Review

Hamstring rehabilitation in elite track and field

Br J Sports Med: first published as 10.1136/bjsports-2017-098971 on 12 July 2019. Downloaded from http://bjsm.bmj.com/ on 20 July 2019 by guest. Protected by copyright.
athletes: applying the British Athletics Muscle Injury
Classification in clinical practice
Ben Macdonald,‍ ‍ 1 Stephen McAleer,1 Shane Kelly,1 Robin Chakraverty,2
Michael Johnston,1,3 Noel Pollock1,4

►► Additional material is Abstract tissue type involved and the extent of injury.13 In
published online only. To view Rationale  Hamstring injuries are common in elite particular, return to sport was delayed, and recur-
please visit the journal online
(http://d​ x.​doi.o​ rg/​10.​1136/​ sports. Muscle injury classification systems aim to rence rates increased, with intratendon hamstring
bjsports-​2017-​098971). provide a framework for diagnosis. The British Athletics injuries. A difference in return to play and/or re-in-
Muscle Injury Classification (BAMIC) describes an MRI jury rates with intratendon hamstring injury has
1
National Performance Institute, classification system with clearly defined, anatomically previously been identified,14–18 although its rele-
British Athletics, Loughborough, vance may vary between different sports. Several
focused classes based on the site of injury: (a) myofascial,
UK
2
St George’s Park, Football (b) muscle–tendon junction or (c) intratendinous; and the rehabilitation programmes have been published
Association, Burton, UK extent of the injury, graded from 0 to 4. However, there for hamstring injuries but despite evidence that
3
A-STEM, Swansea University, are no clinical guidelines that link the specific diagnosis the intratendon injury may have a different prog-
Swansea, UK (as above) with a focused rehabilitation plan. nosis, and that the different hamstring muscles
4
Institute of Sport, Exercise
and Health, University College Objective  We present an overview of the general have distinct actions, none of the rehabilitation
London, London, UK principles of, and rationale for, exercise-based hamstring programmes describe targeted guidelines relating to
injury rehabilitation in British Athletics. We describe how specific diagnoses or injury classification.19–25 Most
Correspondence to British Athletics clinicians use the BAMIC to help manage muscle treatment guidelines describe rehabilitation
Ben Macdonald, British Cycling, elite track and field athletes with hamstring injury. with regard to healing phases (acute, subacute and
National Cycling Centre, Within each class of injury, we discuss four topics: clinical regeneration) and functional rehabilitation progres-
Manchester, UK;
​benmacdonald@​britishcycling.​ presentation, healing physiology, how we prescribe and sion24 but there has been limited comparison of
org.​uk progress rehabilitation and how we make the shared different protocols.23 25 26
decision to return to full training. We recommend a In this two-part paper, we (i) review the general
Accepted 10 June 2019 structured and targeted diagnostic and rehabilitation principles of hamstring injury rehabilitation in
approach to improve outcomes after hamstring injury. British Athletics, and (ii) we discuss how we apply
those principles to the three BAMIC subtypes of
hamstring injuries

Introduction
Hamstring injuries are common in sports requiring Part 1: General management principles
kicking, high-speed running and sprinting, and are of hamstring injury rehabilitation in
a significant cause of missed training and competi- British Athletics
tion.1–4 In a series of international track and field Management principle 1
competitions from 2007 to 2015, muscle injury Establish an accurate structural diagnosis and injury
represented 41% of all injuries and the hamstring classification
was the most commonly affected muscle group.5 After an athlete suffers an acute hamstring injury,
Muscle injury classification systems have provided The British Athletics medical team prioritises
a framework for muscle injury diagnosis.6–8 While initial clinical assessment—which includes injury
the Munich muscle classification consensus has been history and clinical examination. This is followed
implemented in elite soccer players,9 10 its classifica- by imaging with ultrasound and MRI within 72
tion entities have structural and functional elements hours to determine a structural diagnosis and classi-
that are not clearly defined, limiting its utilisation. fication (BAMIC). There is evidence from different
The British Athletics Muscle Injury Classification sports that tendon involvement in muscle injury
(BAMIC) describes a MRI classification system with increases return to play or re-injury,13 14 17 18 27 28
clearly defined, anatomically focused classes based and that clinical examination may not be able to
on the site of injury: either myofascial (a) muscle– discriminate the presence of tendon injury.29 While
© Author(s) (or their tendon junction (MTJ) (b) or intratendinous (c) there are additional reasons to perform MRI,30
employer(s)) 2019. No and the extent of the injury, graded from 0 to 4 we believe the detection of the intratendon injury
commercial re-use. See rights
and permissions. Published (figure 1).7 British Athletics is a national governing warrants MRI in the management of elite athletes.
by BMJ. body that provides expert clinical support to elite We consider that MRI diagnostics, in isolation,
track and field athletes. are limited in providing an accurate prognosis. In
To cite: Macdonald B,
The BAMIC has been validated in two studies some sports or athletes, including a recent study
McAleer S, Kelly S, et al.
Br J Sports Med Epub ahead demonstrating substantial intra-rater and inter-rater performed in Qatar, an intratendon injury may
of print: [please include Day reliability.11 12 A retrospective clinical study demon- only have a moderate impact on time to return
Month Year]. doi:10.1136/ strated that for the different classifications, athletes’ to play.18 However, the BAMIC provides a frame-
bjsports-2017-098971 times to return to full training (RTFT) varied with work for clinical reasoning and rehabilitation

Macdonald B, et al. Br J Sports Med 2019;0:1–13. doi:10.1136/bjsports-2017-098971    1

