Home The challenge of thigh tendon reinjuries: an expert opinion
Article Open Access

The challenge of thigh tendon reinjuries: an expert opinion

  • Stefano Palermi , Filippo Vittadini , Giulio Pasta , Marcello Zappia , Alessandro Corsini , Carles Pedret , Luca Vergani , Italo Leo , Gianni Nanni , Marco Vecchiato , Andrea Demeco , Immacolata Belviso , Felice Sirico , Aleksi Jokela and Lasse Lempainen EMAIL logo
Published/Copyright: October 24, 2024
Download Article (PDF)
Journal of Basic and Clinical Physiology and Pharmacology
From the journal Journal of Basic and Clinical Physiology and Pharmacology Volume 35 Issue 6

Abstract

This review critically examines the issue of thigh tendon reinjury in athletes, drawing on recent advancements and diverse perspectives in sports medicine. The findings underscore the paramount importance of an early and accurate diagnosis, which significantly influences treatment efficacy and rehabilitation outcomes. We explore the intricacies of tendon anatomy and the mechanisms underlying injuries, highlighting how these factors interplay with athlete-specific risk profiles to affect reinjury rates. A major finding from the review is the necessity for individualized rehabilitation approaches that integrate both traditional methods and emerging technologies. These technologies show promise in enhancing monitoring and facilitating precise adjustments to rehabilitation protocols, thus improving recovery trajectories. Additionally, the review identifies a common shortfall in current practices – premature to play (RTP) – which often results from inadequate adherence to tailored rehabilitation strategies or underestimation of the injury’s severity. Such premature RTP significantly heightens the risk of further injury. Through this synthesis of contemporary research and expert opinion, the review advocates for a multidisciplinary approach in managing thigh tendon injuries, emphasizing the need for ongoing research to refine RTP criteria and optimize rehabilitation techniques. The ultimate goal is to support athletes in achieving safer and more effective recoveries, thereby reducing the likelihood of tendon reinjury.

Keywords: muscle injuries; reinjuries; muscle tendon; injury prevention; rehabilitation; sports medicine

Introduction

The classic structure of muscle–tendon–bone units comprises a muscle anchored at two points: the origin and the insertion, bridged by a tendon or aponeurosis that merges at a musculotendinous junction (MTJ), and an enthesis where this tendon or aponeurosis attaches to the bone [1]. While the MTJ has traditionally been identified as the primary site of muscle injury, recent clinical and radiological evidence increasingly points to the muscle belly as a frequent injury site [2]. His view is supported by advanced imaging techniques and meticulous anatomical studies that show free tendons often extend into the muscle belly, leading to injuries at intramuscular myotendinous or myoaponeurotic junctions [3]. These intramuscular tendons, also referred to as central tendons, serve as central struts anchoring the muscle fibers and play a pivotal role in muscle function and injury mechanics. It is important to note that studies in small animals, often using crush/contusion models, may not be directly applicable to human strain-type injuries, as suggested by recent human-focused research [4].

Substantial central tendons in thigh muscles, such as the biceps femoris (BF) and rectus femoris (RF), are particularly prone to strain. The approach to treatment, prognosis, and rehabilitation duration varies significantly depending on the precise injury location and the anatomical structures involved [5, 6]. While ultrasound scanning offers a quicker, more dynamic method for diagnosis, magnetic resonance imaging (MRI) remains the standard for assessing muscle injuries in professional athletes due to its detailed imaging capabilities, which are crucial for diagnosing the extent of injuries that range from minor strains to potentially career-ending tendon ruptures [3, 7].

The British Athletics Muscle Injury Classification (BAMIC) system provides a comprehensive framework for the classification and grading of muscle injuries. It categorizes injuries based on their anatomical location as “a” (myofascial), “b” (musculotendinous/musculotendinous junction), or “c” (intratendinous) and grades them from 0 to 4 according to MRI markers of injury severity. This system has proven its interobserver reliability [8]. Similarly, the 2020 update to the ISMuLT (Italian Society of Muscles, Ligaments and Tendons) classification of muscle injuries refined the categorization of injuries into myofascial (MF), muscle tissue/MTJ (MT), and tendon (T) injuries, further emphasizing the significance of accurately identifying and recording reinjuries [9, 10]. The introduction of a recording system for the primary injury (R0) and subsequent reinjuries (R1–R3) in the updated ISMuLT classification highlights the critical role of this information in guiding recovery and prognostication [11]. However, it is crucial to note that some prognostic data within the ISMuLT paper are derived from expert opinions rather than direct study results.

Addressing the challenge of reinjury, which can extend recovery periods, decrease performance, and even end careers, is crucial. The duration of rehabilitation and the risk of recurrence are significantly influenced by the injury’s location within the tendon or muscle. Recent research highlights that injuries extending into the tendon, such as in the hamstring, are associated with higher rates of reinjury and longer durations before returning to play 12], [13], [14. This becomes particularly significant in elite sports, where precise and timely rehabilitation is crucial for a sustainable return to play (RTP) [9, 15]. The extended recovery time and higher recurrence rate present significant clinical challenges, especially for elite athletes 15], [16], [17. A thorough understanding of the injury mechanism, anatomy, and available treatment options is crucial for medical professionals to optimize the RTP process [18, 19]. Moreover, if for purely muscular injuries the literature provides some evidence of RTP frameworks 20], [21], [22, for the injuries described in this narrative review, there is a complete absence of published studies on clear return-to-play criteria and rehabilitation progression models, making everything even more challenging.

This review investigates the complex issue of reinjury in thigh tendons among athletes, emphasizing the physical, psychological, and career ramifications of recurrent tendon injuries. Understanding the underlying mechanisms, risk factors, and effective prevention and management strategies is essential for athletes, coaches, healthcare professionals, and stakeholders in sports medicine.

Microscopical changes

The healing processes of muscles and tendons significantly differ, with muscle injuries that usually heal facilitated by a satellite cell response and early scaffold formation that supports muscle regeneration and swift functional restoration [23, 24]. However, many studies have shown that muscle injuries can lead to significant complications, such as morphology and functional changes, during the recovery period, and this is an important aspect to consider when planning an RTP 25], [26], [27.

Tendon healing, in contrast, is a complex and prolonged process, beginning with an inflammatory response within the first 24 h that leads to extracellular matrix deposition, predominantly comprising type III collagen initially [28]. This matrix transitions into type I collagen from around 6 to 8 weeks postinjury, a crucial phase for restoring the tendon’s tensile strength [29]. During the early stages of healing (first to third weeks), the scar tissue remains relatively soft, and premature or excessive loading at this stage can predispose the tendon to chronic conditions or increase the risk of reinjury. Mechanotransduction, involving the mechanical stimulation of cells, plays a pivotal role in tendon remodeling, enhancing collagen matrix deposition and the mechanical strength of the tissue through structured rehabilitation and controlled loading [29]. In the context of reinjury, particularly during the central tendon’s healing phase, nonoperative treatments may yield suboptimal outcomes if the delicate balance of loading and rest is not maintained [13].

Addressing the differential strain between central and free tendons, it is essential to understand that while both types share structural similarities in their collagen makeup, their mechanical and functional properties differ markedly. The collagen–proteoglycan matrix within the central tendon displays a less organized, wave-like pattern, indicative of its transitional nature between muscle and bone. In contrast, free tendons, which do not have muscle fibers inserted into them, exhibit a more structured arrangement and are capable of sustaining higher strain levels (6 % strain in free tendons vs. 2 % in central tendons) due to their ability to store and release energy efficiently through interfascicular gliding [30, 31].

This distinction is critical for rehabilitation strategies, as the pathology of central tendons, often resulting from acute strains, significantly differs from the degenerative overuse injuries typically seen in free tendons. Such differences necessitate tailored rehabilitation protocols that recognize the central tendon’s higher vascularity and the substantial stress it endures at the MTJ, especially under high-energy injury mechanisms [32]. Furthermore, the unique histological organization of the central tendon, combined with its surrounding muscular framework, suggests why injuries here may present with less severity but have higher recurrence rates and extended recovery periods compared to free tendon injuries [3].

These insights underscore the importance of customizing rehabilitation efforts to address the specific biomechanical and physiological challenges associated with different tendon types, particularly emphasizing the need for controlled plyometric exercises and sprinting during the recovery phase [33, 34].

