s40279-022-01783-z

Sports Medicine (2023) 53:615–635
https://doi.org/10.1007/s40279-022-01783-z
SYSTEMATIC REVIEW
Effectiveness of Conservative Interventions After Acute Hamstrings

Injuries in Athletes: A Living Systematic Review
José Afonso1 · Jesús Olivares‑Jabalera2,3 · Ricardo J. Fernandes1,4 · Filipe Manuel Clemente5,6 ·
Sílvia Rocha‑Rodrigues5,7,16 · João Gustavo Claudino8,9 · Rodrigo Ramirez‑Campillo10 · Cristina Valente11,12 ·
Renato Andrade4,11,12 · João Espregueira‑Mendes11,12,13,14,15
Accepted: 17 October 2022 / Published online: 9 January 2023

© The Author(s), under exclusive licence to Springer Nature Switzerland AG 2023
Abstract
Background Hamstrings injuries are common in sports and the reinjury risk is high. Despite the extensive literature on
hamstrings injuries, the effectiveness of the different conservative (i.e., non-surgical) interventions (i.e., modalities and
doses) for the rehabilitation of athletes with acute hamstrings injuries is unclear.
Objective We aimed to compare the effects of different conservative interventions in time to return to sport (TRTS) and/or
time to return to full training (TRFT) and reinjury-related outcomes after acute hamstrings injuries in athletes.
Data Sources We searched CINAHL, Cochrane Library, EMBASE, PubMed, Scopus, SPORTDiscus, and Web of Science
databases up to 1 January, 2022, complemented with manual searches, prospective citation tracking, and consultation of
external experts.
Eligibility Criteria The eligibility criteria were multi-arm studies (randomized and non-randomized) that compared conserva-
tive treatments of acute hamstrings injuries in athletes.
Data Analysis We summarized the characteristics of included studies and conservative interventions and analyzed data for
main outcomes (TRTS, TRFT, and rate of reinjuries). The risk of bias was judged using the Cochrane tools. Quality and
completeness of reporting of therapeutic exercise programs were appraised with the i-CONTENT tool and the certainty of
evidence was judged using the GRADE framework. TRTS and TRFT were analyzed using mean differences and the risk of
reinjury with relative risks.
Results Fourteen studies (12 randomized and two non-randomized) comprising 730 athletes (mostly men with ages between
14 and 49 years) from different sports were included. Nine randomized studies were judged at high risk and three at low
risk of bias, and the two non-randomized studies were judged at critical risk of bias. Seven randomized studies compared
exercise-based interventions (e.g., L-protocol vs C-protocol), one randomized study compared the use of low-level laser
therapy, and three randomized and two non-randomized studies compared injections of platelet-rich plasma to placebo or
no injection. These low-level laser therapy and platelet-rich plasma studies complemented their interventions with an exer-
cise program. Only three studies were judged at low overall risk of ineffectiveness (i-CONTENT). No single intervention
or combination of interventions proved superior in achieving a faster TRTS/TRFT or reducing the risk of reinjury. Only
eccentric lengthening exercises showed limited evidence in allowing a shorter TRFT. The platelet-rich plasma treatment did
not consistently reduce the TRFT or have any effect on the risk of new hamstrings injuries. The certainty of evidence was
very low for all outcomes and comparisons.
Conclusions Available evidence precludes the prioritization of a particular exercise-based intervention for athletes with
acute hamstrings injuries, as different exercise-based interventions showed comparable effects on TRTS/TRFT and the risk
of reinjuries. Available evidence also does not support the use of platelet-rich plasma or low-level laser therapy in clinical
practice. The currently available literature is limited because of the risk of bias, risk of ineffectiveness of exercise protocols
(as assessed with the i-CONTENT), and the lack of comparability across existing studies.
Clinical Trial Registration PROSPERO CRD42021268499 and OSF (https://osf.io/3k4u2/).
Extended author information available on the last page of the article
Vol.:(0123456789)
616 J. Afonso et al.
severe injuries [27, 28]. It has been suggested that interven-

Key Points tions could be structured according to the specific injury site
(i.e., semitendinosus vs biceps femoris, intra-tendon or extra-
As exercise-based interventions showed comparable time tendon) [29, 30] and may be mediated by inter-individual and
to return to full training or matches and the risk of rein- intra-individual anatomic and physiologic variations [31], but
juries, no specific strategy needs to be prioritized when experimental studies are still needed to sustain these claims.
rehabilitating athletes with acute hamstrings injuries. Rehabilitation strategies mostly rely on exercise-based inter-
Only eccentric lengthening exercises showed limited evi- ventions that often comprise multimodal approaches (includ-
dence in allowing a shorter time to return to full training. ing movement pattern improvement, progressive strength and
Platelet-rich plasma injections did not consistently sprint training, and strength endurance) [32, 33], but there is
reduce the time to return to full training or have any no consensus on which exercise modes are more effective.
effect on the risk of new hamstrings injuries. Therefore, Although hamstrings injuries treatment relies mainly on exer-
platelet-rich plasma has no current value in clinical cise-based interventions, other therapies such as platelet-rich
practice. plasma (PRP) or corticosteroid injections, sacroiliac manipu-
lation and/or non-steroidal anti-inflammatory drugs can be
The currently available literature is still limited owing to concomitantly used [32, 33]. However, the use of conserva-
a risk of bias, poor description, the risk of ineffective- tive (i.e., non-surgical) non-exercise-related strategies seems
ness of exercise protocols, and a lack of comparability poorly substantiated by scientific evidence [32, 33].
across existing studies. Further studies are clearly war- There are some systematic reviews addressing hamstrings
ranted to allow stronger conclusions. injuries recovery [33–35] and assessing criteria for its reha-
bilitation progress [18]. Since the last systematic review
on the effectiveness of acute hamstrings injuries conserva-
tive treatment [33], some new studies have been published
1 Introduction [36–41], suggesting the need for an update on the topic.
Considering that data from systematic reviews may quickly
Hamstrings injuries are common across sports involving become outdated [42], living reviews provide a regularly
sprinting or excessive muscle lengthening [1–11], result- updated summary of the most up-to-date evidence [43].
ing in ~ 17–27 days lost per 1000 h of training and match Thus, we performed a living systematic review of conserva-
exposure [1, 5, 10, 12], with players missing up to 80 train- tive rehabilitation strategies after acute hamstrings injuries
ing sessions and matches per year because of injury [13]. (excluding complete tears and avulsion injuries) to compare
The unavailability of players to compete owing to injury the effects of different interventions in time to return to sport
implies a considerable financial burden, for example, a (TRTS) and/or time to return to full training (TRFT) and
professional soccer player that is absent from competition reinjury-related outcomes.
for 2 weeks because of injury is estimated to cost around
€250,000 for clubs participating in the UEFA Champions
League [14], while in the Australian Football League the 2 Methods
cost of a single hamstrings injury was $A40,021 in 2021
[15]. Reduced player availability may result in a nega- 2.1 Criteria for Administrating and Updating
tive impact on team performance [16, 17]. The return to the Review
sport still remains a clinical challenge [18, 19], owing to
the unacceptably high injury recurrence rate that ranges This living systematic review followed the PRISMA (Pre-
between 16.0 and 68.0% across different sports [3, 7, 8, ferred Reporting Items for Systematic Reviews and Meta-
20–22], and frequently occurs within the first 2 months Analyses) 2020 [44] and Cochrane guidelines [45], and
after return to play [23]. Hamstrings reinjuries are most was performed under the guidance of PERSiST [46]. It will
common within 1 year of returning to sport (with a higher be updated annually on 1 January for a period of 5 years
risk in the first 2 weeks) and tend to be more severe [20, after completion of the initial database searches. These
24, 25]. The high rate of recurrence suggests that athletes updates will be published in a public OSF project (https://
may be returning to sport unprepared and prematurely [26]. osf.io/3k4u2/) and submitted to publication if new large-
Even if the rehabilitation strategies are appropriate, per- scale studies are available and/or new findings significantly
haps athletes are rushing back to sports without enough change the overall results (e.g., a meta-analysis is possible
time for proper biological healing [26]. for existing comparisons or new comparisons are available).
Rehabilitation is the usual treatment for hamstrings inju- Any updates or amendments to the protocol will be fully
ries, with surgical treatment reserved for more complex and disclosed.
Conservative Interventions After Acute Hamstrings Injuries 617
2.2 Eligibility Criteria EMBASE, PubMed, Scopus, SPORTDiscus, and Web of