 Review
whereas semimembranosus (SM) acts predominantly as a force

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producer.43–45 BF is activated more during the acceleration phase
of sprinting and terminal swing, ST during maximum-velocity
sprinting, whereas SM has an important role in absorbing and
generating power in swing and stance.44 46 47 Therefore, exercise
prescription should be targeted to the injured muscle to develop
these specific functional roles and limit the altered spatial char-
acteristics demonstrated post-injury.48
Sprinting is a complex, coordinated movement, and restoring
normal movement patterns is essential. Cameron et al49 50
discussed the importance of motor control on hamstring injury
risk, and the use of running drills in warm up as an intervention.
Progressive running drills will load the hamstring in a functional
Figure 1  Overview of British Athletics Muscle Injury Classification by manner, with a gradual increase in velocity of movement and
anatomical site in biceps femoris injury. lengthening of the muscle, both of which are important loading
characteristics.51 Altered hip and pelvis kinematics, including a
reduction in hip flexion52 and an increase in anterior tilt of the
decision-making. Different tissues, such as fascia, muscle and pelvis53 have all been noted post-hamstring injury. Increased hip
tendon, differ in their rates of healing and response to load flexion54 and the ability to apply force in a horizontal direction55
following injury.31 We believe these tissues will respond opti- are key determinants of high-speed running, and running drills
mally to specific rehabilitation strategies within a multifaceted can be used to retrain these elements.56
and criteria-based system of progression.24
Management principle 5
Management principle 2 Prescribe strength exercises to achieve a specific goal
Facilitate the collaborative expertise of the sports science and The complexity of hamstring function is well recognised, both
medicine team in relation to the anatomical specialisation of the muscle43 and
The British Athletics sport science and medicine team collabo- its role in high-speed running.57 While eccentric muscle func-
rate within an integrated health and performance model.32 In tion is crucial during maximal velocity running, other hamstring
injury management, roles and responsibilities are defined and adaptations may require alternative strength training stimuli,
the team aligned with the health and performance aims of the particularly isometric loading, which has recently been advo-
rehabilitation process. The BAMIC framework enables targeted cated.57 58 The primary mechanisms by which eccentric and
sports medicine and science strategies. For example, the perfor- isometric loading may positively affect hamstring function will
mance nutrition and medical team provide targeted nutrition, now be discussed, and examples of exercise variations are avail-
pain management or other strategies depending on the class of able online on the British Journal of Sports Medicine website.
injury, supporting optimal adaptation to exercise for specific
tissues.33–37 Eccentric training
Develop high eccentric force
Management principle 3 Eccentric forces are high during the sprinting cycle, especially at
Involve the coach and athlete in shared decision-making terminal swing phase,59–61 and eccentric force deficits and asym-
British Athletics apply an integrated performance health and metries are associated with risk of future hamstring injury.62–66
coaching model and a shared decision-making process when The ability to produce high eccentric force lowers the relative
managing injuries in elite track and field athletes.32 38 This model risk imposed by increasing age and previous injury history—
aligns the health and coaching departments to a defined perfor- factors considered as non-modifiable.66 Therefore, eccentric
mance goal. When managing injury, the role of the medical team, training (figure 2) is a key part of the prevention and rehabili-
in British Athletics a sports physician and physiotherapist, is to tation of hamstring injuries—and is integral in conditioning for
provide the coach and athlete with ongoing expert information athletes who sprint.26 62 67–69
regarding the diagnosis, benefits and risks of proposed manage-
ment strategies. The medical team’s mission is to maximise the Increase fascicle length to enhance the length–tension relationship
availability of athletes for full training to increase the likelihood (get long and strong)
of winning medals at the major championships. The risk of re-in- Hamstring injury predisposes the muscle to architectural changes
jury during rehabilitation and RTFT is an important factor in (fascile shortening) that may predispose athletes to re-in-
the shared decision-making process. A fully informed high-risk jury.70–74 Eccentric training increases fascicle length72 which may
approach may be agreed on by all the participants when there are also lower the injury risk associated with non-modifiable risk
certain performance goals (eg, success at the Olympic Games).38 factors.74 Increasing fascicle length may protect against future
injury by shifting the angle of peak torque to longer muscle
Management principle 4 lengths.75–78
Train movements and muscles While high-volume eccentric training programmes using the
The hamstrings consist of three individual muscles, each of Nordic hamstring exercise (NHE) have demonstrated good
which have functional roles related to their anatomy, and improvements in eccentric strength and fascicle lengthening,
demonstrate various electromyography (EMG) patterns and recent studies have demonstrated similar improvements with a
MRI spatial characteristics in response to exercise stimulus.39–44 low-volume programme consisting of two sets of four repetitions
In sprinting, bicep femoris (BF) is subject to the largest strain, once a week.72 79–81 These lower training volumes may make
semitendinosus (ST) the greatest lengthening velocities, the inclusion of eccentric exercise less of a challenge within the

2 Macdonald B, et al. Br J Sports Med 2019;0:1–13. doi:10.1136/bjsports-2017-098971

 Review

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Figure 3  Example of isometric exercise: single-leg Roman chair hold.