Thigh muscle

The muscles of the thigh are organized into three compartments, delineated by intermuscular septa positioned between the posterior aspect of the femur and the fascia lata. Within the anterior compartment of the thigh reside the sartorius muscle and the four prominent quadriceps femoris muscles: the rectus femoris (RF), vastus lateralis (VL), vastus medialis (VM), and vastus intermedius (VI) [35]. These muscles are indispensable for activities such as knee extension, running, jumping, and kicking. Moving to the posterior compartment, three substantial muscles collectively known as the hamstrings are located: the biceps femoris (BF), semitendinosus (ST), and semimembranosus (SM). These muscles play crucial roles in knee flexion and hip extension, essential for activities like sprinting and sudden changes in speed. Lastly, the medial compartment harbors six muscles: gracilis, pectineus, adductor longus, adductor brevis, adductor magnus, and obturator externus. Their primary function revolves around the thigh adduction at the hip joint. Tendon injuries in the thigh arise from either acute trauma, such as sudden changes in direction, explosive movements, or chronic overuse, as seen in long-distance runners. These injuries’ prevention and treatment hinge on understanding the demands placed on these muscle groups.

Hamstrings

Hamstring injuries, prevalent in sports demanding dynamic movements like acceleration and deceleration, pose a significant challenge due to their complexity and the risk of recurrence [36]. From an anatomical standpoint, the SM muscle is situated beneath the ST muscle. Its attachment points include the superolateral impression on the ischial tuberosity above and primarily the groove and adjacent bone on the medial and posterior surfaces of the medial tibial condyle below. The ST muscle lies medially to the BF and originates alongside the long head of the BF muscle from the inferomedial aspect of the upper area of the ischial tuberosity. With a spindle-shaped muscle belly, it terminates in the lower half of the thigh, forming a long cord-like tendon. This tendon, positioned atop the semimembranosus muscle, descends toward the knee. Curving around the medial condyle of the tibia, it inserts into the medial surface of the tibia just posterior to the tendons of the gracilis and sartorius muscles, forming part of the pes anserinus. It is noteworthy that anatomical variations are frequent, occasionally resulting in the ST having a distinct insertion site.

Central tendons within the hamstrings play a pivotal role in these injuries, extending considerable lengths within the muscle belly and influencing both acute and chronic injury patterns [37]. The hamstrings contain a substantial central tendon, which extends considerable lengths within the muscle belly, influencing both acute and chronic injury patterns. These central tendon tears, typically located 10–20 cm distal from the origin, are difficult to diagnose as they can appear similar to simple muscle strains [38]. The BF’s central tendon, shared with the ST tendon medially, exhibits significant variations; some are completely enveloped by muscle tissue while others lie adjacent to it [39]. The tendon spans a considerable length in both the proximal and distal portions of the muscle belly, affecting injury dynamics and recovery process [38].

Hamstring injuries most commonly occur in athletes during high-speed running or overstretching of the posterior thigh [40, 41]. In football, the injury mechanisms vary greatly involving different closed and open kinetic chain sprint- and stretch-related movements 42], [43], [44. However, rapid movements with high eccentric demands of the hamstrings seem to be the key element in these injuries. The most severe proximal hamstring injuries happen following rapid hip flexion with concurrent knee extension [45]. The severity of hamstring injuries varies, ranging from muscle strains to avulsions of 1 or 2–3 tendinous insertions on the ischial tuberosity. The proximal MTJ of the long head of the BF (PMTJ) is also frequently injured, as attributed to its long, narrow aponeurosis, which leads to poor dissipation of force from the muscle belly to the tendon at this interface 46], [47], [48. While many hamstring injuries can be managed conservatively [49], complete ruptures of the proximal hamstring complex often require surgical intervention to restore function and prevent chronic issues or recurrence [50, 51] (Figure 1).

Figure 1: MRI coronal proton density fat-saturated image of complete proximal hamstring tendon disinsertion with retraction in a professional rugby athlete.
Figure 1:

MRI coronal proton density fat-saturated image of complete proximal hamstring tendon disinsertion with retraction in a professional rugby athlete.

Early surgical treatment is recommended for acute complete hamstring avulsions [52, 53] and in certain cases of incomplete hamstring tears, especially in athletes. However, some hamstring injuries may become chronic and recur [54], possibly due to the involvement of the central tendon and an initial misdiagnosed injury that leads to an RTP process faster than what the injury needs [28, 55]. High recurrence rates of hamstring muscle injuries (16–34 %) further complicate treatment [36]. Incomplete proximal hamstring ruptures, often involving one or two tendons, present a significant challenge to surgeons [56, 57].

Studies have shown that injuries involving the central tendon, especially within the BF, are more likely to recur and require longer recovery times compared to other hamstring injuries. A study confirmed that most hamstring muscle injuries occurred at the MTJ of the central tendon, exhibiting a feather-like pattern of edema on MRI [58]. Comin et al. [13] noted that the appearance of the central tendon in these injuries is variable. Occasionally, the tendon maintains its structural integrity despite the disruption of surrounding muscle fibers, whereas in other instances, this integrity appears to be lost, and the tendon assumes an irregular or wavy contour or is frankly disrupted. They reviewed 62 hamstring injuries among elite Australian Rules footballers. Of the 62 injuries, 45 (72 %) involved the BF, and of these 45, 12 (27 %) had central tendon disruption with the subgroup with no proximal tendon involvement (n=12, mean: 13.0, range 6–26). The authors retrospectively analyzed injury databases from 6 Australian Rules football teams and one professional rugby league team. Of the 62 hamstring muscle injuries included in the study, 12 involved the central tendon. All these injuries were to the BF muscle, with none involving any other hamstring muscle. The authors reported that central tendon injuries were significantly more likely to recur than other injuries. Additionally, the mean recovery time following central tendon disruption was more than three times (72 days; interquartile range [IQR]: 42–109) that of other BF muscle injuries (21 days; IQR: 9–28), as well as 3 times that of the median combined recovery time of injuries to all hamstring muscles (21 days; IQR: 14–42).

Recent research indicates that recovery outcomes can vary significantly based on the athlete’s sport and the specifics of the injury, with some studies showing no clear differences in recovery times between injuries with or without tendon involvement, suggesting that other factors such as injury severity and treatment efficacy may also play crucial roles. Pollock et al. [59] reviewed 65 hamstring injuries in 44 elite track and field athletes. The results showed that injuries that extended into the tendon (“c” injuries) had a longer time to return to full training and were more likely to recur compared to other grades of injuries. There was a significant difference within classifications 1a–3c for time to return to full training. Separate linear regression analysis of grade and site demonstrated that grade 3 severity (p<0.001) and intratendinous (c) site (p=0.008) were associated with an increase in the time to return to full training. Grade 3c injuries (n=7) had a mean return time of 84 days (SD 49.4, range 40–128) compared with grade 2b injuries (n=17) with a return time of 21 days (SD 10.2, range 12–49) and 2c injuries (n=8) of 27 days (SD 49.4, range 40–128). No significant differences were found between grades 1 and 2 (t=−1.138, p=0.263) or between classifications (a) and (b) (t=−0.240, p=0.812). There was also a significant difference within classifications 1a–3c concerning injury recurrence. Separate binary logistic analysis of grade and site suggested that grade was not associated with recurrence (p=0.133–0.968), but that intratendineous injuries (c) were associated with a higher risk of recurrence (p=0.002). This significantly increased repeat injury rate was 63 % in 2c injuries and 57 % in 3c injuries. In comparison, the repeat injury rate in 2b injuries was only 6 % (p<0.001), and there were no recurrences in any myofascial (a) injury class.

Vermeulen et al. [60] in 41 athletes with central tendons showed that in more than 50 % of cases, the RTP was obtained before healing on MRI and 18 of 34 (44 % overall) partial-thickness tendon discontinuities became continuous, and 6 out of 7 (15 % overall) complete thickness tendon discontinuities became partial-thickness tendon discontinuities. However, the reinjury rate was 20 %, lower than that reported by Pollock et al. (33 %) [59].

