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Division of Community
Medicine, Department of
Medical and Health Sciences,
Linkping University,
Linkping, Sweden
2
Football Research Group,
Linkping, Sweden
3
Chelsea and Westminster
Hospital, Imperial College,
London, UK
Correspondence to
Professor Jan Ekstrand, Hertig
Karlsgatan 13B, Linkping
S-582 21, Sweden;
jan.ekstrand@telia.com
Received 7 January 2016
Revised 21 March 2016
Accepted 21 March 2016
ABSTRACT
Aim The present study evaluated whether the MRI
parameters of hamstring injuries in male professional
football players correlate with time to return to play
(RTP).
Methods 46 elite European football teams were
followed prospectively for hamstring injuries between
2007 and 2014. Club medical staff recorded individual
player exposure and time-loss after hamstring injury.
MRI parameters were evaluated by two independent
radiologists and correlated with the RTP data.
Results A total of 255 grade 1 and 2 injuries were
evaluated in this study. RTP was longer for grade 2 than
grade 1 injuries (2413, 95% CI 21 to 26 days vs 18
15, 95% CI 16 to 20 days; mean difference: 6, 95%
CI 2 to 9 days, p=0.004, d=0.39). 84% of injuries
affected the biceps femoris (BF) muscle, whereas 12%
and 4% affected the semimembranosus (SM) and
semitendinosus (ST), respectively. No difference in lay-off
time was found for injuries to the three different muscles
(BF 2015 days, SM 1811 days, ST 2314 days;
p=0.83). The recurrence rate was higher for BF injuries
than for SM and ST injuries combined (18% vs 2%,
p=0.009). The size of the oedema weakly correlated
with time to RTP (r2=612%). No correlation was found
between location of injury and time to RTP. The majority
of the intramuscular injuries affected the MT junction
(56% in grade 1 and 2 injuries), but no difference in
lay-off time was found between the different types of
injuries.
Conclusions The radiological grade and size of the
oedema correlate with time to RTP for both, grade 1
and 2 injuries. No correlations were found between time
to RTP and the location and type of injury.
INTRODUCTION
Copyright Article author (or their employer) 2016. Produced by BMJ Publishing Group Ltd under licence.
Original article
Table 1 Operational definitions used in the study
Training session
Match
Injury
Hamstring injury
Rehabilitation
Lay-off
Early recurrence
Slight/minimal
injury
Mild injury
Moderate injury
Severe injury
Traumatic injury
Overuse injury
Data collection
Baseline player data and consent were collected yearly at the
time of player inclusion. During the season, medical staff registered individual player exposure in minutes during all club and
national team training sessions and matches. Injury cards and
attendance records were sent to the study group once a month.
Each injury was coded according to a modied version of the
Orchard Sports Injury Classication System (OSICS) 2.0.25
from the intramuscular tendon; or fascial, uid in the intermuscular space but no muscle injury.
Thirteen teams used PACSMail (http://www.sybermedica.com)
to send MRI scans for on-line review by two independent radiologists ( JCH and JCL) blinded to clinical details other than the
clinical diagnosis of hamstring injury. Copies of the 212 scans
and associated reports from the 13 teams using PACSMail were
then sent electronically to the study group. The other eight
teams used paper-based MRI forms (n=95) lled in by the club
consultant radiologist, which were sent to the study group by
mail.
Statistical analysis
ANOVA was used for between-group comparisons of lay-off
time, oedema size and size of the tear. These variables were presented as meanSD with 95% CI or range. Effect size, using
Cohens d, was calculated using the mean difference of all pairwise comparisons. The association between continuous variables
was measured using Pearsons correlation coefcient (r).
Multiple linear regression with a backward elimination procedure was used to estimate the effects the Z, X and Y planes of
the oedema have on lay-off time. Estimates were expressed as
the days change in lay-off time per millimetre change in the size
of the oedema. In addition, the coefcient of determination (r2)
of the nal models are presented. The association between
categorical variables was measured using Pearsons 2 test or
Fishers exact test.
For the two independent radiologists ( JH and JL), the reliability of the evaluation of grading, muscles involved, location
of injuries and injury types were assessed using statistics. The
reliability of the assessment of the size of the oedema and/or
tear was evaluated using the intraclass correlation coefcient
(ICC(3,1)).