Overcome selective muscle inhibition

Athletes with a history of hamstring injury exhibit both acute
and chronic responses to pain causing maladaptive neural
Figure 2  Eccentric phase of the single leg Romanian dead lift. responses in the central nervous system.40 In the initial stages
post-injury, it has been suggested that reduced myoelectric
activity in the muscle serves as a protective mechanism to unload
athlete’s strength programme, especially while in competition the healing tissue.95 However, longer-lasting selective inhibition
phases. This may help to prevent the detraining effect on fascicle of the hamstrings during eccentric actions has been reported,
length improvements demonstrated after 2 weeks of ceasing and may compromise rehabilitation and muscular adaptation.96
eccentric loading.82 Specifically, chronic activation deficits during the Nordic curl
post-injury have been reported with reduced hamstring activity
as the knee approaches terminal extension.97 It is possible that
Isometric training isometric training may avoid the inhibitory mechanisms that
Develop muscle–tendon unit specificity occur during eccentric conditions, as voluntary muscle activation
The contractile element of the hamstrings may remain relatively has been shown to be higher during isometric contractions.98 A
isometric at end swing phase, with muscle–tendon unit length- reduction in cortical inhibition, with associated increased motor
ening being provided by the tendon.57 59 60 83 The isometric condi- unit activation, has been demonstrated in patellar tendon pain
tion of the muscle fascicles reduces mechanical work done by subjects completing isometric exercise.99 100 We therefore advo-
the contractile component, facilitating the spring-like behaviour cate using high-load isometrics, particularly in injuries when
of the tendon during the stretch shortening cycle.84 High-load pain and disability are greater, to improve motor unit recruit-
isometric training may therefore provide a more specific stimulus ment, prior to implementing eccentric loading.
related to this functional demand.57 However, further evidence
is required to confirm these processes, and eccentric loading may Management principle 6
also cause a similar isometric condition of the muscle fascicles, Apply a multivariate model and target contributing factors to injury
despite an overall increase in muscle–tendon unit length, similar risk
to that shown in the triceps surae.85 86 There are numerous potential risk factors for hamstring injury
which interact in a complex way increasing risk in any individual
athlete.101 Rehabilitation of a hamstring injury is an opportu-
Develop fatigue resistance nity to apply clinical reasoning and address potential risk factors
Fatigue is consistently associated with hamstring injury3 87 88 and which may be present in the training programme, musculoskel-
has been demonstrated to impair neuromuscular function.89–91 etal system and/or athlete lifestyle. A broad discussion of all
Hamstring re-injuries are more common in football players with these potential risk factors is beyond the scope of this paper.
strength-endurance deficits,48 with injured muscles fatiguing However, we highlight two factors that are an important focus
earlier and demonstrating altered activation patterns.92 Our in our clinical management of hamstring injuries.
injury audit observations at British Athletics are consistent with
these findings and have demonstrated an increased incidence of Spine
injuries occurring in the final third of sprint training sessions. Although there is limited evidence to endorse lumbo-pelvic
Strength training of the hamstrings under fatigue has demon- training,102 we consider that appropriate management of the
strated positive effects on hamstring function and reduced injury spine and lumbo-pelvic function should be a component of
rates.93 94 While suggested protocols for the NHE include multiple hamstring injury rehabilitation. The hamstrings perform a stabi-
repetitions, it is usual to have a brief rest period between repe- lising role on the pelvis with attachments to the sacrotuberous
titions as the athlete returns to the starting position. The Single ligament.103 Abberant motion of the pelvis or a loss of force
leg Roman Chair hold (figure 3), with longer duration muscle closure may increase strain on the hamstrings,83 104–108 and may
contractions, is more effective at increasing hamstring muscle contribute to deficits in hamstring force production.109 There is a
endurance than the Nordic curl.58 This suggests that isometric lack of evidence to support any one lumbo-pelvic neuromuscular
training may be a useful addition alongside eccentric loading to training intervention.110 We advocate a holistic strength training
condition the hamstrings, when improving fatigue resistance is programme of the lumbo-pelvic region that targets specific
the desired training adaptation. biomechanical planes of movement (table 1). While no gold

Macdonald B, et al. Br J Sports Med 2019;0:1–13. doi:10.1136/bjsports-2017-098971 3

 Review
session or competition. We noted that range of movement
Table 1  Lumbo-pelvic re-training

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(ROM) and strength testing were often maintained, despite the
Lumbo-pelvic function Plane of movement Example exercises presence of pain on manual muscle tests, particularly in compar-
Lumbo-pelvic control into flexion Sagittal Leg lowers/aleknas* ison to equivalent grade injuries in b or c classes. We speculate
and extension that clinical manual muscle testing is less affected as fascial tears
Rotational control Coronal Prone hold with arm lift predominantly affect the myofascial expansions connecting
Single-leg stance stability Frontal TRX single-leg squat the deep fascia to the epimysium with relative sparing of the
Increasing spinal stiffness Transverse/coronal Palloff press contractile element of the muscle–tendon unit.138 Tracking of
*Alekna describes simultaneous extension of the lower limbs and elevation of the oedema between the fascial layers, which is characteristic of this
upper limbs holding a weight while supine and maintaining posterior tilt of plevis. injury at the fascial interface,6 7 139 may result in pain and palpa-
tion tenderness over a non-specific and wide area as the fascia is
richly innervated.138
standard exists for measuring abdominal function,102 and the
reproducibility of common motor control tests is questioned,111
tests such as the active straight leg raise have demonstrated reli- Healing physiology
ability and validity,112–114 and can be used to assess improvement Fascia provides stability and dissipates tensional stress, contrib-
in lumbo-pelvic function following a training intervention. utes to pain mechanisms, as well as facilitating coordinated
While there is no direct evidence demonstrating the efficacy of movement.138 It consists of multiple layered sheets of richly
managing spinal pain in hamstring rehabilitation, we believe that innervated collagen fibres which enclose muscle groups.140 Hyal-
the concept of arthrogenic muscle inhibition, widely recognised uronic acid between the fascial layers enables sliding between
in knee pathology,115 should be considered in the management the epimysium and deep fascia.138 Fascial healing is different
of hamstring injury. A previously described association between to muscle and tendon. A recent consensus statement on fascial
spinal pain and pathology and increased risk of hamstring injury tissue research describes healing through an initial inflammatory
supports this consideration.116 Manual therapy has been shown phase followed by a fibrotic stage after fascial injury.141 Fascial
to positively affect a range of lumbo-pelvic biomechanical and wound healing studies suggest that after 7 days fibroblasts are
pain characteristics.117–120 This may be relevant given the role the majority cell type, collagen synthesis has peaked, and that the
pelvic function has on optimising sprint mechanics and the healing scar tissue has reached half of maximal strength before
length–tension relationship of the hamstring.57 83 121 At British returning to full strength by 3 weeks.140 142
Athletics, we have also used spinal epidural or nerve root corti-
costeroid injections to positively improve hamstring function Loading progression
with the intention of reducing spinal inhibition of the hamstring Running progressions
muscle.9 122–124 The most frequent grade of (a) class myofascial injuries are
small 1a injuries and that has been used as an example for this
Hip discussion.13 Grade 2a (and particularly 3a) injuries occur less
The hip is crucial for optimal hamstring function. Weakness and frequently but the principles of progression and monitoring are
reduced activation of the gluteus maximus have both been cited the same. With relatively fast fascial healing time frames, and an
as injury risk factors.125–127 The incidence of femoroacetabular intact muscle–tendon unit, initial management is characterised
impingement (FAI) morphology is high in the athletic popula- by quick progression back to functional activities, emphasising
tion, and a common symptom is a reduction in hip flexion.128–131 an early return to running drills. Pain management strategies,
This is important given that attaining high hip flexion angles such as oral analgesia or manual therapy, may be employed
is considered a critical determinant of high-speed running.54 A to support this functional return. As the athlete may reduce
potential complication of reduced hip flexion during sprinting
is a compensatory increase in pelvic rotation which may subse-
quently increase strain on the hamstring.132 Non-surgical
management of symptomatic or restrictive FAI morphology
should be considered in hamstring injury rehabilitation.