Science, without restrictions on language or publication date
Inclusion and exclusion criteria were set according to the and no filters applied. Manual searches were conducted by
Participants, Intervention, Comparator, Outcome and Study screening the included studies and relevant reviews refer-
design (PICOS) framework. ence lists. Prospective snowballing citation tracking was
performed in Web of Science on 5 October, 2021. Seven
2.2.1 Participants external experts (with published research on the topic)
were consulted to provide further potentially relevant stud-
We included athletes of all competitive levels and sports with ies (from which three responded affirmatively as displayed
an acute hamstrings muscle injury, regardless of age, sex, in the Acknowledgements section). The experts accessed
race, or health status. Hamstrings muscle injury had to be our eligibility criteria, but not the search strategy, to avoid
diagnosed by physical examination (e.g., palpation, strength biasing their searches. Errata, corrections, corrigenda and/
tests, range of motion [ROM], among others) and/or con- or retractions were sought for the included studies [45] and
firmed through magnetic resonance imaging (MRI) and/or pre-registered protocols were retrieved when available. If a
ultrasound within 10 days of initial injury [18, 33]. Studies study had additional and relevant information published in
that comprised individuals with complete hamstrings muscle another article, it was used to complement the information.
ruptures (usually assessed as grade 3, depending on the classi-
fication system), avulsion injuries, or hamstrings tendinopathy 2.4 Search Strategy and Selection Process
[18] were excluded. Complete ruptures or avulsion injuries
usually undergo surgical procedures, while hamstrings ten- The general search strategy used the following free terms,
dinopathy is a chronic injury and therefore the rehabilitation without filters or limits applied (the full search strategies are
procedures may differ from those applied to acute injuries. displayed in the Electronic Supplementary Material [ESM]):
(1) [Ti/Ab] hamstring* OR semitendin* OR semimembran*
2.2.2 Interventions OR “biceps femoris” OR “femoral biceps” OR “posterior
thigh”; AND (2) [Ti/Ab] rehab* OR conserv* OR treat*
We included conservative interventions (i.e., avoiding inva- OR intervention* OR therap* OR manag* OR clinical* OR
sive procedures such as surgery) to treat hamstrings muscle recover* OR exercis* OR train*; AND (3) [All] injur* OR
injuries (e.g., exercise training, PRPs). strain* OR tear* OR ruptur* OR pain OR dysfunction OR
trauma; AND (4) [All] athlet* OR sport*. Two authors (JA
2.2.3 Comparators and SRR) independently screened all database records and
performed the manual searches, with disagreements being
Any other conservative intervention (e.g., different exer- resolved by a third author (JGC). Automated removal of
cise protocols, passive control groups and/or placebo) was duplicates was performed using EndNote™ 20.2 for Mac
accepted as a comparator. (Clarivate™) and confirmed by manual screening.
2.2.4 Outcomes 2.5 Data Collection
We included studies reporting at least one of the primary Assessments were planned for the primary outcomes TRTS,
outcomes: TRTS, TRFT, or occurrence of hamstrings rein- TRFT, reinjuries, and new hamstrings injuries. Data on second-
jury or new hamstrings injury. Secondary outcomes were ary outcomes (pain, strength, strength endurance, power, bal-
defined in the data items but were not used as eligibility ance/stability, sprinting, ROM, pre-bilateral and post-bilateral
criteria. and anteroposterior asymmetries, and adverse effects frequency,
type, and severity), study characteristics (e.g., sample size and
2.2.5 Study Design study design), participant demographics (e.g., age and sex), and
sports participation (e.g., sport and competitive level) were also
Only original randomized and non-randomized multi-group collected. We collected diagnostic characteristics relative to the
study designs, with at least ten participants per group [47, criteria and methods used as reported by the included studies to
48], published in any language or date, were accepted. determine acute hamstrings injury, imaging techniques applied,
number of physicians assessing the images, and specific muscles
2.3 Information Sources injured (i.e., semitendinosus, semimembranosus, biceps femo-
ris long head or short head). The programming details of the
Initial searches were conducted on 31 August, 2021, and interventions were defined for exercise-based interventions (e.g.,
updated on 1 January, 2022, in CINAHL, Cochrane Library, length, weekly frequency, intensity, sets, repetitions, movement
types, and muscle actions) and for PRP-based interventions (e.g., Each domain can be classified as having a low or high risk
number and timing of injections, specific contents, and related of ineffectiveness. The specific criteria used to reach the
information to the PRP-based procedures). The criteria used decisions are detailed in the original publication [52]. Two
for progressing in rehabilitation (e.g., time based and/or goal authors (JA and RA) conducted the data collection and a
based) and to decide on TRTS/TRFT, co-interventions, funding third author (RJF) arbitrated in case of disagreements. If the
sources, and competing interests were recorded. Two authors studies cited other sources to provide relevant information,
(JOJ and JGC) independently collected data and a third author those publications were viewed.
(FMC) arbitrated in case of disagreements.
2.9 Data Synthesis and Analysis
2.6 Risk of Bias of Individual Studies
Demographic data were not pooled because of inconsist-
Parallel randomized studies were judged at low risk, ent and incomplete reporting. Risk-related and continuous
some concerns, or high risk of bias in five domains using variables were treated as risk ratios and mean differences,
Cochrane’s Risk of Bias tool, version 2 (RoB 2) [49]: rand- respectively. Standardized mean differences were planned,
omization process, deviations from intended interventions but not calculated, as continuous variables used the same
(intention-to-treat analysis), missing outcome data, measure- units, and we did not pool the data from different studies.
ment of the outcome, and selection of the reported result. Although a pooled quantitative synthesis was not feasible,
Non-randomized studies were judged at low risk, mod- we computed the between-group mean differences or rela-
erate risk, or critical risk of bias in seven domains using tive risk for each study within each outcome. Findings were
Cochrane’s Risk of Bias In Non-Randomized Studies of reported narratively because of the very low number of stud-
Interventions (ROBINS-I) [50]: confounding, selection of ies per comparison and their clinical heterogeneity precluded
the participants, classification of interventions, deviations us from reliably performing a quantitative synthesis. The
from intended interventions, missing data, measurement of planned quantitative analyses can be viewed in the pre-reg-
outcomes, and selection of the reported result. istered protocol (https://osf.io/3k4u2/).
The risk of bias was judged at outcome (grouped according
to domains, such as reinjuries) and study levels (presenting 2.10 Certainty of Evidence
the worst-case scenario per study). In the absence of a pre-
registered protocol, the risk of bias in selection of the reported Two authors (JA and RA) judged the certainty of evidence
result was judged, at least, as has having some concerns (RoB using the Grading of Recommendations Assessment, Devel-
2) or moderate risk (ROBINS-I). Two authors (JA and SRR) opment and Evaluation (GRADE) [53] and disagreements
independently judged the risk of bias, while a third author were resolved by consensus. Four of five GRADE dimen-
(RA) arbitrated when needed. The overall summaries of risk sions were judged [54, 55]: risk of bias, inconsistency, indi-
of bias judgments were plotted by the main outcome. rectness, and imprecision. The risk of publication bias was
not judged because of an insufficient number of studies per
2.7 Data Management comparison to perform this analysis. Further details on the
criteria for judging certainty of evidence can be viewed in
If multiple measurements were available in the included the ESM, and the originally planned assessments are avail-
studies, the information provided in the current review refers able in the study protocol (https://osf.io/3k4u2/).
to the interventions’ endpoint (unless otherwise stated).
When data were exclusively provided in figures, two authors
(JA and SRR) independently extracted the data using the 3 Results
validated software WebPlotDigitizer version 4.4 [51], and
both values are presented in the relevant tables. 3.1 Study Selection
2.8 Quality and Completeness of Therapeutic Database searches returned 20,644 records, from which
Exercise Program Reporting 12,311 were duplicates, and additional searches (included
studies’ reference lists, snowballing citation tracking,
This item judged seven domains using the international expert consultations, and updated database searches)
Consensus on Therapeutic Exercise and Training (i-CON- did not yield any new studies. Following the titles and
TENT) tool [52]: patient selection, qualified supervisor, abstracts screening, 19 records required a full-text analy-
type and timing of outcome assessment, dosage parameters sis, from which five were excluded because of not ful-
(frequency, intensity, time), type of exercise, safety of the filling participants [56, 57] or outcomes [58–60] eligi-
exercise program, and adherence to the exercise program. bility criteria. Fourteen studies were deemed eligible
for inclusion [24, 36–41, 57, 61–67], one study [66] was 3.3 Study Characteristics and Results
complemented by previously published information [68],
and another [63] had an erratum [69] and a pre-published 3.3.1 Publication Details, Funding, and Competing
protocol [70]. Further details on study selection are shown Interests
in Fig. 1 and in the ESM.
The studies were published between 2004 and 2020, and
3.2 Risk of Bias of Individual Studies five (35.7%) had pre-registered and/or pre-published pro-
tocols [38, 39, 63, 64, 66]. Studies were performed mostly
Twelve parallel randomized studies were included in the in Europe (France, Greece, the Netherlands, Russia, Spain,
current review [24, 36, 38–40, 61–67], with one study [63] and Sweden) [36, 40, 41, 61, 62, 65, 66], followed by North
including an erratum [69] and another [66] a letter to the America (USA) [24, 37, 67], Asia (Malaysia, Qatar) [63,
editor [68] that were considered for judging the risk of bias. 64], Oceania (Australia) [38], and South America (Brazil)
Nine studies (75.0%) [24, 36, 40, 61–63, 65–67] and three [39], and no study was performed in Africa. Funding sources
studies (25.0%) [38, 39, 64] were judged at an overall high were reported in nine studies (64.3%) [24, 37, 38, 61–64, 66,
and low risk of bias for all primary outcomes, respectively. 67] and unreported in three [36, 41, 65], with two studies
The study-level assessment (based on the worst-case sce- reporting no funding [39, 40]. Eight studies (57.1%) dis-
nario for each study) and the percentages for each domain played no competing interests [38–40, 61, 62, 64, 67] or
are displayed in Fig. 2a and b. Two non-randomized studies none beyond the public funding [63], while three studies
[37, 41] were judged at an overall critical risk of bias for all (21.4%) did not address this item [24, 36, 65]. Three stud-
primary outcomes (see Fig. 2c). A more detailed description ies had potentially relevant competing interests [37, 41, 66]
of am outcome-based and domain-based risk of bias judg- although one of them stated the opposite [66]. More detailed
ment is provided in the ESM. information is provided in the ESM.
Fig. 1 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 flow diagram
participants’ sex, 654 were male and 72 were female (89.6%