Wangensteen et al. [61], in a larger prospective analysis, noted only a small difference in recovery time following central tendon injury compared with other hamstring injuries, suggesting that the BAMIC categorization only accounted for a small variance in recovery time. Recent studies from English Premier League soccer clubs also indicated varying impacts of central tendon involvement on recovery and reinjury rates. Shamji et al. [62] reported significantly longer recovery times following central tendon injury compared to other types, while McAuley et al. [63] found no significant differences in recovery or recurrence between injuries with and without tendon involvement of the same grade. Both of these studies describe recovery times that are more comparable to those reported by van der Made et al. [64, 65] than those described by Pollock et al. [59]. As both studies involve a retrospective review of medical records, the physicians involved in the RTP decision were not blinded to MRI characteristics such as intramuscular tendon disruption. This is where the possibility of the aforementioned “self-fulfilling prophecy” is introduced, which may have caused a delay in RTP in cases with tendon disruption.

Injury to the distal musculotendinous T junction (DMTJ) of the BF is a distinct clinical entity that behaves differently from other hamstring injuries due to its complex, multicomponent anatomy and dual innervation [66]. Injury in this region demonstrates a particularly high rate of recurrence, and often surgery is a valid option [67]. According to Entwisie et al. [66], injuries to the DMTJ of the BF involved the long head component in 51 % of cases, both the long and short head components in 43 % of cases, and the short head component in 7 % of cases in this study. The recurrence rate of injury to the DMTJ of the BF in this series was 54 %, suggesting it is one of the most commonly reinjured muscles. However, this concept seems to be not confirmed by a recent study [68], where injuries with either intramuscular tendon or T-junction involvement were not associated with an increased rate of reinjury/subsequent injury to the same limb (intramuscular tendon involvement - odds ratio=0.96, T-junction involvement - odds ratio=1.03) in a cohort of professional rugby players, showing how this topic is complicated.

Rectus femoris

The RF muscle, spanning the hip and knee joints, endures high mechanical stress, especially during activities like soccer kicks [69], sprinting, and directional changes [70, 71]. This muscle originates from two primary tendons: the direct tendon from the anteroinferior iliac spine, and the indirect tendon from the acetabular margin and hip capsule [72]. Recent anatomical studies have identified a third membranous origin, extending from the indirect tendon to the greater trochanter, intertwining with the gluteus minimus [73]. These structures should be considered in future diagnostic algorithms for RF injuries.

Based on their location, RF injuries are classified as proximal, middle-third, or distal injuries 74], [75], [76. The tendon convergence occurs distal to their origins, forming the conjoint tendon. Here, the direct tendon is positioned anteriorly and superficially, while the indirect tendon is deeper and posterior. Below this juncture, the muscular component starts laterally relative to the indirect tendon, and the muscle fibers from the direct tendon spread over the proximal third of the muscle, forming an aponeurotic expansion that merges with the anterior fascia. The indirect tendon’s initial oval shape transforms as it progresses distally, adopting a thinner, comma-like shape before flattening and shifting from a medial to a more central position within the muscle. This transition gives rise to the central tendon, detectable via ultrasound and MRI [77]. In the distal third, this deep tendon becomes almost vertical and lies intramuscularly in the anterior aspect of the distal muscle belly [3].

The distal MTJ appears in the proximal third of the RF. As it extends distally, the connective tissue thickens, evolving into the posterior aponeurosis. The muscle fibers terminate relatively proximal to the patella, leaving a free tendon that integrates with the superficial layer of the quadriceps tendon, while the intermediate and deep layers are formed by the vastus medialis, lateralis, and intermedius, respectively, inserting at the patella’s superior border.

Injuries involving the central tendon tend to be more severe than typical muscle strains involving only muscle tissue [13, 28]. Accurate diagnosis and classification of the injury are crucial in determining the appropriate treatment, considering the extent of the muscle belly affected, the injury location, and connective tissue damage [78, 79]. Severe cases, such as complete proximal RF avulsions or mid-substance ruptures, often necessitate surgical intervention, particularly in high-performance athletes [6, 80, 81] (Figure 2).

Figure 2: MRI coronal proton density fat-saturated image demonstrating complete rupture of the conjoint tendon in a professional athlete, involving both direct and indirect tendons of the RF with retraction.
Figure 2:

MRI coronal proton density fat-saturated image demonstrating complete rupture of the conjoint tendon in a professional athlete, involving both direct and indirect tendons of the RF with retraction.

Hughes et al. [82] described a series of intrasubstance RF injuries originating from the tendon of the indirect head, often resulting in a “bull’s eye” appearance on MRI.

Cross et al. [83] examined the clinical and MRI appearance of 25 quadriceps injuries of which 15 were RF injuries. Seven of the 15 RF injuries involved the central tendon. They described a typical MRI appearance showing a feather-like pattern of injury in the coronal T2 view. The clinical importance of this central tendon involvement is shown by the prolonged rehabilitation time in this group (27 days) compared with the remainder of the RF injuries (9 days).

Balius et al. [77] published an ultrasound study of 35 cases of RF injuries involving the central tendon (aponeurosis). The injuries involving this tendon had a longer time to RTP than the 13 peripheral RF injuries (15 days) in their cohort. Most of the distal central tendon injuries were grade I (14) or II (20) with only one complete tendon tear. The average RTP for grade I injuries was 28 days and the grade II injuries were 46 days. These injuries were equally distributed between proximal and distal, with the proximal injuries having a longer time to RTP (49 vs. 32 days).

Hughes et al. [82] postulated that the indirect (central tendon) and direct heads of the proximal tendon begin to act independently, creating a shearing phenomenon in contrast to what occurs in the normal rectus femoris. This hypothesis was then used as a potential explanation for the longer rehabilitation associated with acute injuries involving the central tendon [83].

Reinjury: from risk factors to management and prevention strategies

Understanding and addressing the risk factors for reinjury in thigh muscle tendons is paramount for developing effective prevention and management strategies [84]. These risk factors are divided into intrinsic and extrinsic categories, each influencing the likelihood of recurrence significantly [9] (Table 1). Unfortunately, to date, the causal relationship of the risk factors recognized in the literature is still unknown. This could result in further difficulties in addressing the issue of these injuries [85].

Table 1:

Risk factors for a thigh muscle tendon reinjury.

Intrinsic Extrinsic
Older age MRI findings
Previous injury Incorrect treatment approach (conservative vs. surgical)
Microscopical tendon healing process Inappropriate return to play (RTP) time
Muscle strength imbalances Type of sport, training load, and intensity
Genetic predispositions Equipment used
Hormonal factors Environmental conditions
Lack of communication between medical staff and coaching staff

Intrinsic factors include physiological and biomechanical attributes such as age, previous injury history, and the microscopical process of tendon healing. Older age may decrease tissue elasticity and recovery capacity, while a history of previous injuries often leads to weakened structures or incomplete rehabilitation, increasing the risk of further injury [9] (Figure 3). Additionally, recent literature emphasizes the role of motor control in the recurrence of muscle or tendon injuries, highlighting it as a critical aspect of the risk profile for tendon injuries [86].

Figure 3: A lesion of the proximal tendon of rectus femoris in a professional football player (ultrasound images): the first episode (a) and the reinjury (b) that occurred 30 days after.
Figure 3:

A lesion of the proximal tendon of rectus femoris in a professional football player (ultrasound images): the first episode (a) and the reinjury (b) that occurred 30 days after.

Extrinsic factors encompass elements like MRI findings, which are essential for assessing the extent of an injury and guiding treatment strategies. Incorrect treatment modalities and the timing of RTP are particularly critical, with both premature and overly delayed RTP increasing the risk of reinjury [9]. Training load, intensity, and the type of sports activity significantly affect tendon stress; high-speed running, sudden directional changes, and jumping are activities associated with higher risks [9].

Effective management of reinjury encompasses interventions across all phases of injury – from acute care through to complete recovery, with an acute phase initiated early following the patient’s clinical presentation to allow for better tissue adaptation [87]. Rehabilitation programs should address not only tendon healing but also muscle imbalances, flexibility, and overall leg strength through progressive loading exercises 88], [89], [90. Rehabilitation programs should address not only tendon healing but also muscle imbalances, flexibility, and overall leg strength through progressive loading exercises. Physiotherapists typically follow a process that begins with identifying the key performance indicators of the sport [91]. They then determine the physical attributes that correspond to these indicators and allocate time for the development of these capacities. Effective training plans are grounded in a theoretical and biological understanding of human movement and adaptation to exercise stimuli [92]. This understanding, combined with knowledge of the optimal sequencing of these stimuli, enables one stimulus and its subsequent adaptation to enhance the next. Therefore, reverse or backward engineering, when effectively integrated with plans for nutrition, conditioning, and technical and tactical training, likely provides athletes with the best chance of achieving their performance goals and reducing the risk of reinjury [93].