Part 2: Specific hamstring injury rehabilitation

guidelines based on the BAMIC
We aim to incorporate the principles described above into the
rehabilitation of all hamstring injuries but we adjust the timing
and balance of the rehabilitation programme depending on the
specific BAMIC class. Within each class, we discuss four topics:
clinical presentation, healing physiology, rehabilitation progres-
sion and RTFT. We provide guidance on exercise prescription in
tables throughout, however given that individuals vary in how
they heal and adapt to resistance training,133–137 appropriate
clinical reasoning is reccommended for the individual athlete.
133–137

Class a: Myofascial
Clinical presentation
Myofascial injuries may present with a sudden or gradual onset
of posterior thigh pain during, or occasionally after, a training Figure 4  Technical cues during running drills.

4 Macdonald B, et al. Br J Sports Med 2019;0:1–13. doi:10.1136/bjsports-2017-098971

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Table 2  Example of running progressions for a female 400 m runner with 1a biceps femoris injury

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Day 1 2 3 4 5 6 7 8
Daily 1. Low impact 1. Functional 1. Low velocity 1. Increase 1. Re-establish 1. Transition 1. Adaptation 1. Event-specific
rehabilitation tissue loading of eccentric load specific optimal to maximal workout
goals loading tissue 2. Re-establish eccentric running speed 2. Speed endurance
2. Re-establish lumbo-pelvic load on mechanics running
foot mechanics control hamstring 2. Progress
running
volume
Running session Pool running Stage 1 drills on Stage 2 drills Stage 3 drills Stage 3 drills 3×3×90 at Rest 300 @ 39 s pace
session: track Jog 5×40–80 m 5×100 m at 15 2×4×100 m @ 10.5–11 s pace 250 @ 30 s pace
30 s on 30 s off repetitions on s pace 14–15 s pace 200 @ 24 s pace
x 10 repetitions track 150 @ 19 s pace
15 min rest between
repetitions

hip flexion as a protective mechanism to reduce strain on the the running drill progression. As a result, less disruption to
healing hamstring, we encourage them to gradually increase the normal training programmes is seen in this class of injury, as
degree of hip flexion, and the velocity with which the hip is rehabilitation takes on a functional emphasis.
extended, progressively through rehabilitation. Running drills
precede high-speed running and can be progressed even in the
RTFT decision-making
presence of moderate pain levels (eg, 4–5 out of 10 on visual
Class a injuries tend to have a quick recovery time.13 RTFT is
analogue scale), which usually dissipates over the course of the
primarily based on the clinical examination of ROM, strength,
first week. We have shared some key areas the athlete should
palpation pain and Askling H-test143 (table 3), alongside the
focus on when performing drills (figure 4). Please see the full
successful progression of running without exacerbation.144 The
description and online supplementary videos (online supple-
clinical information is provided to the RTFT decision process
mentary appendix 1).
and these injuries usually represent a low risk of re-injury.13 38
A typical progression of technical drills and running sessions
for a Grade 1a injury in a 400 m runner is described in table 2.
Class b: MTJ
Strength training progressions Clinical presentation
As the contractile element is intact, and strength is often well Class b injuries occur at the MTJ,7 13 typically as a sudden
maintained, specific hamstring loading is not prioritised. Instead, onset mechanism during high-velocity sprinting or jumping.15
we emphasise a return to the athlete’s normal strength training The force generating capacity of the muscle is impaired as
programme, including appropriate hamstring loading, alongside contractile function is diminished. Contractile testing usually

Table 3  RTFT progression specific to diagnostic class

1a Myofascial 2b Muscle–tendon junction 3c Intratendon
Acute 1. Normal gait pattern but residual 1. Pain-free walking TIME-BASED PROGRESSION; RESTRICTED ACTIVITY
soreness acceptable 2. R1=P1 on PKE IN FIRST 2 WEEKS DESPITE EARLY PRESENCE OF:
2. R1=P1 on PKE 3. Submaximal prone contraction pain free 1. Pain-free jogging ability
3. Prone hamstring contraction strong but Approximately Days 0–5 2. Minimal loss of ROM and power
residual soreness acceptable
Approx. Days 0 to 2
Remodelling 1. PKE normal 1. PKE normal 1. PKE normal
2. Striding mild discomfort allowed (75% 2. Tolerated eccentric and isometric strength training 2. Tolerated isometric followed by eccentric strength
Max speed) with progression in load and elongation stress training with progression in load and elongation
3. Askling test negative 3. Normal spinal and hip examination stress
Approximately Days 2–5 4. Striding pain free (75% Max speed) 3. Normal spinal and hip examination
5. Askling test negative 4. Striding pain free (75% Max speed)
Approx. Days 5–14 5. Askling test negative
6. Review MRI
Approximately Weeks 2–6
Functional 1.Pain-free hamstring palpation 1. Pain-free hamstring palpation 1. Pain-free hamstring palpation
2.Successful progression high intensity 2. Strength markers achieved: 2. Strength markers achieved:
running/training a. Nordbord at pre-injury level a. Nordbord at pre-injury level
Approximately Days 5–10 b. >30 SL bridge capacity b. >30 SL bridge capacity
3. Successful progression high intensity running/training 3. Successful progression high intensity running/
4. Optojump biomechanical review training
5. Team shared decision-making process on risk of RTFT 4. Optojump biomechanical review
and performance target 5. Review MRI
Approximately Days 14–28 6. Team shared decision-making process on risk of
RTFT and performance target
Approximately Weeks 6–9
P1, first point of pain; PKE, passive knee extension; R1, first point of resistance; ROM, range of movement; RTFT, return to full training; SL, single leg.