a) and 9.9%, respectively), with four missing values (0.5%).
Studies reported the practiced sport for 726 participants,
with soccer as the most represented (n = 346, 47.7%), fol-
lowed by track and field (n = 166, 22.9%) and American
football (n = 74, 10.2%). The competitive level ranged
from amateur to professional and was unreported in three
studies [24, 38, 65]. Table 1 synthesizes the participants’
characteristics.
3.3.3 Previous Hamstrings or Lower Limb Injuries
Six studies (42.9%) included participants without any pre-

vious hamstrings injuries in the same thigh in the previous
6–12 months [40, 41, 61, 62] or ever [24, 65]. Previous ipsi-
lateral or contralateral hamstrings injuries were presented
As percentage (intenon-to-treat)
b) in five studies [24, 38, 63, 64, 66] and unreported in four
Overall Risk of Bias
Selecon of the reported result
studies [36, 37, 39, 67]. Previous lower limb injuries (other
Measurement of the outcome than hamstrings injuries) were unreported in nine studies
Missing outcome data
Deviaons from intended intervenons [24, 36, 37, 39, 61–64, 67]. One hundred and thirty-two
Randomizaon process
participants (18.1%) presented previous hamstrings injuries
0 10 20 30 40 50 60 70 80 90 100
and another seven participants (~ 1%) had previous anterior
Low risk Some concerns High risk
cruciate ligament reconstruction using hamstrings autografts
(further information in the ESM).
c)
3.3.4 Injury Classification and Diagnosis
Studies only included participants with acute hamstrings

injuries and adopted a wide range of classification systems.
Two studies did not report the type of injury and classifi-
cation system, but a complete disruption or avulsion were
excluded [38, 67]. Participants were diagnosed within
2–10 days post-injury. One study did not report the timeline
of diagnosis [37], but it can be assumed that examination
Legend: low risk of bias; some concerns; high risk of bias (randomized trials) or serious risk of
took place within 48 h, as the interventions started within
bias (non-randomized trials); critical risk of bias (exclusive of non-randomized trials).
24–48 h after injury. Criteria and methods to determine
acute hamstrings injury varied substantially across studies
Fig. 2 a Risk of bias in randomized trials (study-level assessment);
and the criteria were unclear in two studies [36, 64]. When
b percentage distribution of risk of bias in randomized trials (study-
level assessment); and c risk of bias in non-randomized trials (study- MRI was used to confirm the diagnostic findings [36, 37,
level assessment) 41, 61, 62, 64, 66, 67], it was performed within 2–10 days
[36, 67] after the acute injury (information unreported in
one study [37]). Two studies used ultrasound in addition to
3.3.2 Participant Demographics MRI [36, 41], four studies only used ultrasound performed
within 2–7 days of injury onset [38, 63, 65], and two studies
We present here a summary of participant characteristics used no imaging [24, 39]. Detailed accounts are presented
and further information is available in the ESM. Across in the ESM.
the 14 studies, 730 participants were included, with sam- The biceps femoris (even if the injured long or short
ple sizes that ranged from n = 24–90 [39, 64]. Participants’ head was not always reported) represented 61.8–87.5% [39,
age ranged from 14 to 49 years [24, 63], with 14–49 years 41], the semitendinosus 6.9–21.7% [37, 67], and the semi-
[24] and 22–31 years [36] being the widest and narrowest membranosus 7.0–26.5% [41, 62] of all injuries. In the two
ranges, respectively. Five studies did not provide the age studies that classified sprinting versus stretching-type inju-
range [38–40, 65, 66] and two studies only provided the ries and reported the specific muscles injured, the biceps
average age without a standard deviation [37, 41]. Regarding femoris long head and the semitendinosus corresponded to
Table 1 Participant characteristics (mean ± standard deviation unless otherwise stated)
Study (year) Sample size Age and sex Previous injuries Sports and competitive level
Askling et al. (2013) [61] Initial sample: n = 75 Global: NR Hamstrings Soccer, mainly (unreported percent-
Dropouts: none L-protocol: 25 ± 5 years (median: 24, None in the same leg in the previous age) from the two highest divisions
range: 16–37) 6 months in Sweden. Elite vs non-elite (unclear
C-protocol: 25 ± 6 years (median: 25, Lower limb (non-hamstring) if this refers to the division): n = 67
range: 15–37) NR (89.3%) vs n = 8 (10.7%)
Male (n = 69, 92.0%) and female
(n = 6, 8.0%) In each group: 8.0%
female, 92.0% male
Askling et al. (2014) [62] Initial sample: n = 56 Global: NR Hamstrings Track and field (n = 46 sprinters and
Dropouts: none L-protocol: 21 ± 4 years (median: 19, None in the same leg in the previous n = 10 jumpers). Ranked among the
range: 15–29) 6 months top 20 in each discipline indoors and/
C-protocol: 19 ± 3 years (median: 18, Lower limb (non-hamstring) or outdoors
range: 15–29) NR
Male (n = 38, 67.9%) and female
(n = 18, 32.1%). In each group:
Conservative Interventions After Acute Hamstrings Injuries
32.0% female, 68.0% male