For hamstring injuries involving three tendons, surgical intervention is recommended [94]. Two-tendon injuries are also often treated by operative means, especially in athletes with clear tendon retraction. Isolated one-tendon hamstring injuries most often respond well to conservative treatment, but symptomatic cases with clear tendon retraction and loss of tension of the injured structure often require operative treatment among professional athletes [95]. Surgical treatment of hamstring tendon injuries leads to high satisfaction and return to sports rates, acute repair having better outcomes, and lower rate of complications than chronic repair [57].

Sometimes tendon injuries tend to recur, either during the rehabilitation process or after the successful RTP. Recurring tendon injuries can be difficult to treat successfully, and they can jeopardize athletes’ careers. If tendon injury recurs despite the appropriate conservative treatment, surgical options should be carefully considered. In situations where conservative management falls short, surgical intervention may be considered, particularly for central tendon reinjuries. Surgical aims include tendon repair and addressing any muscle imbalances or anatomical anomalies. Postoperative rehabilitation is imperative for a successful sports return.

Recent studies in the field of sports medicine have shed light on various aspects of thigh tendon reinjury. Advancements in imaging techniques like MRI and ultrasound have greatly enhanced our understanding of tendon pathology and healing processes (Figure 4). The integration of wearable technology in rehabilitation offers real-time monitoring of recovery, ensuring that athletes do not prematurely return to intense activities – a common cause of reinjury.

Figure 4: Axial (1a–c) and coronal (2a–c) STIR MR sequences of a 22-year-old professional soccer player. Initially, Figures (1a–2a), taken 3 days postcompetition following the first indirect trauma, display a musculotendinous junction tear of the biceps femoris with the central tendon intact, classified as grade 3b according to BAMIC. After 45 days, subsequent pain during competition onset is captured in Figures 1b–2b, showing a biceps femoris retear with a central tendon lesion, upgraded to grade 3c BAMIC. Figures (1c–2c) later reveal a fibrous scar indicating “regenerated” central tendon, depicting a normal tear-healing process on MRI.
Figure 4:

Axial (1a–c) and coronal (2a–c) STIR MR sequences of a 22-year-old professional soccer player. Initially, Figures (1a–2a), taken 3 days postcompetition following the first indirect trauma, display a musculotendinous junction tear of the biceps femoris with the central tendon intact, classified as grade 3b according to BAMIC. After 45 days, subsequent pain during competition onset is captured in Figures 1b–2b, showing a biceps femoris retear with a central tendon lesion, upgraded to grade 3c BAMIC. Figures (1c–2c) later reveal a fibrous scar indicating “regenerated” central tendon, depicting a normal tear-healing process on MRI.

From a practitioners’ perspective, eccentric training, high-intensity running, and sprinting, integrated with a variety of other exercise modes that also carry some level of effectiveness in a multidimensional program, represent the most commonly addressed strategies to reduce the risk of muscle injury [96]. The specific load and regimen should be tailored to the severity of the tendon injury, and it might vary between initial and recurrent injuries 97], [98], [99. Programs should incorporate plyometric and functional training to provide comprehensive benefits and facilitate a more robust recovery [100]. Additionally, the role of nutrition and supplements in tendon health is becoming a focus area [100].

Implementing injury mechanisms for injury prevention, rehabilitation, and return to sport protocols can be crucial in avoiding tendon reinjuries [101]. For example, football players rehabilitating with RF injuries are often able to run, jump, and make rapid changes of direction without problems after 4 weeks, but kicking the ball often leads to reinjuries. The reinjuries often occur in similar situations to the initial injuries. In hamstring injuries, the investigated injury mechanisms (closed and open kinetic chain movements, sprinting- and stretching-related movements, specific biomechanical factors, eccentric muscle action) should be assessed and complemented into everyday rehabilitation [44, 71]. The main goal of rehabilitation should be to strengthen the weaknesses, minimize risk factors, and increase the tendons’ capability to tolerate injury-inciting actions. Video analysis of injury mechanisms can reveal individual risk factors, such as poor technique during performance, which should be considered in prevention and rehabilitation to avoid reinjuries [41, 42, 102]. When assessing the appropriate RTP, initial injury mechanisms can be analyzed and implemented into rehabilitation protocols and RTP tests to simulate realistic injury-prone situations. Sport-specific, individual, and mechanism-based prevention and rehabilitation strategies are highly recommended.

Conclusions

In conclusion, this review highlights the importance of a thorough understanding of anatomy and injury mechanisms to effectively manage and prevent thigh tendon reinjuries. It advocates for personalized rehabilitation approaches that incorporate both established practices and innovative technologies, tailored to the individual athlete’s needs. However, the field must address the existing knowledge gaps through ongoing, rigorous research to enhance recovery outcomes and reduce the likelihood of reinjury among athletes. This ongoing research will be crucial in refining current treatment modalities and in developing new strategies that can be reliably recommended across sports medicine.

Corresponding author: Lasse Lempainen, FinnOrthopaedics, Hospital Pihlajalinna, 20520 Turku, Finland, E-mail:

  1. Research ethics: Not applicable.

  2. Informed consent: Not applicable.

  3. Author contributions: Stefano Palermi and Filippo Vittadini, conceptualized and designed the study; Giulio Pasta and Marcello Zappia, managed data collection; Alessandro Corsini and Carles Pedret, analyzed the data; Luca Vergani and Italo Leo, conducted the literature search; Gianni Nanni and Marco Vecchiato, provided clinical insights; Andrea Demeco and Immacolata Belviso, refined the methodology; Felice Sirico, Aleksi Jokela, and Lasse Lempainen, revised the manuscript, focusing on clinical recommendations, with all authors approving the final manuscript.

  4. Use of Large Language Models, AI and Machine Learning Tools: None declared.

  5. Conflict of interest: None.

  6. Research funding: None.

  7. Data availability: On reasonable request to the corresponding author.

References

1. Vila Pouca, MCP, Parente, MPL, Jorge, RMN, Ashton-Miller, JA. Injuries in muscle-tendon-bone units: a systematic review considering the role of passive tissue fatigue. Orthop J Sports Med 2021;9. https://doi.org/10.1177/23259671211020731.Search in Google Scholar PubMed PubMed Central

2. Garrett, WE. Muscle strain injuries: clinical and basic aspects. Med Sci Sports Exerc 1990;22:436–43. https://doi.org/10.1249/00005768-199008000-00003.Search in Google Scholar

3. Brukner, P, Connell, D. “Serious thigh muscle strains”: beware the intramuscular tendon which plays an important role in difficult hamstring and quadriceps muscle strains. Br J Sports Med 2016;50:205–8. https://doi.org/10.1136/bjsports-2015-095136.Search in Google Scholar PubMed PubMed Central

4. Mackey, AL, Kjaer, M. The breaking and making of healthy adult human skeletal muscle in vivo. Skeletal Muscle 2017;7. https://doi.org/10.1186/S13395-017-0142-X.Search in Google Scholar

5. Pasta, G, Nanni, G, Molini, L, Bianchi, S. Sonography of the quadriceps muscle: examination technique. J Ultrasound 2010;13:76–84. https://doi.org/10.1016/j.jus.2010.07.004.Search in Google Scholar PubMed PubMed Central

6. Lempainen, L, Kosola, J, Pruna, R, Puigdellivol, J, Ranne, J, Orava, S. Operative treatment of proximal rectus femoris injuries in professional soccer players: a series of 19 cases. Orthop J Sports Med 2018;6:2325967118798827. https://doi.org/10.1177/2325967118798827.Search in Google Scholar PubMed PubMed Central

7. Lempainen, L, Kosola, J, Valle, X, Puigdellivol, J, Ranne, J, Orava, S, et al.. Chronic and recurrent rectus femoris central tendon ruptures in athletes—clinical picture. Orthop J Sports Med 2021;9:2. https://doi.org/10.1177/2325967120984486.Search in Google Scholar PubMed PubMed Central

8. Patel, A, Chakraverty, J, Pollock, N, Chakraverty, R, Suokas, AK, James, SL. British athletics muscle injury classification: a reliability study for a new grading system. Clin Radiol 2015;70:1414–20. https://doi.org/10.1016/J.CRAD.2015.08.009.Search in Google Scholar