All analyses were two-sided and the signicance level set at
p<0.05. All statistical analyses were performed in SPSS (IBM
SPSS Statistics for Windows, V.22.0. Armonk, New York, USA:
IBM Corp). The study design underwent an ethical review and
was approved by the UEFA Football Development Division and
the Medical Committee.
RESULTS
Examination procedure
Of the 1488 hamstring injuries recorded during the study
period, 917 (62%) were examined by MRI. MRI forms were
received for 307 (33%) of the examinations (gure 1). Since
grade 0 injuries (n=35) have no pathology on MRI, grade 3
injuries (n=9) were too few for robust analyses and data were
missing for eight examinations, only grade 1 (n=173) and grade
2 (n=82) injuries with completed MRI forms were included in
the following results (gure 1).
Reliability of evaluations
An almost perfect agreement between the two independent radiologists was found for the description of radiological grade
( value 0.94, 95% CI 0.85 to 1.00). Substantial agreement was
found for assessing the location of injury ( value 0.71, 95% CI
0.56 to 0.84) and type of injury ( value 0.65, 95% CI 0.49
to 0.80). There was total agreement regarding the muscles
involved. For the measurement of oedema size, the agreement
was substantial to almost perfect (ICC(3,1) 0.88, 95% CI 0.81
to 0.92; 0.80, 95% CI 0.7 to 0.87; 0.76, 95% CI 0.64 to 0.84
for Z, X and Y planes, respectively). For the measurement of
the size of the tear, the agreement was moderate to substantial
(ICC(3,1) 0.69, 95% CI 0.36 to 0.87; 0.45, 95% CI 0.04 to
Ekstrand J, et al. Br J Sports Med 2016;0:17. doi:10.1136/bjsports-2016-095974
Original article
Figure 1 Flow chart of hamstring muscle injuries in the UEFA Elite Club Injury Study in seasons 2007/2008, 2008/2009, 2009/2010, 2010/2011,
2011/2012, 2012/2013 and 2013/2014.
0.74; 0.70, 95% CI 0.38 to 0.87 for Z, X and Y planes,
respectively).
Muscles involved
Of the 253 injuries for which data on muscle involvement were
available, 212 (84%) affected the biceps femoris (BF) muscle,
30 (12%) in the semimembranosus (SM) muscle and 11 (4%) in
the semitendinosus (ST) muscle. There was no signicant difference in lay-off time for injuries to the three different muscles
(BF 2015, 95% CI 18 to 22 days; SM 1811, 95% CI 14 to
Ekstrand J, et al. Br J Sports Med 2016;0:17. doi:10.1136/bjsports-2016-095974
Original article
(r=0.26, p<0.001; r=0.26, p<0.001; and r=0.15, p=0.043,
respectively). Linear regression with backward elimination
revealed a 2.0 day (95% CI 1.0 to 3.1 days) change in lay-off
time per 10 mm change in the X plane oedema ( p<0.001)
when modelling all planes of the oedema on lay-off time.
However, as indicated by the coefcient of determination (r2),
the longitudinal length of the oedema only explained 7% of the
variation in lay-off time. No signicant two-way interaction
effects were found between the Z, X and Y planes.
Grade 1
There was a small to medium correlation between lay-off time
and the length and width of the oedema for grade 1 injuries
(r=0.24, p=0.003 and r=0.23, p=0.005, respectively) but no
signicant correlation with the depth of the oedema (r=0.16,
p=0.06). Linear regression for grade 1 injuries revealed a
0.7 day (95% CI 0.2 to 1.1 days) change in lay-off time per
10 mm change in the Z plane of the oedema ( p=0.003,
r2=6%). No signicant two-way interaction effects were found
between the Z, X and Y planes (gure 2).
Grade 2
For grade 2 injuries, there was a medium correlation between
lay-off time and the Z and X planes of the oedema (r=0.31,
p=0.03 and r=0.35, p=0.01, respectively) but no signicant
correlation with the Y plane (r=0.12, p=0.43). Linear regression for grade 2 injuries revealed a 1.8 day (95% CI 0.4 to
3.3 days) change in lay-off time per 10 mm change in the
X plane of the oedema ( p=0.013, r2=12%). No two-way interaction contributed signicantly to the model (gure 2).
Grade 2
Grade 2 injuries were more common in the middle third than in
the proximal and distal thirds (44% vs 31% and 24%). Grade 2
injuries had a mean 2311 to 15 days of lay-off time independent of location ( p=0.99).