Bezuglov et al. (2019) [36] Initial sample: n = 40 Global: 27 ± 3.3 years (range: 22–31) Hamstrings Soccer: Russia Football Premier
Dropouts: none PRP: NR NR League and Russian Football
Placebo: NR Lower limb (non-hamstring) National League
Male individuals NR
Bradley et al. (2020) [37] Initial sample: n = 69 Global: NR Hamstrings Single American football team from
Dropouts: NR PRP group: 28.8 years (SD or range: NR the National Football League
NR) Lower limb (non-hamstring)
Non-PRP group: 25.7 years (SD or NR
range: NR)
Only male individuals
Guillodo et al. (2015) [41] Initial sample: n = 34 Global: NR Hamstrings Running (n = 2), basketball (n = 2),
Dropouts: NR PRP group: 26.3 ± 3.7 years (range: None in the same leg in the previous soccer (n = 27), handball (n = 1), Thai
NR) 12 months boxing (n = 1), weightlifting (n = 1)
Non-PRP group: 28.8 ± 7.4 years Lower limb (non-hamstring) Non-league (n = 1), district (n = 6),
(range: NR) Participants were excluded if present- regional (n = 18), national (n = 5),
Only male ing a history of direct impact at the international (n = 4)
site of injury
Hamid et al. (2014) [63] Initial sample: n = 28 Global median and IQR: 21.00, 8.50 Hamstrings Track and field (n = 12), soccer (n = 9),
Dropouts: n = 4 (n = 2 in each group) (range: 17–49) Not directly reported, but previous other (n = 7, hockey, netball, basket-
PRP: 20.00, 6.50 hamstrings injury was included as ball, rugby, tennis, shot put)
Non-PRP: 21.00, 8.50 a covariate National level (n = 15), state level
Male (n = 24, 85.7%). Female (n = 4, Lower limb (non-hamstrings) (n = 3), club level (n = 2), school level
14.3%) NR (n = 8)
621
Table 1 (continued)
622
Hamilton et al. (2015) [64] Initial sample: n = 90 Global: NR Hamstrings Athletics (n = 4), basketball (n = 2),
Dropouts: n = 5 lost to primary out- PRP: 26.6 ± 5.9 years (median 26.3, Supposedly, it was an exclusion decathlon (n = 1), soccer (n = 66),
come analysis; n = 4 lost at 2-month range: 21.2–31.4) criterion, but the authors report futsal (n = 8), handball (n = 3),
follow-up; n = 7 lost at 6-month PPP: 25.6 ± 5.8 years (median 24.9, previous hamstrings injuries in all hockey (n = 2), physical coach foot-
follow-up range: 22.1–29.3) groups: PRP (n = 19, 63.3%), PPP ball (n = 1), squash (n = 1), volleyball
No injection: 25.5 ± 5.7 years (n = 15, 50.0%), and non-injection (n = 1), weightlifting and bodybuild-
(median 24.3, range: 20.7–29.4) (n = 15, 50.0%) ing (n = 1)
Only male Lower limb (non-hamstrings) Professional athletes (n = 87), “com-
NR petitive” athletes (n = 3)
Hickey et al. (2020) [18] Initial sample: n = 43 Global: NR Hamstrings Australian rules football (n = 32), other
Dropouts: none Pain-free group: 27.4 ± 5.2 years. Pain-free: n = 16 (72.7%) had a previ- (n = 11). Competitive level: NR
Range: NR ous hamstrings injury
Pain-threshold: 24.9 ± 5.3 years. Pain-threshold: n = 14 (66.7%) had a
Range: NR previous hamstrings injury
Only male Lower limb (non-hamstrings)
None with other causes of posterior
thigh pain (e.g., hamstrings tendi-
nopathy, low back pain)
Malliaropoulos et al. (2004) [65] Initial sample: n = 80 Global: 20.5 ± unreported years. Hamstrings Presumably, track and field (as this
Dropouts: NR Range: NR None Federation provided the ethics
One daily session: 20.6 ± 3.7 years. Lower limb (non-hamstring) approval). Competitive level: NR
Range: NR Free medical history for hamstrings,
Four daily sessions: 20.3 ± 3.3 years. lumbar spine, or lower-extremity
Range: NR injuries
Male (n = 52, 65.0%). Female (n = 28,
35.0%)
Medeiros et al. (2020) [39] Initial sample: n = 24 Global: NR Hamstrings Soccer (n = 14), futsal (n = 5), Ameri-
Dropouts: n = 2 (n = 1 per group) LLLT: 30.4 ± 7.1 years. Range: NR NR can football (n = 2), track and field
Placebo: 28.0 ± 7.4 years. Range: NR Lower limb (non-hamstrings) (n = 2), rugby (n = 1) Amateur
Only male NR
Mendiguchia et al. (2017) [40] Initial sample: n = 54 Global: NR Hamstrings Semiprofessional soccer
Dropouts: n = 6 Individualized: 24.0 ± 4.4 years. None in the same leg in the previous
Range: NR 6 months
General: 22.9 ± 6.0 years. Range: NR Lower limb (non-hamstrings)
Only male None who had experienced extrinsic
trauma to the posterior thigh or
chronic hip, knee, leg, ankle, foot,
or lumbopelvic injuries
J. Afonso et al.
Table 1 (continued)
Reurink et al. (2015) [66] Initial sample: n = 80 Global: NR Hamstrings Soccer (n = 57), field hockey (n = 12),
Dropouts: none for primary outcome PRP: 28 ± 7 years. Range: NR PRP: n = 27 (65.9%). Ipsilateral: track and field (n = 4), American
analysis. n = 7 dropouts at 1-year Placebo: 30 ± 8 years. Range: NR n = 24 (58.5%) football (n = 3), fitness (n = 2), cricket
follow-up PRP: Male (n = 39, 95.1%) and Placebo: n = 23 (59.0%). Ipsilateral: (n = 1). [1 missing in the placebo
female (n = 2, 4.9%) n = 18 (46.2%) group]
Placebo: male (n = 37, 94.9%) and Lower limb (non-hamstring) PRP: competitive (n = 30, 73.2%) and
female (n = 2, 5.1%) Previous ipsilateral hamstrings ante- recreational (n = 11, 26.8%)
rior cruciate ligament-graft harvest- Placebo: competitive (n = 29, 74.4%)
ing (no injury but of importance): and recreational (n = 10, 25.6%)
PRP group: n = 5 (12.2%) Unclear definition of recreational and
Placebo group: n = 2 (5.1%) competitive
Sherry and Best (2004) [24] Initial sample: n = 28 Global: NR Hamstrings Multi-sports (n = 11), softball (n = 3),
Dropouts: n = 4 (n = 3 in intervention, PATS: 23.2 ± 11.1 years. Range: None with chronic hamstrings triathlon (n = 1), tennis (n = 1),
n = 1 in comparator) 15–49 years injuries nor previous hamstrings sprinter/jumper (n = 4), soccer (n = 4)
STST: 24.3 ± 12.4 years. Range: injuries in the same leg Competitive level: NR
Conservative Interventions After Acute Hamstrings Injuries
14–49 years STST: n = 2 had a previous contralat-