9. Palermi, S, Vittadini, F, Vecchiato, M, Corsini, A, Demeco, A, Massa, B, et al.. Managing lower limb muscle reinjuries in athletes: from risk factors to return-to-play strategies. J Funct Morphol Kinesiol 2023;8:155. https://doi.org/10.3390/JFMK8040155.Search in Google Scholar

10. Pieters, E, Wezenbeek, E, Schuermans, J, Witvrouw, E. Return to play after a hamstring strain injury: it is time to consider natural healing. Sports Med 2021;51:1–11. https://doi.org/10.1007/s40279-021-01494-x.Search in Google Scholar PubMed

11. Nanni, G, Frizziero, A, Di Miceli, R, Vittadini, F, Finotti, P, Gamberini, J, et al.. Muscle injuries: 2020 update of the I.S.Mu.L.T. classification. Muscles Ligaments Tendons J 2020;10:562–7. https://doi.org/10.32098/MLTJ.04.2020.03.Search in Google Scholar

12. Askling, C, Tengvar, M, Saartok, T, Thorstensson, A. Acute first-time hamstring strains during high-speed running: a longitudinal study including clinical and magnetic resonance imaging findings. Am J Sports Med 2007;35:197–206. https://doi.org/10.1177/0363546506294679.Search in Google Scholar PubMed

13. Comin, J, Malliaras, P, Baquie, P, Barbour, T, Connell, D. Return to competitive play after hamstring injuries involving disruption of the central tendon. Am J Sports Med 2013;41:111–15. https://doi.org/10.1177/0363546512463679.Search in Google Scholar PubMed

14. Cohen, SB, Towers, JD, Zoga, A, Irrgang, JJ, Makda, J, Deluca, PF, et al.. Hamstring injuries in professional football players: magnetic resonance imaging correlation with return to play. Sports Health 2011;3:423–30. https://doi.org/10.1177/1941738111403107.Search in Google Scholar PubMed PubMed Central

15. Palermi, S, Massa, B, Vecchiato, M, Mazza, F, De Blasiis, P, Romano, AM, et al.. Indirect structural muscle injuries of lower limb: rehabilitation and therapeutic exercise. J Funct Morphol Kinesiol 2021;6:75. https://doi.org/10.3390/JFMK6030075.Search in Google Scholar PubMed PubMed Central

16. Di Meglio, F, Sacco, AM, Belviso, I, Romano, V, Sirico, F, Loiacono, C, et al.. Influence of supplements and drugs used for the treatment of musculoskeletal disorders on adult human tendon-derived stem cells. Muscles Ligaments Tendons J 2020;10:376–84. https://doi.org/10.32098/MLTJ.03.2020.04.Search in Google Scholar

17. Palermi, S, Gnasso, R, Belviso, I, Iommazzo, I, Vecchiato, M, Marchini, A, et al.. Stem cell therapy in sports medicine: current applications, challenges and future perspectives. J Basic Clin Physiol Pharmacol 2023;34:699–706. https://doi.org/10.1515/JBCPP-2023-0200.Search in Google Scholar PubMed

18. Lempainen, L, Mechó, S, Valle, X, Mazzoni, S, Villalon, J, Freschi, M, et al.. Management of anterior thigh injuries in soccer players: practical guide. BMC Sports Sci Med Rehabil 2022;14:1–9. https://doi.org/10.1186/S13102-022-00428-Y/FIGURES/9.Search in Google Scholar

19. Cross, TM, Gibbs, N, Houang, MT, Cameron, M. Acute quadriceps muscle strains: magnetic resonance imaging features and prognosis. Am J Sports Med 2004;32:710–19. https://doi.org/10.1177/0363546503261734.N.G.M.H.M.C.Search in Google Scholar PubMed

20. Zambaldi, M, Beasley, I, Rushton, A. Return to play criteria after hamstring muscle injury in professional football: a Delphi consensus study. Br J Sports Med 2017;51:1221–6. https://doi.org/10.1136/BJSPORTS-2016-097131.Search in Google Scholar

21. Vergani, L, Cuniberti, M, Zanovello, M, Maffei, D, Farooq, A, Eirale, C. Return to play in long-standing adductor-related groin pain: a Delphi study among experts. Sports Med Open 2022;8:11. https://doi.org/10.1186/S40798-021-00400-Z.Search in Google Scholar

22. Van Der Horst, N, Backx, FJG, Goedhart, EA, Huisstede, BMA. Return to play after hamstring injuries in football (soccer): a worldwide Delphi procedure regarding definition, medical criteria and decision-making. Br J Sports Med 2017;51:1583–91. https://doi.org/10.1136/BJSPORTS-2016-097206.Search in Google Scholar

23. Maffulli, N, Nanni, G. ISMuLT skeletal muscles injuries guidelines. Muscles Ligaments Tendons J 2013;3:240. https://doi.org/10.11138/mltj/2013.3.4.240.Search in Google Scholar

24. Järvinen, TAH, Järvinen, TLN, Kääriäinen, M, Kalimo, H, Järvinen, M. Muscle injuries: biology and treatment. Am J Sports Med 2005;33:745–64. https://doi.org/10.1177/0363546505274714.Search in Google Scholar PubMed

25. Pedret, C, Rupérez, F, Mechó, S, Balius, R, Rodas, G. Anatomical variability of the soleus muscle: a key factor for the prognosis of injuries? Sports Med 2022;52:2565–8. https://doi.org/10.1007/S40279-022-01731-X/TABLES/1.Search in Google Scholar

26. Balius, R, Alomar, X, Pedret, C, Blasi, M, Rodas, G, Pruna, R, et al.. Role of the extracellular matrix in muscle injuries: histoarchitectural considerations for muscle injuries. Orthop J Sports Med 2018;6:2325967118795863. https://doi.org/10.1177/2325967118795863.Search in Google Scholar PubMed PubMed Central

27. Pedret, C. Hamstring muscle injuries: MRI and ultrasound for diagnosis and prognosis. J Belg Soc Radiol 2022;105:91. https://doi.org/10.5334/JBSR.2617.Search in Google Scholar PubMed PubMed Central

28. Brukner, P, Connell, D. “Serious thigh muscle strains”: beware the intramuscular tendon which plays an important role in difficult hamstring and quadriceps muscle strains. Br J Sports Med 2016;50:205–8. https://doi.org/10.1136/BJSPORTS-2015-095136.Search in Google Scholar

29. James, R, Kesturu, G, Balian, G, Chhabra, AB. Tendon: biology, biomechanics, repair, growth factors, and evolving treatment options. J Hand Surg Am 2008;33:102–12. https://doi.org/10.1016/J.JHSA.2007.09.007.Search in Google Scholar

30. Purslow, PP. The structure and role of intramuscular connective tissue in muscle function. Front Physiol 2020;11. https://doi.org/10.3389/FPHYS.2020.00495.Search in Google Scholar PubMed PubMed Central

31. Farris, DJ, Trewartha, G, McGuigan, MP, Lichtwark, GA. Differential strain patterns of the human achilles tendon determined in vivo with freehand three-dimensional ultrasound imaging. J Exp Biol 2013;216:594–600. https://doi.org/10.1242/JEB.077131.Search in Google Scholar

32. Glasgow, P, Phillips, N, Bleakley, C. Optimal loading: key variables and mechanisms. Br J Sports Med 2015;49:278–9. https://doi.org/10.1136/BJSPORTS-2014-094443.Search in Google Scholar

33. MacDonald, B, McAleer, S, Kelly, S, Chakraverty, R, Johnston, M, Pollock, N. Hamstring rehabilitation in elite track and field athletes: applying the British Athletics muscle injury classification in clinical practice. Br J Sports Med 2019;53:1464–73. https://doi.org/10.1136/BJSPORTS-2017-098971.Search in Google Scholar PubMed

34. Balius, R, Blasi, M, Pedret, C, Alomar, X, Peña-Amaro, J, Vega, JA, et al.. A histoarchitectural approach to skeletal muscle injury: searching for a common nomenclature. Orthop J Sports Med 2020;8:2325967120909090. https://doi.org/10.1177/2325967120909090.Search in Google Scholar PubMed PubMed Central

35. Refai, NA, Black, AC, Tadi, P. Anatomy, bony Pelvis and lower limb: thigh femoral nerve. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; 2024. https://www.ncbi.nlm.nih.gov/books/NBK556065/ [Accessed 22 Aug 2023].Search in Google Scholar