Macdonald B, et al. Br J Sports Med 2019;0:1–13. doi:10.1136/bjsports-2017-098971 5

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Table 4  Running progressions in male 100 m and 200 m sprinter with 2b biceps femoris injury

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Week 1 2 3 4 5
Weekly rehabilitation 1. Re-establish foot 1. Increase specific load 1. Increase specific strength 1. Increased running 1. Transition to Max velocity
goals mechanics at lower intensities endurance of tissue intensity 80%–90% running (>90% Max)
2. Re-establish lumbo-pelvic (60%–70% Max) 2. Increased intensity Max 2. Transition to maximal
control 2. Low velocity eccentric at shorter distances 2. Exposure to bend accelerations from blocks
3. Avoid muscle inhibition load (70%–80% Max) running
3. Re-establish good running
mechanics
Running Progress through stage 1–2 Stage 3 drills 6×80 m @ 10 s pace 2×2×150 m @ 17 s pace 50 m, 60 m, 70 m×2 Max
sessions drills 10×50 m @ 8 s 4×150 m @ 19 s pace 4×200 m @ 21–21.5 s accelerations
10×50 m @ 10 s 4×100 m @ 16 s pace Blocks to 10 m, 20 m, 30 m×2
2×2×150 m @ 16 s pace
4×200 m @<21 s pace

reveals pain and weakness, and ROM is reduced, as the injured when tissue healing is in the acute stage.51 Completing drills
fibres are painful to stretch.145 of increasing volume and intensity (online supplementary
appendix 1), and further improvement in the clinical markers
Healing physiology of ROM, strength and a negative Askling-H test (table 3), are
Muscle injury induces a satellite cell response and early scaf- milestones for us to introduce higher speed running (table 4).
fold on which muscle regeneration can occur, enabling early Specific biomechanical demands are placed on the hamstrings
return of muscular function.146 Evidence from healing physi- during bend running, spiked running and block starts, and
ology research suggests that the functional scar is no longer the these are key sport specific functional progressions within late
weakest point of the muscle at approximately day 10 post-in- stage rehabilitation.147–149
jury. Maturation of type 1 collagen is well underway by early
in the third week, with myofibre regeneration by the end of Strength training progressions
the third week.146 Understanding this satellite cell response, In our experience, the most commonly injured muscle group
myofibre regeneration and scar scaffold provide the basis for in class (b) injuries is the long head of BF, which is consis-
optimal loading, and interventions from the sports science tent with data from other reports.145 150 151 Numerous
and medicine team, such as nutritional or heat strategies, to studies report different spatial recruitment patterns between
support this physiological recovery of muscle–tendon unit exercises, with hip dominant exercises loading the prox-
function. imal hamstring and knee dominant exercises loading the
distal hamstring.40 42 75 152 153 The ratio of lateral to medial
Rehabilitation progression hamstring activation is higher for hip-based exercises such
Running progressions as the single-leg Romanian dead lift, 45° hip extension and
Running drills are introduced as walking becomes pain free, in Glut-Ham raise154 due to the greater moment arm at the
agreement with previous reviews.19 20 Running progression is hip providing a mechanical advantage.155 This may promote
not usually as quick as the class (a) myofascial injuries, due to greater hypertrophy in BF than knee dominant exercises such
muscle fibre disruption. Greater emphasis is placed on keeping as the Nordic curl.80 However in absolute terms, the Nordic
pain to a low level (below 3 out of 10 on a visual analogue curl provides the greatest EMG activation of BF and therefore
scale) during drill execution in comparison to class (a) inju- both hip and knee training interventions are required.154 An
ries. Dynamic drills commence as clinical markers of strength example of potential training progressions with targeted adap-
and ROM improve (approximately day 5 for a 2b injury). tations for a 2b BF injury is described in table 5. It includes
Drills with low hamstring elongation stress are used at a time a combination of hip and knee dominant exercises, eccentric

Table 5  Hamstring loading progressions for 2b distal biceps femoris injury

Week 1 2 3 4
Rehabilitation and adaptation 1. Avoid inhibition 1. Develop muscle fatigue resistance 1. Progress eccentric loading at 1. Increase knee dominant
aim 2. Promote tissue healing 2. Emphasise hip dominant eccentric longer lengths eccentric loading
loading 2. Increase distal hamstring eccentric
loading with knee dominant
exercise
Elongation stress Low Low–moderate Moderate High
Load intensity/volume Low (eg,10–12 RM)/moderate– Moderate (8–10 RM)/moderate (three Moderate–high (eg, 6–8 RM)/moderate High (eg, 2–6 RM)/
high, for example, four to five to four sets) (three to four sets) moderate–low (two to three
sets sets)
Frequency per week 3–4 3–4 3 2
Exercise selection Isometric hamstring curls SL Roman chair isometric SL RDL SL RDL
DL Roman chair isometric 90–90 bridge capacity SL Roman chair with load SL Roman chair with row
Squats Isometric hamstring curls at increased Nordic curl Nordic curl
Step ups length Fly wheel
SL RDL
DL, double leg; NHE, Nordic hamstring exericse; RDL, Romanian dead lift; SL, single leg.