PATS: Male (n = 9, 69.2%) and eral hamstrings injury
female (n = 4, 30.8%) PATS: n = 1 had a previous contralat-
STST: male (n = 9, 81.8%) and eral hamstrings injury
female (n = 2, 18.2%) Lower limb (non-hamstrings)
None currently with other lower limb
injuries
Silder et al. (2013) [67] Initial sample: n = 29 Global: 24 ± 9 years. Range: Hamstrings Sports requiring high-speed running.
Dropouts: n = 4 (n = 3 in intervention, 16–46 years NR No further information provided.
n = 1 in comparator) PATS: 25.4 ± 10.2 years. Range: Lower limb (non-hamstrings) None was professional
16–46 years NR
PRES: 22.3 ± 7.9 years. Range:
16–44 years
PATS: Male (n = 11, 68.7%) and
female (n = 5, 31.3%)
PRES: male (n = 12, 90.9%) and
female (n = 1, 9.1%)
IQR interquartile range, NR non-reported, LLLT low-level laser therapy, PATS progressive agility and trunk stabilization, PPP platelet-poor plasma, PRES progressive running and eccentric
strengthening, PRP platelet-rich plasma, SD standard deviation, STST hamstrings stretching and strengthening
623
85.0–94.0% [61, 62] and 76.0–100.0% [61, 62] of sprinting- (but the information for the latter was unclear [37]), and
type injuries, respectively. The specific muscles injured were two studies focusing only on TRTS [39, 67]. Terminology
not reported in five studies [24, 40, 64–66]. varied, sometimes even within the same study (e.g., return
to play, full return to sports, return to full training, return
3.3.5 Interventions, Comparators, and Co‑interventions to full participation in the training process). Eleven studies
(78.6%) assessed reinjuries and/or new injuries, from which
Seven randomized studies compared different therapeutic six studies reported reinjury rates < 5.0% [36, 37, 39, 41, 61,
exercise-based interventions, particularly the L-protocol 62]. Details are presented in the ESM.
(focused on the lengthening phase of the hamstrings actions)
versus the C-protocol (focused on the hamstrings actions 3.3.8 Secondary Outcomes
shortening phase) [61, 62], pain-free versus pain-threshold
exercise [38], single versus four stretching daily sessions Few studies reported pre-intervention to post-intervention
[65], multimodal individualized exercise versus a general changes in strength and ROM [39, 67], bilateral asymmetries
exercise program [40], progressive agility and trunk stabili- [66, 67], and pain [36, 66]. Overall, no between-group dif-
zation (PATS) versus hamstrings stretching and strengthen- ferences could be detected for secondary outcomes. Adverse
ing (STST) [24], and PATS versus progressive running and effects (beyond new hamstrings injuries or reinjuries) were
hamstrings eccentric strengthening (PRES) [67]. A single unreported in six studies (42.9%) [24, 39, 40, 61, 62, 65]. In
randomized trial compared low-level (LLLT) to placebo the remaining studies, there were either no adverse effects
laser therapy [39]. Three randomized studies compared PRP to report or these were mostly minor and/or isolated cases.
to placebo injections [36, 66] or no injection [63], one trial A detailed account is provided in the ESM.
compared all these three conditions [64], and the two non-
randomized trials compared PRP injections to no injection 3.4 Narrative Synthesis
[37, 41]. A complete description is reported in Tables S4
and S5 of the ESM. 3.4.1 Studies Comparing Therapeutic Exercise‑Based
The intervention length was not predetermined in any Interventions
study and rehabilitation was progressive and stepwise
depending on goal-based criteria to progress (which could Therapeutic exercise-based interventions were diverse,
be assessed through TRTS and/or TRFT). Commonly, daily with only a few comparisons available for each program.
[36] and weekly [24, 61–64, 67] assessments were per- Two studies compared the L-protocols and the C-protocols
formed, or even prior to every rehabilitation session [38, [61, 62], with one study [62] also including a running and
39]. Follow-up (when existing and described) ranged from stationary cycling program. The L-protocol compared
4 to 12 months after return to full sports training [24, 41, with the C-protocol showed faster TRFT (28 ± 15 days vs
61, 62, 66, 67], but was unclear in two studies [37, 65]. All 51 ± 21 days [61]; 49 ± 26 days vs 86 ± 34 days [62]), but
studies included therapeutic exercise as intervention or co- data were compromised because of a risk of selection (rand-
intervention (the details of each intervention and compara- omization) and detection bias. All negative-MRI participants
tor, including information dosage, is shown in the ESM). were purposely allocated to the L-protocol, with implica-
tions for the recovery time: in one study [61], negative-MRI
3.3.6 Quality and Completeness of Therapeutic Exercise participants had an average TRFT of 6 days, and four of the
Program Reporting 11 soccer players recovered within 5 days of injury and did
not even perform the L-protocol. In the other study [62],
The completeness and quality of exercise and physical reha- the negative-MRI participants returned after 15 days, com-
bilitation protocols were appraised for all studies as either pared with 45 days for the other participants. Moreover, the
interventions or co-interventions (Fig. 3). Overall, only three assessors were unblinded to the intervention and the authors
studies (21.4%) were judged with a low risk of ineffective- explicitly stated that this knowledge could have influenced
ness in all seven domains [38, 39, 64]. The remaining 11 the Askling H test, which determined discharge to return to
studies (78.6%) had a high risk of ineffectiveness in two [40, sport. Therefore, the evidence from these two studies is asso-
63, 66, 67], three [24, 61, 62], four [65], five [36, 41], or six ciated with important methodological problems that could
domains [37]. A detailed analysis is provided in the ESM. have influenced the results. One reinjury (0.8%) [61] and two
reinjuries (3.6%) were registered [62] in the C-protocol, and
3.3.7 Primary Outcomes none in the L-protocol.
Two studies analyzed the PATS [24, 67], with one com-
Eleven studies (78.6%) assessed TRFT [24, 36, 38, 40, 41, paring PATS to PRES (based on running and eccentric
61–66], with one study assessing both TRTS and TRFT strengthening) [67]. Both intervention and comparator were
Study Patient Dosage of the Type of the exercise Risk of ineffectiveness Type and timing of Safety of the Adherence to the
selection exercise program program in Qualified supervisor outcome assessment exercise program exercise program
Askling et al. Low High Low High Low Low High
(2013) [61]
Askling et al. Low High Low High Low Low High
(2014) [62]
Bezuglov et al. Low High High High Low High High
(2019) [36]
Bradley et al. Low High High High High High High
(2020) [37]
Guillodo et al. Low High Low High High High High
(2015) [41]
Hamid et al. Low Low Low High Low Low High
(2014) [63]
Hamilton et al. Low Low Low Low Low Low Low
(2015) [64]
Hickey et al. Low Low Low Low Low Low Low
(2020) [18]
Malliaropoulos Low Low High High High Low High
et al. (2004)
[65]
Medeiros et al. Low Low Low Low Low Low Low
(2020) [39]
Mendiguchia et Low High High Low Low Low Low
al. (2017) [40]
Reurink et al. Low High Low Low Low Low High
(2015) [66]
Sherry and Best Low Low Low High High Low High
(2004) [24]
Silder et al. Low Low Low High Low Low High
(2013) [67]
Fig. 3 Risk of ineffectiveness in qualified supervisor
home based and performed daily (with only one weekly including a running-based program and the L-protocol [40],
supervised session guaranteed and poor adherence-related with no description of the general rehabilitation components
measures). No differences were detected in TRTS between or the running program specifications. There were no differ-
PATS and PRES groups, but one versus three reinjuries ences in TRFT, but there were fewer reinjuries in the indi-
(6.3 vs 23.1%) were registered in the PATS and PRES vidualized group versus the general rehabilitation group
groups, respectively. The other study [24] compared PATS (n = 1, 4.0% vs n = 6, 25.0%). Finally, one study applied a
to STST (based on hamstrings stretching and concentric, strength-based exercise program (combined with running)
eccentric, and isometric strengthening), again in a mostly performed at different pain-threshold intensities (0 and ≤ 4
home-based setting with very poor control of adherence. out of a ten-point scale) [38]. No differences were found in
The PATS group had a shorter TRFT (22.2 ± 8.3 days ver- TRFT between groups and two reinjuries were registered
sus 37.4 ± 27.6 days), but a closer analysis raised concerns, in each group (9.1% and 9.5% in the pain-free and pain-
as 72.0% of participants in the PATS groups had a grade 2 threshold groups, respectively).
injury versus only 36.0% of participants in the STST group. In summary, few studies have assessed each exercise
These baseline differences suggest problems with the ran- program type (e.g., PATS and L-protocol), relevant heter-
domization process. Furthermore, the authors planned an ogeneity was observed regarding their study populations,
intention-to-treat analysis, but instead performed a per-pro- diagnosis and criteria for progressing in rehabilitation, and
tocol analysis, suggestive of bias due to selective reporting. methodological problems associated with these studies were
This study also presented an outlier value of reinjuries in the detected. Currently, the available evidence does not allow
STST group (n = 7, 63.6%) versus a single reinjury (7.7%) us to confidently assume or suggest a superiority of one
in the PATS group. exercise program over another in terms of TRTS/TRFT or
A single study compared one versus four daily sessions reinjuries.
of hamstrings static stretching [65]. The single daily session
group took longer to return to training than the other group 3.4.2 Studies Comparing PRP Injections to Placebo
(15.1 ± 0.8 days vs 13.3 ± 0.7 days) and, although this dif- or Control
ference was statistically significant, in absolute values there
was only a 2-day difference in recovery time. Reinjuries Two randomized studies compared PRP to placebo injec-
were not reported, and the study [65] was judged at a high tions [36, 66], one contrasted PRP with no injection [63],
risk of bias in all domains and a high risk of ineffectiveness and another compared the three conditions [64]. Because the
in several i-CONTENT domains (type of exercise program, three studies comparing PRP to placebo injections [36, 64,
qualified supervisor, type and timing of outcome assessment, 66] were very heterogeneous (regarding participants, injury
and adherence to the exercise program). diagnosis, injection contents and dosages, and co-interven-
One study compared an individualized and multifactorial tions), a quantitative pooled synthesis was not accomplished.
criteria-based algorithm to a general rehabilitation protocol Most studies applied a single PRP injection [36, 63, 64] and
one study [66] applied two injections 5–7 days apart, with bias. Overall, the evidence on PRP injections is contentious
dosages varying from 3 to 8-mL single applications [36, 63] and they may not result in a faster TRTS/TRFT or reduced
to 1-mL injections in three sites [64, 66]. Injection platelet reinjury rates than placebo injections or no injection.
count varied from unreported [63, 64, 66] to 700,000 per
1 mL [36] and activation agents varied from none [63, 64] 3.4.3 Single Study Assessing Low‑Level Laser Therapy
to 20 µL per mL of plasma [36] (or were unreported [66]).
Placebo injections also varied in content (0.9% NaCl [36], One study compared three weekly sessions of LLLT (60 s
isotonic saline solution [66], platelet-poor plasma [64]), and 30 J per site, 850-nm wavelength, and continuous fre-
quantity (1–2 [36, 64, 66]), dosage (8 mL or 3 × 1 mL [36, quency) to placebo LLLT (with the device turned off), both
64, 66]), activating agents (unreported [36, 66] and no agent supplemented by a rehabilitation exercise program focused
used [64]), and number of injection sites (single to three on hamstrings strength, trunk stabilization, and agility [39].
locations [36, 64, 66]). There were no differences between the groups in TRTS,
A shorter TRFT was observed in the PRP group compared TRFT was not assessed, and no reinjuries were reported.
with the placebo group (11.4 ± 1.2 days vs 21.3 ± 2.7 days) Lack of imaging techniques (such as MRI or ultrasound) to
in one study [36] and no reinjuries were registered; informa- confirm diagnosis may have resulted in the inclusion of low-
tion was insufficient to assess baseline differences between grade or unequal injuries, potentially influencing recovery
groups. Another study showed a faster TRFT in the PRP time. Conversely, the study [39] was judged at low risk of
group than in the platelet-poor plasma group (median 21 bias in all domains and at low risk of ineffectiveness in all
vs 27 days and interquartile range 16–33 vs 19–33) [64]. i-CONTENT domains.
Both groups sustained two reinjuries (6.7% and 8.0%) at
the 2-month follow-up, with an additional reinjury in the 3.5 Certainty of Evidence
platelet-poor plasma group at the 6-month follow-up. Last,
there were no differences in TRFT between PRP and placebo Three studies reported TRTS [37, 39, 67], 11 studies referred
injections in a third study [66]. In this study, at the 1-year to TRFT [24, 36, 38, 40, 41, 61–66], and 12 studies identi-
follow-up, 10 and 11 players (27.0% and 30.0%), respec- fied reinjuries or new injuries [24, 36–41, 61, 62, 64, 66, 67].
tively, in the PRP and placebo groups sustained a reinjury. The reduced number of studies for each comparison (one
One study reported faster TRFT (26.7 ± 7.0 vs to three studies), the high risk and critical risk of bias, the
42.5 ± 20.6 days) when comparing PRP to no injection serious inconsistency, and the high imprecision resulted in a
groups [63], but there were important baseline differences very low certainty of evidence for all outcomes and compari-
between the groups (particularly the fact that 42.9 vs 78.6% sons analyzed. Therefore, no current recommendation can be
of participants had reinjuries and 57.1 vs 78.6% of them provided based on existing evidence (Table 2 synthesizes the
had biceps femoris injuries, respectively). A study with main findings, including the GRADE judgments).
three groups (PRP, placebo, no injection) showed a faster
TRFT with PRP injection versus placebo (platelet-poor
plasma) [64]; however, the same study reported no differ- 4 Discussion
ences between PRP and the group taking no injections. This
study [64] also reported two reinjuries in each group at the The high incidence of hamstrings injuries and their associ-
2-month follow-up (with an additional reinjury in the no ated financial costs and performance losses [14–17] require
injection group at the 6-month follow-up). effective rehabilitation protocols to facilitate return to sport
The two non-randomized cohort studies compared PRP and reduce the reinjury risk. We systematically reviewed 14
to no injection [37, 41]. One study [37] applied one to three studies (n = 730) that assessed the impact of different con-
leukocyte-poor PRP injections and both groups engaged in servative rehabilitation strategies to treat acute hamstrings
poorly defined physiotherapy and physical therapy protocols. injuries on the TRTS/TRFT and reinjuries.
There were no differences in the TRTS and in the number of
days off, and each group sustained one reinjury. The authors 4.1 What Does the Current Literature Tell Us?
mentioned lost games, but this may have been affected by
match scheduling or coaching decisions. The other non-ran- Based on the existing evidence, it is unclear which con-
domized cohort trial [41] compared a single PRP injection servative approaches are more effective in allowing a faster
to no injection, with both groups engaging in unclear physi- TRTS/TRFT or reducing the reinjury risk. Our results sup-
otherapy protocols and exercise programs with undisclosed port the findings of a previous systematic review [33] where
dosage. There were no differences in TRFT and there were the authors did not find any effect of the PRP interventions
no reinjuries to report. Both non-randomized studies were and reported limited evidence for exercise-based interven-
judged at high risk of ineffectiveness and at critical risk of tions. In our systematic review, we included six new studies
Table 2 Synthesis and certainty of evidence regarding the effects of conservative interventions on time to return to sport, time to return to full
training, and reinjuries
Outcome Study (year) Intervention Comparator Estimate RoB i-Content Grade
MD/RR (95% CI)
Time to return to sport Silder et al. (2013) [67] PATS (n = 13) PRES (n = 12) 3.60 (− 3.94 to 11.14) Very low certaintya,b,c
(3 studies) 25.2 ± 6.3 days 28.8 ± 11.4 days
Bradley et al. (2020) PRP (n = 30) No injection (n = 39) 3.20 (− 6.68 to 13.08) Very low certaintya,b,c
[37] 22.5 ± 20.1 days 25.7 ± 20.6 days
Medeiros et al. (2020) LLLT (n = 11) Placebo LLLT (n = 11) 0.70 (− 9.08 to 10.48) Very low certaintya,c
[39] 23.1 ± 9.1 days 23.8 ± 12.6 days
(12–41 days) (11–45 days)
Time to return to full Askling et al. (2013) L-protocol (n = 37) C-protocol (n = 38) 23.00 (14.58 to 31.42) Very low certaintyb,d,e
training [61] 28.0 ± 15.0 days 51.0 ± 21.0 days
(11 studies) (8–58 days) (12–94 days)
Askling et al. (2014) L-protocol (n = 28) C-protocol (n = 28) 37.00 (20.78 to 53.22)
[62] 49.0 ± 26.0 days 86.0 ± 34.0 days
(18–107 days) (26–140 days)
Hickey et al. (2020) [18] Pain-free exercise Pain-threshold exercise 2.00 (− 4.47 to 8.47) Very low certaintya,c
(n = 22) (n = 21)
15 daysf (95% CI 13 17 daysf (95% CI 11 to 24)
to 17)
Malliaropoulos et al. 4 × /day stretching 1 × /day stretching (n = 40) − 1.80 (− 2.13 to − 1.47) Very low certaintya,b,e
(2004) [65] (n = 40) 13.3 ± 0.7
15.1 ± 0.8
Mendiguchia et al. Individualized, multifac- General rehabilitation, − 2.20 (− 7.98 to 3.58) Very low certaintya,b,c
(2017) [40] torial criteria-based running-based program,
algorithm (n = 24) and L-protocol (n = 24)
25.5 ± 7.8 days 23.3 ± 11.7 days
Sherry and Best (2004) PATS (n = 13) STST (n = 11) 15.20 (− 1.45 to 31.85) Very low certaintya,b,c
[24] 22.2 ± 8.3 days 37.4 ± 27.6 days
(10–35 days) (10–95 days)
Bezuglov et al. (2019) PRP (n = 20) Placebo (n = 20) 9.90 (8.56 to 11.24) Very low certaintyc,h,i
[36] 11.4 ± 1.2 days 21.3 ± 2.7 days
Reurink et al. (2015) PRP (n = 41) Placebo (n = 39) 0.00 (− 8.22 to 8.22)
[66] 42 daysf (IQR 30–58) 42 daysf (IQR 37–56)
(19–105 days)g (14–149 days)
Hamilton et al. (2015) PRP (n = 28) Placebo (PPP) (n = 30) 6.00 (− 0.38 to 12.38)
Guillodo et al. (2015) PRP (n = 15) No injection (n = 19) 1.90 (− 7.77 to 11.57) Very low certaintyb,c,i
[41] 50.9 ± 10.7 days 52.8 ± 15.7 days
Hamid et al. (2014) [63] PRP (n = 12) No injection (n = 12) 15.80 (2.77 to 28.83)
26.7 ± 7.0 days 42.5 ± 20.6 days
Hamilton et al. (2015) PRP (n = 28) No injection (n = 27) 4.00 (− 1.93 to 9.93)
New hamstrings inju- Askling et al. (2013) L-protocol (n = 37) C-protocol (n = 38) 0.34 (0.01 to 8.14) Very low certaintyb,c
ries or reinjuries [61] 0/37 (0.0%) 1/38 (2.6%)
(12 studies)
Askling et al. (2014) L-protocol (n = 28) C-protocol (n = 28) 0.20 (0.01 to 3.99)
[62] 0/28 (0.0%) 2/28 (7.1%)
Hickey et al. (2020) [18] Pain-free exercise Pain-threshold exercise 0.96 (0.15 to 6.17) Very low certaintya,c
(n = 22) (n = 21)
2/22 (9.1%) 2/21 (9.5%)
Table 2 (continued)
Outcome Study (year) Intervention Comparator Estimate RoB i-Content Grade
MD/RR (95% CI)
Mendiguchia et al. Individualized, multifac- General rehabilitation, 0.17 (0.02 to 1.28) Very low certaintya,b,c
(2017) [40] torial criteria-based running-based program,
algorithm (n = 24) and L-protocol (n = 24)
1/24 (4.2%) 6/24 (25.0%)
Sherry and Best (2004) PATS (n = 13) STST (n = 11) 0.12 (0.02 to 0.84) Very low certaintya,b,e
[24] 1/13 (7.7%) 7/11 (63.6%)
Silder et al. (2013) [67] PATS (n = 13) PRES (n = 12) 0.31 (0.04 to 2.57) Very low certaintya,b,c
1/13 (7.7%) 3/12 (25.0%)
Bezuglov et al. (2019) PRP (n = 20) Placebo (n = 20) 1.00 (0.02 to 48.01) Very low certaintyc,d,h
[36] 0/20 (0.0%) 0/20 (0.0%)
Reurink et al. (2015) PRP (n = 37) Placebo (n = 36) 0.89 (0.43 to 1.82)
[66] 10/37 (27.0%) 11/36 (30.6%)
Hamilton et al. (2015) PRP (n = 26) Placebo [PPP] (n = 28) 0.72 (0.13 to 3.96)
[64] 2/26 (7.7%) 3/28 (10.7%)
Bradley et al. (2020) PRP (n = 30) No injection (n = 39) 1.30 (0.08 to 19.95) Very low certaintyb.c,d
[37] 1/30 (3.3%) 1/39 (2.6%)
Guillodo et al. (2015) PRP (n = 15) No injection (n = 19) 1.25 (0.03 to 59.60)
[41] 0/15 (0.0%) 0/19 (0.0%)
Hamilton et al. (2015) PRP (n = 26) No injection (n = 29) 0.74 (0.13 to 4.11)
[64] 2/26 (7.7%) 3/29 (10.3%)
Medeiros et al. (2020) LLLT (n = 11) Placebo LLLT (n = 11) 1.00 (0.02 to 46.41) Very low certaintya,c
[39] 0/11 (0.0%) 0/11 (0.0%)
CI confidence interval, IQR interquartile range, LLLT low-level laser therapy, MD mean difference, PATS progressive agility and trunk stabiliza-
tion, PPP platelet-poor plasma, PRES progressive running and eccentric strengthening, PRP platelet-rich plasma, RoB risk of bias, RR risk ratio
for sustaining a reinjury or new injury, STST hamstrings stretching and strengthening
a
Automatically judged at very low certainty because of a single study being available for this comparison
b
Downgraded by two levels because of a high risk of bias in all the studies and/or due to critical risk of bias
c
Downgraded by two levels if there was also no clear direction of the effects
d
Downgraded by one level because of clinical and/or statistical heterogeneity
e
Downgraded by one level because of < 800 participants for the comparison
f
Median value
g
One participant still had not returned at day 182 and this player was censored from the analysis
h
Downgraded by one level because of a high risk of bias in more than half of the studies
i
Downgraded by two levels because of clinical and statistical heterogeneity
i-CONTENT: first row, from left to right: risk of ineffectiveness in patient selection, dosage of the exercise program, type of the exercise pro-
gram, and qualified supervisor. Second row, from left to right: risk of ineffectiveness in type and timing of outcome assessment, safety of the
exercise program, and adherence to the exercise program. indicates a low risk of ineffectiveness, indicates a high risk of ineffectiveness
Risk of bias: indicates a low risk of bias, indicates a high risk of bias, indicates a critical risk of bias
[36–41] and excluded two studies that did not meet the eli- injury location, especially if affecting the intramuscular
gibility criteria for population [56] and outcomes [58]. In tendon, may change the length of recovery [29, 30, 79], the
contrast to the previous systematic review [33], we consid- evidence is still preliminary and it is unclear how conserva-
ered that the reduced number of studies for each comparison tive interventions could be adapted.
and their clinical heterogeneity advised against performing a Very recent clinical practice guidelines [80] maintained
meta-analysis; we thus avoided pooling data from different that moderate-level evidence supports faster TRTS/TRFT
studies and reported the between-group differences for each with interventions focusing on eccentric training, added to
study and described them in a narrative manner. stretching, general strengthening, stabilization, and pro-
When comparing different exercise-based interventions, gressive running programs. Likewise, the guidelines [80]
it is unclear which exercise modalities are more effective reported moderate-level evidence in support of PATS in
(although there is some support for eccentric training) and addition to stretching, general strengthening, and “func-
even less is known concerning dose–response relationships, tional” exercises to reduce reinjury risk after an acute ham-
which aligns with the main findings of the previous review strings injury. The results of our systematic review do not
[33]. Also aligned with this review [33], the effectiveness of fully support either of these claims and, with the scarce and
PRPs and placebo injections remains unclear. Independent limited available data, no recommendations can be made on
of participants’ age, sex, sport background, or injury char- which is the best rehabilitation strategy for acute hamstrings
acteristics (e.g., severity, anatomical location, and etiology), injuries.
no recommendations on the best rehabilitation strategy can Notwithstanding the limitations discussed above and
be provided based on current knowledge for TRTS/TRFT the very low certainty of evidence, some clinical findings
and reinjuries. may temporarily guide clinical practice: (1) adding eccen-
The literature has devoted considerable attention to the tric lengthening exercises seems superior to conventional
incidence of hamstrings injuries and reinjuries [3, 4, 7, 12] stretching and strengthening exercises for returning sooner
as well as to their financial and performance-related costs to full training [61, 62], but these findings are from a single
[14–17]. The literature has also extensively focused on the research group and require confirmation by replication stud-
primary prevention of hamstrings injuries [5, 71–76], but ies; (2) no intervention was superior in reducing the rein-
their number continues to grow [2, 77], and thus we assumed jury risk, thus no intervention should be prioritized over
that many studies would be found focusing on rehabilitation any other for purposes of secondary prevention; and (3) PRP
strategies. However, only 14 studies fulfilled eligibility crite- did not consistently allow a faster TRFT or reduce the rein-
ria (12 randomized and two non-randomized with 730 par- jury risk and therefore seems to add no value in accelerating
ticipants), with a maximum of three studies per comparison. recovery from hamstrings injuries.
Most randomized studies (75.0%) were judged at high risk of
bias, both non-randomized studies (100.0%) were judged at 4.2 Are We Comparing the Same Things?
critical risk (i.e., above serious risk), and 78.6% of the exer-
cise programs were judged at high risk of ineffectiveness. Our systematic review highlighted extensive heterogeneity
These findings corroborate the poor reporting of exercise in intervention and comparators (including mode, dosage
interventions in the context of hamstrings injury rehabilita- and supervision of the exercise programs, and content and
tion that was recently highlighted by a scoping review [78]. dosages of PRP and placebo injections) and outcome reg-
The GRADE judgments denoted very low confidence in the istration. Even within a single group of the same study, the
existing published data. ranges of TRTS/TRFT exhibited extreme interindividual
These findings emphasize it is not possible to deter- variation, which may be partially related to interindividual
mine which are the most effective conservative interven- variations in hamstrings anatomy and physiology [31], but
tions for recovery after acute hamstrings injuries. Studies also to age. Indeed, the age range within a single study was
have focused mostly on exercise-based interventions and on as wide as 14–49 years [24]. As older players are at a higher
comparing PRP to placebo or no injection (with exercise as risk of injury than their younger counterparts [81, 82], inves-
a co-intervention). The benefits of adding PRP to exercise tigating and comparing samples with large age variations
interventions remain unclear (conflicting findings) and the may affect the results. Moreover, because women comprise
most appropriate exercise modalities and dosages are not only a minority of the studied samples (~ 10%), it is currently
yet known. Although rehabilitation should be customized to unclear if there are relevant sex-related differences that can
individual needs, it is unknown whether the most appropri- affect the recovery process and/or the risk of reinjury.
ate conservative interventions may vary depending on injury The competitive level was not reported uniformly
mechanism, injury classification and severity, type of sport, across studies, a problem that creates difficulty performing
competitive level, sex, age, or other individual character- between-study comparisons and to which a recent solution
istics. Although it has been hypothesized that the specific has been proposed [83]. Still, it could be easily identified
that the competitive level in the included studies ranged from sports participation [89, 90], further research on hamstrings
amateur practitioners to professional athletes. Comparing injuries rehabilitation focusing on women is needed. We fur-
rehabilitation processes between very distinct competitive ther identified several features that require more detailed
levels is tricky, as there are other factors that can come into reporting in future studies: (1) explicitly report previous
play, such as higher motivation from professional players or hamstrings injuries or their absence, as well as surgeries
their easier access to high-quality resources and rehabilita- involving hamstrings autografts; (2) different hamstrings
tion. The pressure on an early return to competition may be muscles may be injured differently (mechanisms, conse-
superior at the highest levels, considering the performance quences, recovery) and proper reporting of which muscles
and financial stakes. Of note, nearly 50% of research on were injured is advised; (3) provide means and standard
the topic is focused on soccer, followed by track and field deviations (or medians and interquartile ranges, when appro-
(~ 22%) and American football (~ 10%), with only scarce priate) for participants’ age and preferably also the range;
information on return to sports and reinjury risk being avail- (4) use the i-CONTENT tool [52] to more completely report
able for other sports. on the exercise-based interventions; (5) openly monitor and
With regard to secondary outcomes, nearly nothing is report adverse effects; and (vi) assess pre-intervention to
known about how effective these interventions are for other post-intervention changes in secondary outcomes (such as
relevant variables such as strength, ROM, bilateral and strength and ROM), providing measures of assessment reli-
anteroposterior asymmetries, balance, power, speed, endur- ability and reporting the smallest worthwhile changes.
ance, and adverse effects. Even exercise-based interventions Future research should strive to reduce the risk of bias by
largely neglected these outcomes or assessed them as solely following simple procedures: (1) pre-register or pre-publish
post-intervention values. Recent clinical practice guidelines the research protocols; (2) describe how randomization was
further underline the need to evaluate the ability to walk, achieved, explicitly state whether allocation sequence was
run, and sprint [80]. concealed and attempt to guarantee balanced baseline val-
The included studies also varied considerably with ues for the most relevant variables (e.g., using minimization
respect to injury classification systems, diagnostic and inclu- techniques when randomizing the participants); (3) attempt
sion criteria, criteria for returning to sport, and assessments to equate the intervention and comparator dosages; (4)
timing, contributing to clinical heterogeneity and making ensure proper supervision and monitoring of adherence and/
between-study comparisons very difficult, as had been pre- or compliance; in largely home-based interventions, strate-
viously pinpointed elsewhere [84]. The sheer diversity of gies such as regular texting, daily logs, and video calls may
classification systems denotes a lack of agreement and con- help to improve compliance; (5) blind the outcome assessors
sistency across studies and may contribute to increasing the to eliminate the risk of detection bias; and (6) provide data
heterogeneity of findings, which is further exacerbated by on the inter-assessor reliability of outcome measurement
mixing grade I and II injuries and MRI-positive with MRI- or, when applicable, measures of error for the used devices
negative participants. The absence of imaging in some stud- (e.g., coefficient of variation, typical error of measures).
ies, although justified by the authors, cannot completely rule Research on conservative intervention to treat acute ham-
out avulsion or complete rupture, which was an exclusion strings injuries in athletes has been continuing at a slow
criterion of our review. pace. There is a clear need for more homogeneous studies
Different sports have specific physical demands and may to allow comparisons and achieve a valid pooled estimate of
require different rehabilitation protocols. Perhaps the time TRTS/TRFT and reinjuries. To reliably compare the rein-
has come for a complete and more definitive international jury risk across different conservative interventions, studies
consensus on the classification of hamstrings injuries, diag- with a very large sample size are needed, but these studies
nostic criteria, and criteria for return to full training. Finally, are not easy to conduct in real-world club-based sports. We
more than half of the studies mixed participants with and need combined efforts from several clubs implementing the
without previous hamstring injuries, which represents a rel- same conservative strategies to increase the comparability
evant confounder for the results of the interventions, as the and statistical power before clinical practice guidelines can
history of a hamstrings injury greatly increases the risk of be reliably established. Because we are performing a living
having a reinjury [75, 82, 85, 86]. systematic review, future updates will reveal changes to the
status quo.
4.3 Room for Improvement: Priorities for Future
Research 4.4 Limitations
Although men are up to 60.0% more likely to sustain ham- The inclusion of non-randomized trials may be interpreted
strings injuries than women [3, 87, 88], they comprise 90% as a weakness of our systematic review, but these trials
of the research sample. With the rapid increase in female were analyzed separately from randomized trials and so we
provide a more complete picture without mixing the find- included in the review, as none of those studies had been
ings from two fundamentally different study designs. Fur- excluded based on that criterion; (2) the remaining changes
thermore, randomized trials are not always feasible, espe- were properly identified in the methods (e.g., absence of
cially with high-level athletes. As previously mentioned, quantitative synthesis).
some studies lacked imaging to confirm diagnosis, and thus
complete rupture or avulsion could not be completely ruled
Supplementary Information The online version contains supplemen-
out. Despite planned at the protocol stage, we opted to not tary material available at https://doi.org/10.1007/s40279-022-01783-z.
perform a meta-analysis or network meta-analysis because
of the wide clinical heterogeneity in populations, interven- Acknowledgements José Afonso, Jesús Olivares-Jabalera, Ricardo
tions, comparators, and other methodological features of the Fernandes, Filipe Manuel Clemente, Sílvia Rocha-Rodrigues, João
Gustavo Claudino, Rodrigo Ramirez-Campillo, Cristina Valente,
studies (including how the outcomes were assessed), which Renato Andrade, and João Espregueira-Mendes thank Professors Gus-
precluded us from confidently pooling the data from dif- taaf Reurink, Jack Hickey, and Noel Pollock for their role as external
ferent studies and is coherent with Cochrane’s guidelines experts: they verified our eligibility criteria and the list of included
[45]. Still, to provide useful information, we calculated the studies, providing additional suggestions of potentially relevant studies.
between-group mean differences and relative risks for each
study within each outcome and provide a narrative summary Declarations
that is supported with a best evidence synthesis using the Funding There was no financial or non-financial support for this
GRADE framework. review. There were no funders or sponsors in the review.
Conflicts of Interest/Competing Interests José Afonso, Jesús Oli-