36. Kerin, F, O’Flanagan, S, Coyle, J, Farrell, G, Curley, D, McCarthy Persson, U, et al.. Intramuscular tendon injuries of the hamstring muscles: a more severe variant? A narrative review. Sports Med Open 2023;9:75. https://doi.org/10.1186/S40798-023-00621-4.Search in Google Scholar PubMed PubMed Central

37. Central Tendon Injuries of Hamstring Muscles. Case series of operative treatment - PubMed. https://pubmed.ncbi.nlm.nih.gov/29479545/ [Accessed 1 Dec 2023].Search in Google Scholar

38. Woodley, SJ, Mercer, SR. Hamstring muscles: architecture and innervation. Cells Tissues Organs 2005;179:125–41. https://doi.org/10.1159/000085004.Search in Google Scholar PubMed

39. Koulouris, G, Connell, D. Hamstring muscle complex: an imaging review. Radiographics 2005;25:571–86. https://doi.org/10.1148/RG.253045711.Search in Google Scholar PubMed

40. Askling, CM, Malliaropoulos, N, Karlsson, J. High-speed running type or stretching-type of hamstring injuries makes a difference to treatment and prognosis. Br J Sports Med 2012;46:86–7. https://doi.org/10.1136/BJSPORTS-2011-090534.Search in Google Scholar

41. Aiello, F, Di Claudio, C, Fanchini, M, Impellizzeri, FM, McCall, A, Sharp, C, et al.. Do non-contact injuries occur during high-speed running in elite football? Preliminary results from a novel GPS and video-based method. J Sci Med Sport 2023;26:465–70. https://doi.org/10.1016/J.JSAMS.2023.07.007.Search in Google Scholar PubMed

42. Della Villa, F, Massa, B, Bortolami, A, Nanni, G, Olmo, J, Buckthorpe, M. Injury mechanisms and situational patterns of severe lower limb muscle injuries in male professional football (soccer) players: a systematic video analysis study on 103 cases. Br J Sports Med 2023;57:1550–8. https://doi.org/10.1136/BJSPORTS-2023-106850.Search in Google Scholar PubMed

43. Jokela, A, Valle, X, Kosola, J, Rodas, G, Til, L, Burova, M, et al.. Mechanisms of hamstring injury in professional soccer players: video analysis and magnetic resonance imaging findings. Clin J Sport Med 2023;33:217–24. https://doi.org/10.1097/JSM.0000000000001109.Search in Google Scholar PubMed PubMed Central

44. Gronwald, T, Klein, C, Hoenig, T, Pietzonka, M, Bloch, H, Edouard, P, et al.. Hamstring injury patterns in professional male football (soccer): a systematic video analysis of 52 cases. Br J Sports Med 2022;56:165–71. https://doi.org/10.1136/BJSPORTS-2021-104769.Search in Google Scholar

45. Folsom, GJ, Larson, CM. Surgical treatment of acute versus chronic complete proximal hamstring ruptures: results of a new allograft technique for chronic reconstructions. Am J Sports Med 2008;36:104–9. https://doi.org/10.1177/0363546507312167.Search in Google Scholar PubMed

46. Lempainen, L, Kosola, J, Pruna, R, Sinikumpu, JJ, Valle, X, Heinonen, O, et al.. Tears of biceps femoris, semimembranosus, and semitendinosus are not equal—a new individual muscle-tendon concept in athletes. Scand J Surg 2021;110:483–91. https://doi.org/10.1177/1457496920984274.Search in Google Scholar PubMed PubMed Central

47. Kayani, B, Ayuob, A, Begum, F, Singh, S, Haddad, FS. Surgical repair of distal musculotendinous T junction injuries of the biceps femoris. Am J Sports Med 2020;48:2456–64. https://doi.org/10.1177/0363546520938679.Search in Google Scholar PubMed

48. Ayuob, A, Kayani, B, Haddad, FS. Musculotendinous junction injuries of the proximal biceps femoris: a prospective study of 64 patients treated surgically. Am J Sports Med 2020;48:1974–82. https://doi.org/10.1177/0363546520926999.Search in Google Scholar PubMed

49. Fouasson-Chailloux, A, Menu, P, Mesland, O, Guillodo, Y. Evolution of isokinetic strength and return to sport after proximal hamstring rupture without surgical repair: a retrospective series of cases. Muscles, Ligaments & Tendons Journal 2019;9:173–80. https://doi.org/10.32098/mltj.02.2019.03.Search in Google Scholar

50. Cohen, SB, Rangavajjula, A, Vyas, D, Bradley, JP. Functional results and outcomes after repair of proximal hamstring avulsions. Am J Sports Med 2012;40:2092–8. https://doi.org/10.1177/0363546512456012.Search in Google Scholar PubMed

51. Bodendorfer, BM, Curley, AJ, Kotler, JA, Ryan, JM, Jejurikar, NS, Kumar, A, et al.. Outcomes after operative and nonoperative treatment of proximal hamstring avulsions: a systematic review and meta-analysis. Am J Sports Med 2018;46:2798–808. https://doi.org/10.1177/0363546517732526.Search in Google Scholar PubMed

52. Lempainen, L, Sarimo, J, Mattila, K, Heikkilä, J, Orava, S. Distal tears of the hamstring muscles: review of the literature and our results of surgical treatment. Br J Sports Med 2007;41:80–3. https://doi.org/10.1136/BJSM.2006.031211.Search in Google Scholar

53. Sarimo, J, Lempainen, L, Mattila, K, Orava, S. Complete proximal hamstring avulsions: a series of 41 patients with operative treatment. Am J Sports Med 2008;36:1110–15. https://doi.org/10.1177/0363546508314427.Search in Google Scholar PubMed

54. Sonnery-Cottet, B, Daggett, M, Gardon, R, Pupim, B, Clechet, J, Thaunat, M. Surgical management of recurrent musculotendinous hamstring injury in professional athletes. Orthop J Sports Med 2015;3:2325967115606393. https://doi.org/10.1177/2325967115606393.Search in Google Scholar PubMed PubMed Central

55. Lempainen, L, Kosola, J, Pruna, R, Puigdellivol, J, Sarimo, J, Niemi, P, et al.. Central tendon injuries of hamstring muscles: case series of operative treatment. Orthop J Sports Med 2018;6. https://doi.org/10.1177/2325967118755992.Search in Google Scholar PubMed PubMed Central

56. Lempainen, L, Sarimo, J, Heikkilä, J, Mattila, K, Orava, S. Surgical treatment of partial tears of the proximal origin of the hamstring muscles. Br J Sports Med 2006;40:688–91. https://doi.org/10.1136/BJSM.2006.028191.Search in Google Scholar

57. Jokela, A, Stenroos, A, Kosola, J, Valle, X, Lempainen, L. A systematic review of surgical intervention in the treatment of hamstring tendon ruptures: current evidence on the impact on patient outcomes. Ann Med 2022;54:978–88. https://doi.org/10.1080/07853890.2022.2059560.Search in Google Scholar PubMed PubMed Central

58. Connell, DA, Schneider-Kolsky, ME, Hoving, JL, Malara, F, Buchbinder, R, Koulouris, G, et al.. Longitudinal study comparing sonographic and MRI assessments of acute and healing hamstring injuries. AJR Am J Roentgenol 2004;183:975–84. https://doi.org/10.2214/AJR.183.4.1830975.Search in Google Scholar PubMed

59. Pollock, N, Patel, A, Chakraverty, J, Suokas, A, James, SLJ, Chakraverty, R. Time to return to full training is delayed and recurrence rate is higher in intratendinous (‘c’) acute hamstring injury in elite track and field athletes: clinical application of the British Athletics muscle injury classification. Br J Sports Med 2016;50:305–10. https://doi.org/10.1136/BJSPORTS-2015-094657.Search in Google Scholar PubMed

60. Vermeulen, R, Whiteley, R, Van Der Made, AD, Van Dyk, N, Almusa, E, Geertsema, C, et al.. Early versus delayed lengthening exercises for acute hamstring injury in male athletes: a randomised controlled clinical trial. Br J Sports Med 2022;56:792–800. https://doi.org/10.1136/BJSPORTS-2020-103405.Search in Google Scholar

61. Wangensteen, A, Guermazi, A, Tol, JL, Roemer, FW, Hamilton, B, Alonso, JM, et al.. New MRI muscle classification systems and associations with return to sport after acute hamstring injuries: a prospective study. Eur Radiol 2018;28:3532–41. https://doi.org/10.1007/S00330-017-5125-0.Search in Google Scholar

