscular tendon injury on MRI is not necessary for a clinically successful return studies (CREDES) in palliative care: recommendations based on a methodological
to play. Br J Sports Med 2021;55:397–402. systematic review. Palliat Med 2017;31:684–706.

13 of 14 Paton BM, et al. Br J Sports Med 2023;57:254–265. doi:10.1136/bjsports-2021-105371


Consensus statement

Br J Sports Med: first published as 10.1136/bjsports-2021-105371 on 17 January 2023. Downloaded from http://bjsm.bmj.com/ on December 29, 2024 by guest. Protected by copyright.
67 Eysenbach G. Improving the quality of web surveys: the checklist for reporting results 82 European Society of Skeletal Radiology Sports Sub-­Committee. Hamstrings -
of Internet E-­Surveys (cherries). J Med Internet Res 2004;6:e34. Guidelines for MR Imaging of Sports Injuries, 2016.
68 Powell C. The Delphi technique: myths and realities. J Adv Nurs 2003;41:376–82. 83 Klauser AS, Tagliafico A, Allen GM, et al. Clinical indications for musculoskeletal
69 Hsu CC, Sandford BA. The Delphi technique: making sense of consensus. Practical ultrasound: a Delphi-­based consensus paper of the European Society of
Assessment, Research and Evaluation 2007;12:1–8. musculoskeletal radiology. Eur Radiol 2012;22:1140–8.
70 de Villiers MR, de Villiers PJT, Kent AP. The Delphi technique in health sciences 84 Sconfienza LM, Albano D, Allen G, et al. Clinical indications for musculoskeletal
education research. Med Teach 2005;27:639–43. ultrasound updated in 2017 by European Society of musculoskeletal radiology (ESSR)
71 Harper D, Thompson AR. Qualitative research methods in mental health and
consensus. Eur Radiol 2018;28:5338–51.
psychotherapy: a guide for students and practitioners, 2011.
85 Barcelona F. Muscle injuries clinical guide 3.0, 2015. Available: https://​
72 Fink A, Kosecoff J, Chassin M, et al. Consensus methods: characteristics and
muscletechnetwork.org/wp-content/uploads/2015/04/MUSCLE-INJURIES-CLINICAL-​
guidelines for use. Am J Public Health 1984;74:979–83.
73 Fuller CW, Ekstrand J, Junge A, et al. Consensus statement on injury definitions and GUIDE-3.0-LAST-VERSION.pdf
data collection procedures in studies of football (soccer) injuries. Clin J Sport Med 86 Messina C, Bignotti B, Tagliafico A, et al. A critical appraisal of the quality of adult
2006;16:97–106. musculoskeletal ultrasound guidelines using the agree II tool: an EuroAIM initiative.
74 Griffin DR, Dickenson EJ, O’Donnell J, et al. The Warwick agreement on Insights Imaging 2017;8:491–7.
femoroacetabular impingement syndrome (FAI syndrome): an international consensus 87 De Smet AA, Best TM. Mr imaging of the distribution and location of acute hamstring
statement. Br J Sports Med 2016;50:1169–76. injuries in athletes. AJR Am J Roentgenol 2000;174:393–9.
75 Shrier I. Consensus statements that fail to recognise dissent are flawed by design: a 88 Slavotinek JP, Verrall GM, Fon GT. Hamstring injury in athletes: using MR imaging
narrative review with 10 suggested improvements. Br J Sports Med 2021;55:545–9. measurements to compare extent of muscle injury with amount of time lost from
76 Blazey P, Crossley KM, Ardern CL, et al. It is time for consensus on ’consensus competition. AJR Am J Roentgenol 2002;179:1621–8.
statements’. Br J Sports Med 2022;56:306. 89 Crema MD, Guermazi A, Reurink G, et al. Can a clinical examination demonstrate
77 Verhagen AP, de Vet HC, de Bie RA, et al. The Delphi list: a criteria list for quality intramuscular tendon involvement in acute hamstring injuries? Orthop J Sports Med
assessment of randomized clinical trials for conducting systematic reviews developed 2017;5:2325967117733434.
by Delphi consensus. J Clin Epidemiol 1998;51:1235–41. 90 Koulouris G, Connell D. Evaluation of the hamstring muscle complex following acute
78 Huisstede BMA, Hoogvliet P, Coert JH, et al. Multidisciplinary consensus guideline injury. Skeletal Radiol 2003;32:582–9.
for managing trigger finger: results from the European HANDGUIDE study. Phys Ther
91 Allen GM. The use of ultrasound in athletes. Eur J Radiol 2018;109:136–41.
2014;94:1421–33.
92 Nazarian LN. The top 10 reasons musculoskeletal sonography is an important
79 Kleynen M, Braun SM, Bleijlevens MH, et al. Using a Delphi technique to seek
complementary or alternative technique to MRI. AJR Am J Roentgenol
consensus regarding definitions, descriptions and classification of terms related to
implicit and explicit forms of motor learning. PLoS One 2014;9:e100227. 2008;190:1621–6.
80 De Vos R-­J, Reurink G, Goudswaard G-­J, et al. Clinical findings just after return to 93 Bodendorfer BM, Curley AJ, Kotler JA, et al. Outcomes after operative and
play predict hamstring re-­injury, but baseline MRI findings do not. Br J Sports Med Nonoperative treatment of proximal hamstring Avulsions: a systematic review and
2014;48:1377–84. meta-­analysis. Am J Sports Med 2018;46:2798–808.
81 Orchard J. What role for MRI in hamstring strains? An argument for a difference 94 Martin RL, Cibulka MT, Bolgla LA, et al. Hamstring strain injury in athletes. J Orthop
between recreational and professional athletes. Br J Sports Med 2014;48:1337–8. Sports Phys Ther 2022;52:CPG1–44.

Paton BM, et al. Br J Sports Med 2023;57:254–265. doi:10.1136/bjsports-2021-105371 14 of 14

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