5 Conclusions vares‑Jabalera, Ricardo Fernandes, Filipe Manuel Clemente, Sílvia
Rocha‑Rodrigues, João Gustavo Claudino, Rodrigo Ramirez‑Campil-
lo, Cristina Valente, Renato Andrade and João Espregueira‑Mendes
No single intervention or combination of interventions have no competing interests.
proved superior in achieving a faster return to sports or
reducing the reinjury risk. Exercise-based interventions Ethics Approval Not applicable.
seem comparable and no specific strategy needs to be pri- Consent to Participate Not applicable.
oritized when rehabilitating athletes with acute hamstrings
injuries. Only eccentric lengthening exercises showed lim- Consent for Publication Not applicable.
ited evidence (very low certainty) in allowing a shorter
Availability of Data and Material The data used to inform this review
TRFT. Platelet-rich plasma did not consistently reduce the are fully disclosed either in the manuscript or in its Electronic Sup-
TRFT or the reinjury risk and, at the moment, has no value plementary Material.
in clinical practice. The use of passive interventions (LLLT)
also did not yield any clinical value when added to exercise- Code Availability Not applicable.
based rehabilitation. The currently available literature is lim- Authors’ Contributions JA and RA were responsible for the initial
ited owing to the risk of bias, the high risk of ineffectiveness drafting of the article, which was reviewed and edited by all authors.
of exercise protocols (especially due to poor or uncontrolled All authors were involved in the conception, design, and interpreta-
adherence, absence of proper supervision, and incomplete tion of data. All authors read and reviewed the manuscript critically
for important intellectual content and approved the final version to be
information to assess dosage of the prescribed exercise pro- submitted. Specific contributions pertaining data selection, extraction,
gram), and the lack of comparability across existing studies. and analysis are detailed in the methods section. All authors read and
Future studies should strive to overcome these limitations approved the final manuscript.
and provide a pool of evidence that allows meaningful com-
parisons and stronger clinical directions to be achieved. Our
living review will be attentive and update the knowledge References
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Authors and Affiliations
José Afonso1 · Jesús Olivares‑Jabalera2,3 · Ricardo J. Fernandes1,4 · Filipe Manuel Clemente5,6 ·

