Association of the British Athletic Muscle Injury Classification and anatomic location with return to full training and reinjury following hamstring injury in elite football

Abstract

BackgroundThe relationship between hamstring muscle injuries (HMIs) that involve the intramuscular tendon and prolonged recovery time and increased reinjury rate remains unclear in elite footballers.ObjectiveTo determine the association of time to return to full training (TRFT) and reinjury of HMIs using the British Athletic Muscle Injury Classification (BAMIC) and specific anatomical injury location in elite-level football players.MethodsThe electronic medical records of all players at an English Premier League club were reviewed over eight consecutive seasons. All players who sustained an acute HMI were included. Two experienced musculoskeletal radiologists independently graded each muscle using the BAMIC, categorised each injury location area (proximal vs middle vs distal third and proximal vs distal tendon) and reported second muscle involvement. TRFT and reinjury were recorded.ResultsOut of 61 HMIs, the intramuscular tendon (BAMIC ‘c’) was involved in 13 (21.3%). HMI involving the intramuscular tendon (‘c’) had a mean rank TRFT of 36 days compared with 24 days without involvement (p=0.013). There were 10 (16.4%) reinjuries with a significant difference of 38.5% reinjury rate in the group with intramuscular tendon injury (‘c’) and 12.5% in the group without (p=0.031). TRFT and reinjury involving a second muscle was statistically significantly higher than without. Most of the HMIs to the biceps femoris with reinjury (5 out of 9) were in the distal third section related to the distal tendon site involving both the long and short head.ConclusionTRFT in HMI involving the intramuscular tendon (‘c’) of the Biceps femoris is significantly longer with significantly higher reinjury rate compared with injuries without, in elite football players. The finding that most reinjures of the biceps femoris occurring in the distal third muscle at the distal tendon site, involving both the long and short head, merits further investigation.

Time to return to full training and recurrence of rectus femoris injuries in elite track and field athletes 2010–2019; a 9‐year study using the British Athletics Muscle Injury Classification

“…The most unique feature of this system is the structural classification (a, b or c), which may direct a more specific rehabilitation management approach to the specific tissue damage and has been advocated in hamstring injury 29 . In hamstring and calf muscle injuries, the BAMIC diagnosis has been associated with TRFT, in both retrospective and prospective studies 22,30–37 …”

“…29 In hamstring and calf muscle injuries, the BAMIC diagnosis has been associated with TRFT, in both retrospective and prospective studies. 22,[30][31][32][33][34][35][36][37] The aim of this study was to describe and compare TRFT and repeat injury rates in BAMIC classified RF injuries,sustained by elite track, and field athletes on a world class performance program over a 9-year period. It was hypothesized that intratendon tears would have an increased TRFT and higher repeat injury rates in comparison with myofascial and MTJ RF injuries.…”

Is there a need to reconsider the importance of myoaponeurotic injury within the nomenclature of sports-related muscle injury?

“…The importance of understanding its anatomy has been highlighted by recent workers who have identified the ‘T’ junction at the site of the distal musculotendinous junction of biceps femoris as a region prone to re-injury 7. Furthermore, type ‘c’ injuries (intratendinous) have also been described as being associated with longer return to play and higher re-injury rates 8 9. With this in mind, accurate anatomical description of muscle injury merits further consideration to facilitate a better understanding of return to play and re-injury.…”

“…Given the anatomical and functional similarities between tendon and aponeurosis, a myoaponeurotic injury may reflect a more significant injury than a myofascial one because of this functional role. While it is recognised that myofascial injuries often have a faster return to play time, there is quite significant variation and a lack of predictability 8 9. Aponeurotic extension of these injuries, which until now have been described as myofascial injuries, might explain the longer return to play time of some of these individuals, in the same way that intratendinous extension of musculotendinous injury has been demonstrated as a significant factor for BAMIC type c injury 8 9.…”

“…While it is recognised that myofascial injuries often have a faster return to play time, there is quite significant variation and a lack of predictability 8 9. Aponeurotic extension of these injuries, which until now have been described as myofascial injuries, might explain the longer return to play time of some of these individuals, in the same way that intratendinous extension of musculotendinous injury has been demonstrated as a significant factor for BAMIC type c injury 8 9. Further work is needed to assess the significance of aponeurotic extension of injury on MRI, and then to correlate these injuries with return to play time.…”