6 Macdonald B, et al. Br J Sports Med 2019;0:1–13. doi:10.1136/bjsports-2017-098971

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Table 6  Running progressions in a female sprint hurdler with 3c proximal biceps femoris Injury

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Week 1–2 3 4 5 6 7 8+9
Weekly rehabilitation 1.Promote tissue 1.Introduce 1.Re-establish 1.Progress 1.Transition to high- 1.Transition to maximal 1.Maximal velocity
goals healing specific load at low optimal running running speed running (80% velocity running (80%– running (>90%
2.Avoid inhibition intensities mechanics volumes Max) 90% Max) Max)
3.Re-establish 2.Introduce low 2.Increase specific 2.Increase 2.Acceleration re- 2.Maximal acceleration 2.Block starts
foot mechanics velocity eccentric eccentric loading specific strength introduction efforts 3.Maximal hurdle
4.Re-establish loads at moderate endurance of 3.High-speed running 3.Progress hurdle height height introduction
lumbo-pelvic intensities tissue 4.Introduction to hurdle-
control 3.Introduce specific training
5.Increase range hurdle-specific
of movement movement
worked through patterns
Running session Stage 1–3 drills Stage 3 drills Stage 3 drills 100 m @15–6 100 [email protected]–13 s 100 m @11.5–12 s 100 m @ 11.5 s
Jogging 10×50 m @10 s pace Low hurdle runs Submaximal hurdle Full height hurdle
s pace Hurdle walk height running running
overs 3×5 hurdles 5×8 hurdles
30–40–50m accelerations

and isometric variations, and exercises that will develop both Class c: Intratendon
high force, fatigue resistance and high strain characteristics. Clinical presentation
Initial exercise prescription is at higher volumes and lower Class (c) intratendon injuries typically present with a sudden
load, with a gradual increase in load through rehabilitation onset, high force mechanism. Although frequently occurring
as tissue tolerance improves. It is important to increase load during sprinting, they can also occur during a high-velocity
to optimise hamstring adaptation.156 Increased load is accom- stretch.162 163 Initially, class (c) injuries may demonstrate
panied by a reduction in strength training volume as running an antalgic gait, and a significant loss of ROM and power.
intensity/volume increases to achieve more performance-based However, in a high-grade (3c) intratendon injury with loss of
goals (tables 5 and 6). Successfully tolerating each stage of tension, the clinical presentation may have less pain on palpa-
progression allows further progression in load magnitude and tion and stretch than would be expected with such an exten-
muscle length, using clinical markers of ROM, strength, pain sive injury.29 163 An interesting observation in these injuries is
on palpation and area of palpation tenderness to monitor the speed at which clinical symptoms can improve. If signifi-
reaction. cant parts of the contractile element of the muscle–tendon unit
Weekly programme design is an important consideration for remain intact and the intratendon injury is partial, then force
strength training prescription. Reduced levels of hamstring
production in low-level tasks or clinical assessments may return
activation have been demonstrated following the performance
quickly. As described further below, tendon healing is slow in
of a set of Nordic curls.157 Neuromuscular function post-sprint
comparison to muscle and fascia. In addition, Schache et al164
training follows a bimodal recovery pattern, with the initial
describe how the tendon provides an increasing role in muscle–
recovery observed immediately post-training being followed
tendon unit force production as running speed increases, as
by a secondary decline the following day.158 A decline in
the muscle–tendon unit demand increases non-linearly. There-
neuromuscular performance occurs following concentric exer-
fore, as clinical symptoms settle, if training progresses at too
cise when metabolic disturbance is sufficient; however, this
recovers quickly and decline in performance does not persist fast a rate, this may pre-dispose the athlete to re-injury at a
as it does with eccentric exercise.159 160 Together, these find- time when tendon healing is still taking place.13 14 The British
ings suggest that high-speed running is not recommended Athletics approach to intratendon injury with loss of tension
either immediately after or the day following heavy hamstring (3c) has consistently been to prescribe structured and targeted
strength training. However, the addition of a heavy weight conservative rehabilitation. Surgical intervention is not recom-
training session containing significant eccentric load after high- mended as primary management for this class of injury.
speed running does not result in increased muscle damage or
loss of function.160 Therefore, when considering rehabilitation
structure, it is recommended that eccentric hamstring loading
is programmed 1–2 hours after high-speed running sessions,
with the following day a lower intensity running session,
placing less demand on the hamstring.

RTFT decision-making
RTFT testing includes the same clinical and functional
processes as class (a) injuries (table 3), but due to the disruption
to the muscle–tendon unit, more thorough eccentric strength
assessment is also conducted using the Nordbord (figure 5).161
Results of this strength testing are interpreted to pre-injury
baseline values of limb symmetry and peak force, as well as
event group normative data (eg, sprinter/long jumper). Figure 5  Nordbord assessment of eccentric hamstring strength.