Sílvia Rocha‑Rodrigues5,7,16 · João Gustavo Claudino8,9 · Rodrigo Ramirez‑Campillo10 · Cristina Valente11,12 ·
Renato Andrade4,11,12 · João Espregueira‑Mendes11,12,13,14,15
6
* José Afonso Delegação da Covilhã, Instituto de Telecomunicações,
jneves@fade.up.pt Covilhã, Portugal
7
* Renato Andrade Tumor & Microenvironment Interactions Group,
randrade@espregueira.com INEB-Institute of Biomedical Engineering, i3S-Instituto de
Investigação e Inovação em Saúde, Universidade do Porto,
Jesús Olivares‑Jabalera
Porto, Portugal
jesusyolivares@gmail.com
8
Group of Research, Innovation and Technology
Ricardo J. Fernandes
Applied to Sport (GSporTech), Multi-user Laboratory
ricfer@fade.up.pt
of the Department of Physical Education (MultiLab
Filipe Manuel Clemente of the DPE), Department of Physical Education, Center
Filipeclemente@esdl.Ipvc.pt for Health Sciences, Federal University of Piauí,
Teresina, Piauí, Brazil
Sílvia Rocha‑Rodrigues
9
silviadarocharodrigues@gmail.com Department of Physical Education, Center for Health
Sciences, Federal University of Piauí, Teresina, Piauí, Brazil
João Gustavo Claudino
10
claudinojg@ufpi.edu.br Exercise and Rehabilitation Sciences Laboratory, School
of Physical Therapy, Faculty of Rehabilitation Sciences,
Rodrigo Ramirez‑Campillo
Universidad Andres Bello, Santiago, Chile
rodrigo.ramirez@unab.cl
11
Clínica Espregueira - FIFA Medical Centre of Excellence,
Cristina Valente
Porto, Portugal
cvalente@saudeatlantica.pt
12
Dom Henrique Research Centre, Porto, Portugal
João Espregueira‑Mendes
13
espregueira@dhresearchcentre.com School of Medicine, University of Minho, Braga, Portugal
14
1 ICVS/3B’s-PT Government Associate Laboratory,
Centre of Research, Education, Innovation, and Intervention
Braga/Guimarães, Portugal
in Sport (CIFI2D), Faculty of Sport, University of Porto, R.
15
Dr. Plácido da Costa 91, 4200‑450 Porto, Portugal 3B’s Research Group Biomaterials, Biodegradables
2 and Biomimetics, Headquarters of the European Institute
Sport Research Lab, Football Science Institute, Granada,
of Excellence on Tissue Engineering and Regenerative
Spain
Medicine, University of Minho, AvePark, Parque de
3
Department of Physical and Sports Education, Sport Ciência e Tecnologia, Zona Industrial da Gandra, Barco,
and Health University Research Institute (iMUDS), 4805 017 Guimarães, Portugal
University of Granada, Granada, Spain 16
Research Center in Sports Performance, Recreation,
4
Porto Biomechanics Laboratory (LABIOMEP), University Innovation and Technology (SPRINT), Melgaço, Portugal
of Porto, Porto, Portugal
5
Escola Superior de Desporto e Lazer, Instituto Politécnico de
Viana do Castelo, Viana do Castelo, Portugal

