This review focused on the fact that not all hamstring injuries are the same and that certain types of injuries require prolonged rehabilitation and return to play (RTP).
It has also been suggested that variability of aponeurosis widths may be important in determining muscle injury susceptibility; this may explain why injuries involving the central tendon have been shown to be associated with prolonged RTP.
There are a number of factors that have been suggested as good indicators of severity and prolonged time to return to play.
Of the four studies performed to date, three studies reported a significant association between a shorter distance to the ischial tuberosity and a longer time to RTP, whereas one study found no association.
In a study comparing clinical and MRI indicators of RTP, the clinical parameters of self-predicted time to RTP (TTRTP) and passive straight leg raise deficit were independently associated with the TTRTP.
Re-injury after RTP is more common when the injury involves the biceps femoris.
The number of previous hamstring injuries, active knee extension deficit, isometric knee flexion force deficit at 15 degrees, and presence of localised discomfort on palpation just after RTP are also associated with a higher hamstring re-injury rate.
More emphasis should be placed on reduction of pain in the early days after hamstring injury to reduce the neuromuscular inhibition associated with pain, while at the same time encouraging early muscle activation, particularly eccentric exercise at longer muscle lengths, and early return to running with rapid progression to high-speed running.
While the concept of eccentric muscle training as an important component of the rehabilitation process has existed for many years, it now appears that these exercises must be in the lengthened position.
Prevention of these injuries is the ultimate aim and there is increasing evidence that Nordic hamstring exercises are effective in reducing the incidence.
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