Macdonald B, et al. Br J Sports Med 2019;0:1–13. doi:10.1136/bjsports-2017-098971 7

 Review
Healing physiology to avoid placing excessive mechanical strain on the healing

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Tendon healing occurs in a very different way to muscle. tendon structures. This is in contrast to other rehabilitation
Tendon repair is characterised by extracellular matrix depo- guidelines advocating early inclusion of eccentric loading.175
sition and a functionally limited scar that requires collagen However, these guidelines do not consider the specific struc-
synthesis and remodelling for return of tensile strength.165 ture injured and how this may relate to healing physiology and
The tendon remodelling phase, which occurs from around muscle–tendon interaction. In a typical 3c injury, this delay is
6 weeks after injury, replaces the early type III collagen and approximately 3 weeks. Given that increases in fascicle length
extracellular matrix with longitudinally orientated type I have been shown to occur after only 14 days of eccentric
collagen.165 166 Consolidation occurs over the subsequent 6 loading,72 we believe that this delay will not negatively affect
weeks and maturation over many months.167 This is neces- this adaptation in the overall rehabilitation process.
sary to restore the tendon stiffness and function required for The primary variables considered during strength training are
athletic activity such as elite-level sprinting. progressions in load, length and contraction mode (table 7).51
Bohm et al176 concluded that load magnitude, of greater than
80% maximal voluntary contraction, rather than the mode of
Rehabilitation progression contraction, was the key determinant to develop the material
Running progressions and mechanical properties of tendon. Therefore, considering the
The rehabilitation framework for 3c injuries provides a longer tendon healing and adaptation process, early eccentric loading
time at each stage of running progression than those described will not necessarily provide additional benefit to the healing
for a 2b injury, due to slower tendon adaptation. Forces in the tendon over isometric loading, but may cause excessive strain
hamstring increase non-linearly as the percentage of maximal when considering muscle–tendon interactions.86 168 Long-term
running speed increases, while the length change in the muscle loading (>12 weeks duration) was also identified as a key
remains the same.83 At the end of swing phase, tendon elon- variable in tendon adaptation, and further supports our belief
gation may be primarily responsible for this length change.59 that these injuries require a longer approach to rehabilitation.
Tensile stress placed on the tendon will therefore be high. A The optimal loading frequency for tendon adaptation has been
gradual increase in running speed will provide this stimulus recommended as 36–72 hours between sessions, to ensure that
functionally, as the amount of negative work increases as the tissue synthesis occurs rather than degradation.177 The location
percentage of maximal running speed increases.168 of injury also needs consideration. In the case of a proximal
To avoid re-injury, a gradual increase in training volume and tendon injury, knee-based eccentric exercises are started first
intensity (table 6) is prescribed with enough time spent at each to avoid over straining the proximal injury site, progressing to
stage to accumulate high chronic workloads and avoid loading hip-based eccentrics at a later stage as tissue healing progresses
spikes, which is believed to mitigate injury risk.169–172 In 3c (figure 6).75
injuries, this concept is even more important as the greater
severity of injury and subsequent loss of normal training time
mean that protective chronic training loads are lost. RTFT decision-making
The most important measures remain clinical, functional and
Strength training progressions strength testing for class c injuries (table 3). Given the higher
A body of evidence exists suggesting that during dynamic risk of re-injury in class c injuries, and a longer period of modi-
human movement an increase in muscle–tendon unit length fied training, we gather further information to help the RFTF
occurs via the passive component (ie, tendon) while the contrac- decision-making process (figure 7). This includes biomechan-
tile component remains isometric.59 85 168 173 174 As a result, ical analysis to compare ground contact times and stride length
and considering the slower healing physiology described, we to pre-injury values, and force plate testing with the strength
recommend that eccentric loading is delayed in class (c) injuries and conditioning staff to assess whether the strength qualities

Table 7  Hamstring loading progressions for 3c proximal biceps femoris injury

Week 1+2 3 4+5 6+7 8+9
Rehabilitation and 1. Promote tissue healing 1. Introduce low-load 1. Increase eccentric 1. Increase eccentric loads 1. High eccentric loads at
adaptation aim 2. Avoid inhibition eccentric contractions loads at shorter at longer lengths long length
3. Avoid tensile load on tendon with knee dominant lengths 2. Large fatigue resistance 2. Maintain heavy isometric
exercises 2. Introduce low-load and strength endurance loading for tendon and
2. Build tissue capacity eccentrics at longer component aponeurotic adaptation
and fatigue resistance tissue lengths
3. Increase isometric loads with hip dominant
exercises
Elongation stress Low Low Moderate Moderate–high High
Load intensity /volume Low (eg, 10–15 RM)/ high (four Low–moderate (eg, 8–10 Moderate–high (eg, 6–8 High (eg, 2–6 RM)/Mod High (eg, 2–6 RM)/moderate–
to five sets) RM)/high (four sets) RM)/moderate–high (three sets) low (two to three sets)
(three to four sets)
Frequency per week 4 3–4 3 3 2
Exercise selection Isometric-concentric hams curls Eccentric knee curls RDL+SL RDL movement RDL+SL RDL loaded 45° hip extension
Bridging patterns DL-SL Roman chair iso pattern SL Roman chair with row Cable hip extension
holds SL Roman chair with load Nordics increased volume SL RDL increased load
90–90 bridge capacity Nordics Flywheel curl SL Roman chair with row
Nordics loaded
DL, double leg; NHE, Nordic hamstring exercise; RDL, Romanian dead lift; SL, single leg.

8 Macdonald B, et al. Br J Sports Med 2019;0:1–13. doi:10.1136/bjsports-2017-098971

 Review

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Figure 6  Example of a knee dominant exercise used in early eccentric
loading (A. fly wheel) progressing to a hip dominant eccentric exercise
(B. 45° hip extension).

required for elite sprinting have been met. The judicious use
of repeat MRI can assess the appearance of structural tendon
integrity which may provide additional information, partic-
ularly when an athlete is looking to accelerate the rehabilita-
tion process. A repeat MRI scan within rehabilitation may also
provide additional information if the initial MRI had a very
extensive high signal intensity pattern that obscured full assess-
ment of tendon integrity. However, MRI appearance may not be
a good correlate of tendon or muscle–tendon unit function and Figure 8  Summary of British Athletics Rehabilitation strategy.
MRI appearance should only be one factor that contributes to
clinical reasoning. The limited available evidence suggests that
use of MRI in return to play decision-making has limited benefit
although this has not been specifically evaluated for intratendon What is already known
injuries.178 The importance of the initial shared decision-making
►► Injuries to the hamstring muscle group can be at the muscle–
process and agreement on the rehabilitation approach must be
emphasised with this class of injury, as at times patience may be tendon junction, at the myofascial border, or intratendinous.
►► Evidence exists for the efficacy of eccentric strengthening in
required to ensure appropriate tendon adaptation and healing
for the reasons already discussed. the rehabilitation of hamstring injuries.

