Return-to-Play Criteria After Hamstring Injury: Actual Medicine Practice in Professional Soccer Teams

Abstract

BackgroundReturn-to-play (RTP) criteria after a sport injury represent a key point in order to decrease the risk of subsequent re-injury.ObjectiveTo analyze how clinicians decide, in their daily practice, when a hamstring injured professional soccer player is fully able to get back to competitive activities.MethodsThirty-seven doctors for French and Belgian professional soccer clubs filled in a questionnaire formulated with multiple choice questions.ResultsNearly 80% of the questioned doctors declared to use at least 7 criteria in order to assess player's ability to return to competitive soccer after a hamstring injury. The most important ones are: complete pain relief, normalized muscle strength assessment, subjective feeling reported by the player, normalized flexibility and achievement of a specific soccer test. For some of these criteria, most notably muscle strength assessment, there is a lack of consensus about the choice of assessment parameters and the limit value allowing doctors to authorize or forbid RTP. Our study also highlighted the interest for clinicians to consider the opinion of physical therapists and physical trainers.ConclusionAfter a hamstring injury, clinicians for professional soccer clubs assess player's ability to return to full sport according to a “criteria-approach” instead of a “timed-based” approach. However, even if the scientific evidence about this topic is not sufficient at the moment, the implementation, in daily practice, of scientifically demonstrated assessment parameters and limit values should help the RTP decision and decrease the risk of re-injury.

Return to play criteria after hamstring muscle injury in professional football: a Delphi consensus study

“…The criteria reaching consensus in this Delphi study can be grouped into five core domains: ‘functional performance’ (criteria 1, 2, 3, 4, 7, 8, 11, 12 in table 4) ‘strength’ (criterion 6), ‘flexibility’ (criterion 10), ‘pain’ (criterion 9) and ‘player’s confidence’ (criterion 5). Our findings are in agreement with the results of a one-round survey conducted using team physicians from French and Belgian elite football clubs 5. The five criteria that were considered most important ( ‘complete pain relief’ , ‘muscle strength performance’ , ‘subjective feeling reported by the player’ , ‘muscle flexibility’ and ‘specific soccer test performance’ ) are analogous to those reaching consensus in our study, while interestingly, others were not mentioned in this Delphi process ( ‘respect of a theoretical period of competition break’ , ‘balance control assessment’ , ‘medical imaging’ , ‘correction of potential sacroiliac or lumbar joint dysfunction’ and ‘quadriceps - hamstrings EMG analysis’ ) 5.…”

“…Our findings are in agreement with the results of a one-round survey conducted using team physicians from French and Belgian elite football clubs 5. The five criteria that were considered most important ( ‘complete pain relief’ , ‘muscle strength performance’ , ‘subjective feeling reported by the player’ , ‘muscle flexibility’ and ‘specific soccer test performance’ ) are analogous to those reaching consensus in our study, while interestingly, others were not mentioned in this Delphi process ( ‘respect of a theoretical period of competition break’ , ‘balance control assessment’ , ‘medical imaging’ , ‘correction of potential sacroiliac or lumbar joint dysfunction’ and ‘quadriceps - hamstrings EMG analysis’ ) 5. Recent evidence has shown that HMI recurrence rates have not reduced in professional football in the last decade 16.…”

“…As reported in a recent qualitative systematic review, numerous criteria are used but none of these have been validated 4. In the absence of scientific evidence, Delvaux et al 5 explored current practice with a survey of physicians from French and Belgian elite football clubs. The authors produced a list of RTP criteria but did not investigate the degree of consensus between responders.…”

At return to play following hamstring injury the majority of professional football players have residual isokinetic deficits

“…4 Other elements which may assist in RTS decision include questionnaires ( personal medical history), specific functional tests ( physical examination), additional diagnostics ( particularly MRI) and sports-specific field tests. History taking represents an essential tool of our daily clinical decision-making process and may be enhanced by using patient-reported outcome (PRO) questionnaires.…”

“…3 Despite this recommendation, there remains a lack of consensus whether isokinetic assessment is useful in assisting RTS decisions. 4 In Creighton et al's 5 three-step decision-based RTS model, medical factors including an isokinetic evaluation and sport-specific field testing comprise the first step of RTS evaluation. Applying this approach, evidence of an injured muscle returning or nearly returning to preinjury strength levels, or attaining equivalence with the contralateral uninjured limb (5-10% is generally considered to be an acceptable threshold), 6 may typically be recommended prior to progressing through the decisionbased RTS model.…”