Re-injuries
Re-injuries constituted 16% (41/255) of grade 1 and 2 injuries,
with no signicant difference in rates between the grades
(p=0.95). For grade 1 injuries, the re-injury rates differed signicantly between locations, as they were more common the
more distal the injuries were located ( proximal 5%, middle
14% and distal 21%, p=0.03). Recurrences of grade 2 injuries
Original article
were too few (n=13) for robust analyses, but the tendency was
opposite to grade 1 injuries with more recurrences in proximal
injuries (27% vs 13% and 6% for middle and distal locations,
p=0.06).
DISCUSSION
Radiological grading is clearly related to time to RTP
The principal nding of our study of mens professional football
is that radiological grading relates to lay-off duration. In our
analysis of the ECIS material during the seasons in 20072010,
we found that the lay-off time differed signicantly between the
four grades of muscle injury.4 In pairwise comparisons, the differences were signicant between all pairs except between grade
1 and 2 ( p=0.053).4 In the present extended study of seasons
in 20072014, in which we evaluated only grade 1 and 2 injuries, we found signicant differences in lay-off times for these
two grades of injury, indicating that radiological grading of MRI
is a helpful prognosticator for RTP. On average, grade 2 injuries
were associated with 6 additional days to RTP.
Grade 2
Injury type
Frequency
Per
cent
Absence
(days)
MT junction
Muscle
Fascial
Myofascial
Total
Missing data
96
11
10
45
162
11
56
6
6
26
94
6
1816
176
156
1916
Frequency
46
11
0
14
71
Per
cent
Absence
(days)
56
13
0
17
97
13
2413
2412
179
Injuries were classified as one of four different types according to the involvement of
intramuscular tissue: MT junction (injury affecting the myotendinous junction),
Myofascial (injury at the surface of the muscle), Muscle (injury away from the
intramuscular tendon), or Fascial (fluid in the intermuscular space but no injury to the
muscle).
Radiological grades were classified according to modified Peetrons: Grade 1=oedema
but no architectural distortion, grade 2=architectural disruption indicating partial tear.
Absence expressed as meanSD.
Original article
statement, as injuries to ST and SM are less frequent than BF
injuries.
Contributors JE, JCL and JCH were responsible for the conception and design of
the study. All the authors were involved in data collection over the study period. JE
conducted the analyses with the biostatistician (HM). All the authors contributed to
interpreting the ndings. JE wrote the rst draft of the paper, which was critically
revised by JCL and JCH. The nal manuscript was approved by all the authors. JE is
the study guarantor.
Funding The Football Research Group was established in Linkping, Sweden, in
collaboration with Linkping University and through grants from the Union of
European Football Associations, the Swedish Football Association, the Football
Association Premier League Limited and the Swedish National Centre for Research
in Sports.
Competing interests None declared.
Ethics approval The study design was approved by the UEFA Medical Committee
and the UEFA Football Development Division.
Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES
1
2
10
11
12
13
14
15
16
17
18
Original article
19
20
21
22
23
24
25
26
Reurink G, Brilman EG, de Vos RJ, et al. Magnetic resonance imaging in acute
hamstring injury: can we provide a return to play prognosis? Sports Med
2015;45:13346.
Ekstrand J, Hgglund M, Kristenson K, et al. Fewer ligament injuries but
no preventive effect on muscle injuries and severe injuries: an 11-year
follow-up of the UEFA Champions League Injury Study. Br J Sports Med
2013;47:7327.
Fuller CW, Ekstrand J, Junge A, et al. Consensus statement on injury denitions and
data collection procedures in studies of football (soccer) injuries. Br J Sports Med
2006;40:193201.
Hgglund M, Waldn M, Bahr R, et al. Methods for epidemiological study of
injuries to professional football players: developing the UEFA model. Br J Sports
Med 2005;39:3406.
Mueller-Wohlfahrt H, Haensel L, Mithoefer K, et al. Terminology and classication
of muscle injuries in sport: the Munich consensus statement. Br J Sports Med
2013;47:34250.
Mller-Wohlfahrt H, Ueblacker P, Hnsel L. Muskelverletzungen im sport. Stuttgart:
Georg Thieme Verlag KG, 2010 (Series Editor).
Orchard J. Orchard sports injury classication system (Osics). Sports Health
1993;11:3941.
Peetrons P. Ultrasound of muscles. Eur Radiol 2002;12:3543.
27
28
29
30
31
32
33
34
35
These include:
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