Limitations to our approach

This paper presents the British Athletics rehabilitation approach properties of intratendon injuries, including potential differ-
to hamstring muscle injuries in an elite athletics cohort. While ences between the intramuscular tendon and free tendon. While
the clinical reasoning principles are transferable, the rehabilita- MRI is unlikely to provide an accurate prognosis in isolation,
tion approach may not be appropriate for athletes in different we believe the modality has value in providing a framework for
sports, particularly those with lower tendon or muscle–tendon clinical reasoning and limited value in monitoring rehabilitation
unit demand. Further basic science and clinical research is progress. The rehabilitation programme we have presented is
required on the specific structural, healing and functional our interpretation of the available evidence but we recognise
that our specific approach requires evaluation and testing in
prospective studies.

Summary
This paper outlines the British Athletics approach to the manage-
ment of hamstring injury rehabilitation with a general discussion
on rehabilitation principles and specific rehabilitation guidelines
based on the BAMIC, as summarised in figure 8. Since imple-
menting this structured and targeted approach to diagnosis
and rehabilitation, our injury audit has demonstrated a marked
reduction in the previously published re-injury rates. We believe
a generic approach to hamstring injury rehabilitation has limita-
tions and we encourage clinicians working in other sports to
identify loading and rehabilitation strategies to limit hamstring
Figure 7  Return to full training decision-making. injuries in elite sports.

Macdonald B, et al. Br J Sports Med 2019;0:1–13. doi:10.1136/bjsports-2017-098971 9

 Review
14 Brukner P, Connell D. ’serious thigh muscle strains’: beware the intramuscular tendon
What are the new findings

Br J Sports Med: first published as 10.1136/bjsports-2017-098971 on 12 July 2019. Downloaded from http://bjsm.bmj.com/ on 20 July 2019 by guest. Protected by copyright.
which plays an important role in difficult hamstring and quadriceps muscle strains.
Br J Sports Med 2016;50:205–8.
►► The clinical application of the British Athletics Muscle 15 Askling CM, Tengvar M, Saartok T, et al. Acute first-time hamstring strains during
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anatomical structure within a clinical reasoning framework. 17 Comin J, Malliaras P, Baquie P, et al. Return to competitive play after hamstring
injuries involving disruption of the central tendon. Am J Sports Med 2013;41:111–5.
►► We contend that isometric strengthening of the hamstrings 18 van der Made AD, Almusa E, Whiteley R, et al. Intramuscular tendon involvement on
complement eccentric loading. MRI has limited value for predicting time to return to play following acute hamstring
►► Milestone criteria are suggested to aid progressions and injury. Br J Sports Med 2018;52:83–8.
decision-making 19 Mendiguchia J, Brughelli M. A return-to-sport algorithm for acute hamstring injuries.
Phys Ther Sport 2011;12:2–14.
20 Heiderscheit BC, Sherry MA, Silder A, et al. Hamstring strain injuries:
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Correction notice  This article has been corrected since it published Online First. 21 Askling CM, Tengvar M, Thorstensson A. Acute hamstring injuries in Swedish
The second author’s name has been corrected. elite football: a prospective randomised controlled clinical trial comparing two
Acknowledgements  The authorswould like to recognise the work of colleagues rehabilitation protocols. Br J Sports Med 2013;47:953–9.
in the British Athletics Sports Science and Medicine team past and present who 22 Sherry MA, Johnston TS, Heiderscheit BC. Rehabilitation of acute hamstring strain
have contributed to the evolution of this strategy. We also thank Danny Talbot, injuries. Clin Sports Med 2015;34:263–84.
Andrew Pozzi and Harry Aikines Aryeetey for help producing figures and drill videos, 23 Silder A, Sherry MA, Sanfilippo J, et al. Clinical and morphological changes following
and in particular Jon Murray for acting as a subject for hamstring exercise videos. 2 rehabilitation programs for acute hamstring strain injuries: a randomized clinical
The authors also acknowledge the work of Louise Carrier for help producing the trial. J Orthop Sports Phys Ther 2013;43:284–99.
infographic. Ben Macdonald would like to specifically thank Dr Polly Mcguigan for 24 Mendiguchia J, Martinez-Ruiz E, Edouard P, et al. A multifactorial, Criteria-based
her invaluable insight into muscle function and support over many years working progressive algorithm for hamstring injury treatment. Med Sci Sports Exerc
together. 2017;49:1482–92.
25 Sherry MA, Best TM. A comparison of 2 rehabilitation programs in the treatment of
Contributors  BM, NP, SM, RC, SK and MJ all contributed to the initial drafting and acute hamstring strains. J Orthop Sports Phys Ther 2004;34:116–25.
editing of the manuscript. RC led the design of the infographic. 26 Askling CM, Tengvar M, Tarassova O, et al. Acute hamstring injuries in Swedish elite
Funding  The authors have not declared a specific grant for this research from any sprinters and jumpers: a prospective randomised controlled clinical trial comparing
funding agency in the public, commercial or not-for-profit sectors. two rehabilitation protocols. Br J Sports Med 2014;48:532–9.
27 van Heumen M, Tol JL, de Vos R-J, et al. The prognostic value of MRI in determining
Competing interests  None declared. reinjury risk following acute hamstring injury: a systematic review. Br J Sports Med
Patient consent for publication  Not required. 2017;51:1355–63.
28 Pedret C, Rodas G, Balius R, et al. Return to play after soleus muscle injuries. Orthop
Provenance and peer review  Not commissioned; externally peer reviewed.
J Sports Med 2015;3.
29 Crema MD, Guermazi A, Reurink G, et al. Can a clinical examination demonstrate
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