62. Shamji, R, James, SLJ, Botchu, R, Khurniawan, KA, Bhogal, G, Rushton, A. Association of the British athletic muscle injury classification and anatomic location with return to full training and reinjury following hamstring injury in elite football. BMJ Open Sport Exerc Med 2021;7. https://doi.org/10.1136/BMJSEM-2020-001010.Search in Google Scholar

63. McAuley, S, Dobbin, N, Morgan, C, Goodwin, PC. Predictors of time to return to play and Re-injury following hamstring injury with and without intramuscular tendon involvement in adult professional footballers: a retrospective cohort study. J Sci Med Sport 2022;25:216–21. https://doi.org/10.1016/J.JSAMS.2021.10.005.Search in Google Scholar

64. Van Der Made, AD, Almusa, E, Whiteley, R, Hamilton, B, Eirale, C, Van Hellemondt, F, et al.. Intramuscular tendon involvement on MRI has limited value for predicting time to return to play following acute hamstring injury. Br J Sports Med 2018;52:83–8. https://doi.org/10.1136/BJSPORTS-2017-097659.Search in Google Scholar

65. Van Der Made, AD, Almusa, E, Reurink, G, Whiteley, R, Weir, A, Hamilton, B, et al.. Intramuscular tendon injury is not associated with an increased hamstring reinjury rate within 12 Months after return to play. Br J Sports Med 2018;52:1261–6. https://doi.org/10.1136/BJSPORTS-2017-098725.Search in Google Scholar PubMed

66. Entwisle, T, Ling, Y, Splatt, A, Brukner, P, Connell, D. Distal musculotendinous T junction injuries of the biceps femoris: an MRI case review. Orthop J Sports Med 2017;5. https://doi.org/10.1177/2325967117714998.Search in Google Scholar PubMed PubMed Central

67. Kayani, B, Ayuob, A, Begum, F, Singh, S, Haddad, FS. Surgical repair of distal musculotendinous T junction injuries of the biceps femoris. Am J Sports Med 2020;48:2456–64. https://doi.org/10.1177/0363546520938679.Search in Google Scholar PubMed

68. Kerin, F, O’Flanagan, S, Coyle, J, Curley, D, Farrell, G, Persson, UM, et al.. Are all hamstring injuries equal? A retrospective analysis of time to return to full training following BAMIC type “c” and T-junction injuries in professional men’s rugby union. Scand J Med Sci Sports 2024;34:e14586. https://doi.org/10.1111/SMS.14586.Search in Google Scholar

69. Dörge, HC, Bull Andersen, T, Sørensen, H, Simonsen, EB, Aagaard, H, Dyhre-Poulsen, P, et al.. EMG activity of the iliopsoas muscle and leg kinetics during the soccer place kick. Scand J Med Sci Sports 1999;9:195–200. https://doi.org/10.1111/J.1600-0838.1999.TB00233.X.Search in Google Scholar PubMed

70. Santos, RCG, Van Hellemnondt, F, Yamashiro, E, Holtzhausen, L, Serner, A, Farooq, A, et al.. Association between injury mechanisms and magnetic resonance imaging findings in rectus femoris injuries in 105 professional football players. Clin J Sport Med 2022;32:E430–5. https://doi.org/10.1097/JSM.0000000000000935.Search in Google Scholar PubMed

71. Jokela, A, Mechó, S, Pasta, G, Pleshkov, P, García-Romero-Pérez, A, Mazzoni, S, et al.. Indirect rectus femoris injury mechanisms in professional soccer players: video analysis and magnetic resonance imaging findings. Clin J Sport Med 2023;33:475–82. https://doi.org/10.1097/JSM.0000000000001131.Search in Google Scholar PubMed PubMed Central

72. Hasselman, CT, Best, TM, Hughes, C, Martinez, S, Garrett, WE. An explanation for various rectus femoris strain injuries using previously undescribed muscle architecture. Am J Sports Med 1995;23:493–9. https://doi.org/10.1177/036354659502300421.Search in Google Scholar PubMed

73. Mechó, S, Iriarte, I, Pruna, R, Pérez-Andrés, R, Rodríguez-Baeza, A. A newly discovered membrane at the origin of the proximal tendinous complex of the rectus femoris. Surg Radiol Anat 2022;44:835–43. https://doi.org/10.1007/S00276-022-02954-3.Search in Google Scholar PubMed PubMed Central

74. Tubbs, RS, Caycedo, FJ, Oakes, WJ, Salter, EG. Descriptive anatomy of the insertion of the biceps femoris muscle. Clin Anat 2006;19:517–21. https://doi.org/10.1002/ca.20168.Search in Google Scholar PubMed

75. Balius, AMCP, Maestro, A, Pedret, C, Estruch, A, Mota, J, Rodríguez, L, et al.. Central aponeurosis tears of the rectus femoris: practical sonographic prognosis. Br J Sports Med 2009;43:818–24. https://doi.org/10.1136/bjsm.2008.052332.Search in Google Scholar

76. Ca Mariluis, JCFM, Cupito, J, Mamone, F. Muscle injuries of the rectus femoris muscle. MR update. Revista Argentina de Radiología 2015;79:182–91. https://doi.org/10.1016/j.rard.2015.08.002.Search in Google Scholar

77. Balius, R, Maestro, A, Pedret, C, Estruch, A, Mota, J, Rodríguez, L, et al.. Central aponeurosis tears of the rectus femoris: practical sonographic prognosis. Br J Sports Med 2009;43:818–24. https://doi.org/10.1136/BJSM.2008.052332.Search in Google Scholar

78. Lempainen, L, Kosola, J, Pruna, R, Sinikumpu, JJ, Valle, X, Heinonen, O, et al.. Tears of biceps femoris, semimembranosus, and semitendinosus are not equal-a new individual muscle-tendon concept in athletes. Scand J Surg 2021;110:483–91. https://doi.org/10.1177/1457496920984274.Search in Google Scholar PubMed PubMed Central

79. Valle, X, Mechó, S, Alentorn-Geli, E, Järvinen, TAH, Lempainen, L, Pruna, R, et al.. Return to play prediction accuracy of the MLG-R classification system for hamstring injuries in football players: a machine learning approach. Sports Med 2022;52:2271–82. https://doi.org/10.1007/S40279-022-01672-5.Search in Google Scholar

80. Sonnery-Cottet, B, Barbosa, NC, Tuteja, S, Gardon, R, Daggett, M, Monnot, D, et al.. Surgical management of rectus femoris avulsion among professional soccer players. Orthop J Sports Med 2017;5. https://doi.org/10.1177/2325967116683940.Search in Google Scholar PubMed PubMed Central

81. Lempainen, L, Mechó, S, Valle, X, Mazzoni, S, Villalon, J, Freschi, M, et al.. Management of anterior thigh injuries in soccer players: practical guide. BMC Sports Sci Med Rehabil 2022;14:41. https://doi.org/10.1186/s13102-022-00428-y.Search in Google Scholar PubMed PubMed Central

82. Hughes, C, Hasselman, CT, Best, TM, Martinez, S, Garrett, WE. Incomplete, intrasubstance strain injuries of the rectus femoris muscle. Am J Sports Med 1995;23:500–6. https://doi.org/10.1177/036354659502300422.Search in Google Scholar PubMed

83. Cross, TM, Gibbs, N, Houang, MT, Cameron, M. Acute quadriceps muscle strains: magnetic resonance imaging features and prognosis. Am J Sports Med 2004;32:710–19. https://doi.org/10.1177/0363546503261734.Search in Google Scholar PubMed

84. Ekstrand, J, Ueblacker, P, Van Zoest, W, Verheijen, R, Vanhecke, B, Van Wijk, M, et al.. Risk factors for hamstring muscle injury in male elite football: medical expert experience and conclusions from 15 European champions league clubs. BMJ Open Sport Exerc Med 2023;9. https://doi.org/10.1136/BMJSEM-2022-001461.Search in Google Scholar PubMed PubMed Central

85. Kalkhoven, JT. Athletic injury research: frameworks, models and the need for causal knowledge. Sports Med 2024;54:1121–37. https://doi.org/10.1007/S40279-024-02008-1/FIGURES/9.Search in Google Scholar