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Sports Medicine (2023) 53:615–635

Effectiveness of Conservative Interventions After Acute Hamstrings

Accepted: 17 October 2022 / Published online: 9 January 2023

Extended author information available on the last page of the article

severe injuries [27, 28]. It has been suggested that interven-

2.2 Eligibility Criteria EMBASE, PubMed, Scopus, SPORTDiscus, and Web of

2.2.4 Outcomes 2.5 Data Collection

participants’ sex, 654 were male and 72 were female (89.6%

3.3.3 Previous Hamstrings or Lower Limb Injuries

Six studies (42.9%) included participants without any pre-

Studies only included participants with acute hamstrings

32.0% female, 68.0% male

14–49 years STST: n = 2 had a previous contralat-

Fig. 3 Risk of ineffectiveness in qualified supervisor

Conflicts of Interest/Competing Interests José Afonso, Jesús Oli-

Authors and Affiliations

José Afonso1 · Jesús Olivares‑Jabalera2,3 · Ricardo J. Fernandes1,4 · Filipe Manuel Clemente5,6 ·

You might also like

s40279-022-01783-z

Uploaded by

Copyright:

Available Formats

s40279-022-01783-z

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

s40279-022-01783-z

Uploaded by

Copyright:

Available Formats

Sports Medicine (2023) 53:615–635

Effectiveness of Conservative Interventions After Acute Hamstrings

Accepted: 17 October 2022 / Published online: 9 January 2023

Extended author information available on the last page of the article

severe injuries [27, 28]. It has been suggested that interven-

2.2 Eligibility Criteria EMBASE, PubMed, Scopus, SPORTDiscus, and Web of

2.2.4 Outcomes 2.5 Data Collection

participants’ sex, 654 were male and 72 were female (89.6%

3.3.3 Previous Hamstrings or Lower Limb Injuries

Six studies (42.9%) included participants without any pre-

Studies only included participants with acute hamstrings

32.0% female, 68.0% male

14–49 years STST: n = 2 had a previous contralat-

Fig. 3 Risk of ineffectiveness in qualified supervisor

Conflicts of Interest/Competing Interests José Afonso, Jesús Oli-

Authors and Affiliations

José Afonso1 · Jesús Olivares‑Jabalera2,3 · Ricardo J. Fernandes1,4 · Filipe Manuel Clemente5,6 ·

You might also like

2.2 Eligibility Criteria EMBASE, PubMed, Scopus, SPORTDiscus, and Web of

2.2.4 Outcomes 2.5 Data Collection

3.3.3 Previous Hamstrings or Lower Limb Injuries