86. Hides, JA, Stanton, WR. Can motor control training lower the risk of injury for professional football players? Med Sci Sports Exerc 2014;46:762–8. https://doi.org/10.1249/MSS.0000000000000169.Search in Google Scholar PubMed

87. Bayer, ML, Magnusson, SP, Kjaer, M. Early versus delayed rehabilitation after acute muscle injury. N Engl J Med 2017;377:1300–1. https://doi.org/10.1056/NEJMC1708134.Search in Google Scholar

88. Tarantino, D, Mottola, R, Resta, G, Gnasso, R, Palermi, S, Corrado, B, et al.. Achilles tendinopathy pathogenesis and management: a narrative review. Int J Environ Res Publ Health 2023;20. https://doi.org/10.3390/IJERPH20176681.Search in Google Scholar

89. Loiacono, C, Palermi, S, Massa, B, Belviso, I, Romano, V, Di Gregorio, A, et al.. Tendinopathy: pathophysiology, therapeutic options, and role of nutraceutics. A narrative literature review. Medicina (Kaunas) 2019;55. https://doi.org/10.3390/MEDICINA55080447.Search in Google Scholar PubMed PubMed Central

90. Lamberti, V, Palermi, S, Franceschin, A, Scapol, G, Lamberti, V, Lamberti, C, et al.. Della the effectiveness of adapted personalized motor activity (AMPA) to improve health in individuals with mental disorders and physical comorbidities: a randomized controlled trial. Sports (Basel) 2022;10:30. https://doi.org/10.3390/SPORTS10030030.Search in Google Scholar PubMed PubMed Central

91. Turner, AN, Read, P, Maestroni, L, Chavda, S, Yao, X, Papadopoulos, K, et al.. Reverse engineering in strength and conditioning: applications to agility training. Strength Condit J 2022;44:85–94. https://doi.org/10.1519/SSC.0000000000000681.Search in Google Scholar

92. Blanchard, S, Glasgow, P. A theoretical model for exercise progressions as part of a complex rehabilitation programme design. Br J Sports Med 2019;53:139–40. https://doi.org/10.1136/BJSPORTS-2017-097486.Search in Google Scholar PubMed

93. Glasgow, P. Optimising load to optimise outcomes. Br J Sports Med 2017;51:985. https://doi.org/10.1136/BJSPORTS-2017-098048.Search in Google Scholar PubMed

94. Lempainen, L, Banke, IJ, Johansson, K, Brucker, PU, Sarimo, J, Orava, S, et al.. Clinical principles in the management of hamstring injuries. Knee Surg Sports Traumatol Arthrosc 2015;23:2449–56. https://doi.org/10.1007/S00167-014-2912-X.Search in Google Scholar PubMed

95. Allahabadi, S, Salazar, LM, Obioha, OA, Fenn, TW, Chahla, J, Nho, SJ. Hamstring injuries: a current concepts review: evaluation, nonoperative treatment, and surgical decision making. Am J Sports Med 2024;52:832–844. https://doi.org/10.1177/03635465231164931.Search in Google Scholar PubMed

96. McCall, A, Pruna, R, Van der Horst, N, Dupont, G, Buchheit, M, Coutts, AJ, et al.. Exercise-based strategies to prevent muscle injury in male elite footballers: an expert-led Delphi Survey of 21 practitioners belonging to 18 teams from the big-5 European leagues. Sports Med 2020;50:1667–81. https://doi.org/10.1007/S40279-020-01315-7/TABLES/5.Search in Google Scholar

97. Tarantino, D, Palermi, S, Sirico, F, Corrado, B. Achilles tendon rupture: mechanisms of injury, principles of rehabilitation and return to play. J Funct Morphol Kinesiol 2020;5. https://doi.org/10.3390/JFMK5040095.Search in Google Scholar PubMed PubMed Central

98. Sirico, F, Palermi, S, Massa, B, Corrado, B. Tendinopathies of the hip and pelvis in athletes: a narrative review. Journal of Human Sport and Exercise 2020;15:S748–62. https://doi.org/10.14198/JHSE.2020.15.PROC3.25.Search in Google Scholar

99. Tarantino, D, Palermi, S, Sirico, F, Balato, G, D’addona, A, Corrado, B. Achilles tendon pathologies. How to Choose the Best Treatment 2020;15:95. https://doi.org/10.14198/jhse.2020.15.Proc4.29.Search in Google Scholar

100. Palermi, S, Guelfi, M, Corsini, A, Siagascot, SMG. Sports medicine group of SIAGASCOT comprehensive management of lower limb tendinopathies in athletes: advances and challenges. JOINTS 2024;2:e931. https://doi.org/10.26355/joints_20244_931.Search in Google Scholar

101. Bahr, R, Krosshaug, T. Understanding injury mechanisms: a key component of preventing injuries in sport. Br J Sports Med 2005;39:324–9. https://doi.org/10.1136/BJSM.2005.018341.Search in Google Scholar

102. Della Villa, F, Buckthorpe, M, Tosarelli, F, Zago, M, Zaffagnini, S, Grassi, A. Video analysis of achilles tendon rupture in male professional football (soccer) players: injury mechanisms, patterns and biomechanics. BMJ Open Sport Exerc Med 2022;8:e001419. https://doi.org/10.1136/BMJSEM-2022-001419.Search in Google Scholar
Received: 2024-09-26
Accepted: 2024-10-05
Published Online: 2024-10-24

© 2024 the author(s), published by De Gruyter, Berlin/Boston

This work is licensed under the Creative Commons Attribution 4.0 International License.

Articles in the same Issue

  1. Frontmatter
  2. Editorial
  3. IcoSema’s leap forward: new data from COMBINE 3 paves the way
  4. Reviews
  5. Bimagrumab: an investigational human monoclonal antibody against activin type II receptors for treating obesity
  6. The challenge of thigh tendon reinjuries: an expert opinion
  7. Original Articles
  8. Effect of omega-3 fatty acids supplementation on muscle mass, fat mass, and visceral fat of hemodialysis patients; A randomized clinical trial
  9. Identification of ocular artifact in EEG signals using VMD and Hurst exponent
  10. Choroidal and retinal alteration after long-term use of tadalafil: a prospective non-randomized clinical trial
  11. Short Communication
  12. Immediate effect of sunlight exposure through blue glass on blood pressure in hypertensive patients: a randomized controlled trial
  13. Letter to the Editor
  14. The alarming link between the COVID-19 pandemic and stroke: why ignoring this association after relapse of the disease has dangerous consequences
  15. Corrigendum
  16. Corrigendum to: 6-OHDA mediated neurotoxicity in SH-SY5Y cellular model of Parkinson disease suppressed by pretreatment with hesperidin through activating L-type calcium channels
https://doi.org/10.1515/jbcpp-2024-0177
Keywords for this article
muscle injuries; reinjuries; muscle tendon; injury prevention; rehabilitation; sports medicine
Creative Commons
BY 4.0

Articles in the same Issue

  1. Frontmatter
  2. Editorial
  3. IcoSema’s leap forward: new data from COMBINE 3 paves the way
  4. Reviews
  5. Bimagrumab: an investigational human monoclonal antibody against activin type II receptors for treating obesity
  6. The challenge of thigh tendon reinjuries: an expert opinion
  7. Original Articles
  8. Effect of omega-3 fatty acids supplementation on muscle mass, fat mass, and visceral fat of hemodialysis patients; A randomized clinical trial
  9. Identification of ocular artifact in EEG signals using VMD and Hurst exponent
  10. Choroidal and retinal alteration after long-term use of tadalafil: a prospective non-randomized clinical trial
  11. Short Communication
  12. Immediate effect of sunlight exposure through blue glass on blood pressure in hypertensive patients: a randomized controlled trial
  13. Letter to the Editor
  14. The alarming link between the COVID-19 pandemic and stroke: why ignoring this association after relapse of the disease has dangerous consequences
  15. Corrigendum
  16. Corrigendum to: 6-OHDA mediated neurotoxicity in SH-SY5Y cellular model of Parkinson disease suppressed by pretreatment with hesperidin through activating L-type calcium channels
Sign up now to receive a 20% welcome discount
Institutional Access
How does access work?
Have an idea on how to improve our website?
Please write us.
© 2025 De Gruyter Brill
Downloaded on 3.10.2025 from https://www.degruyterbrill.com/document/doi/10.1515/jbcpp-2024-0177/html
Scroll to top button