Evidence-Based

Management and Factors

Associated With Return to
Play After Acute Hamstring
Injury in Athletes: A
Systematic Review
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Abstract
Background:

Considering the lengthy recovery and high recurrence risk

after a hamstring injury, effective rehabilitation and
accurate prognosis are fundamental to timely and safe
return to play (RTP) for athletes.

Purpose:
To analyze methods of rehabilitation for acute proximal
and muscular hamstring injuries and summarize
prognostic factors associated with RTP.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

In August 2020, MEDLINE, CINAHL, Cochrane Central

Register of Controlled Trials, and SPORTDiscus were
queried for studies examining management and factors
affecting RTP after acute hamstring injury. Included were
randomized controlled trials, cohort studies, case-control
studies, and case series appraising treatment effects on
RTP, reinjury rate, strength, flexibility, hamstrings-to-
quadriceps ratio, or functional assessment, as well as
studies associating clinical and magnetic resonance
imaging factors with RTP. Risk of bias was assessed using
the Cochrane Risk-of-Bias Tool for Randomized Trials or
the Methodological Index for Non-Randomized Studies
(MINORS).

Results:

Of 1289 identified articles, 75 were included. The

comparative and noncomparative studies earned MINORS
scores of 18.8 ± 1.3 and 11.4 ± 3.4, respectively, and 12 of
the 17 randomized controlled trials exhibited low risk of
bias. Collectively, studies of muscular injury included
younger patients and a greater proportion of male athletes
compared with studies of proximal injury. Surgery for
proximal hamstring ruptures achieved superior outcomes
to nonoperative treatment, whereas physiotherapy
incorporating eccentric training, progressive agility, and
trunk stabilization restored function and hastened RTP
after muscular injuries. Platelet-rich plasma injection for
muscular injury yielded inconsistent results. The following
initial clinical findings were associated with delayed RTP:
greater passive knee extension of the uninjured leg,
greater knee extension peak torque angle, biceps femoris
injury, greater pain at injury and initial examination,
“popping” sound, bruising, and pain on resisted knee
flexion. Imaging factors associated with delayed RTP
included magnetic resonance imaging-positive injury,
longer lesion relative to patient height, greater
muscle/tendon involvement, complete central tendon or
myotendinous junction rupture, and greater number of
muscles injured.

Conclusion:

Surgery enabled earlier RTP and improved strength and

flexibility for proximal hamstring injuries, while muscular
injuries were effectively managed nonoperatively.
Rehabilitation and athlete expectations may be managed
by considering several suitable prognostic factors derived
from initial clinical and imaging examination.
Keywords: hamstring injury, imaging, rehabilitation, return
to play

Hamstring injury is one of the most common injuries

among athletes. 31 Athletes involved in activities requiring
high-speed running 6,10 or stretching to extreme muscle
lengths 7,8 are particularly subject to hamstring injury,
which is classified according to location within the muscle
complex, specific muscle(s) affected, severity, and
chronicity. Because of the complex anatomic and
biomechanical properties necessary to facilitate
movement at both the hip and the knee, however, uniform
assessment of hamstring injury epidemiology is
challenging. 22 Determining whether the injury affects the
proximal origin or muscle belly is an important first step to
elucidating injury epidemiology, understanding clinical
presentation, and identifying potential complications.
Proximal hamstring injuries occur predominantly in
middle-aged patients and are often more severe, 43
usually associated with prolonged convalescence and
carrying greater risk for complications such as
postoperative weakness and sciatic nerve injury. 13,81
Conversely, muscular injuries occur more commonly in
younger male athletes with risk factors such as strength
or flexibility deficits, and although initially milder than
proximal injuries, there exists substantial risk for recurrent
injury of greater severity. 32,67

Consideration of injury location is also important when

determining clinical management. Although approach to
rehabilitation is tailored according to injury location,
severity, and patient goals of therapy, management
∥
generally includes physiotherapy with possible
¶
concomitant surgical intervention or injections of
＃
platelet-rich plasma (PRP). Despite extensive research
investigating methods of rehabilitation and advances in
therapeutic techniques designed to return athletes to
competition quickly while minimizing reinjury risk, 61,74
acute hamstring injury continues to account for significant
absence from sports, and little consensus has been
reached regarding optimal management strategies.
Accurate prediction of time to return to play (RTP) is
necessary to guide activity progression and manage
patient expectations for recovery. Although clinicians
often rely on clinical and structural factors gleaned from
initial examination and magnetic resonance imaging (MRI)
scans to inform their prognosis, whether these adequately
correlate with recovery time remains a topic of debate.

The purpose of this study was to systematically review

the literature concerning evidence-based management of
acute proximal and muscular hamstring injuries in athletes
and to report the baseline clinical and MRI factors
associated with RTP.

Methods
Research Framework

The design and reporting of this systematic review are

compliant with the PRISMA (Preferred Reporting Items for
Systematic Reviews and Meta-Analyses) guidelines. 60

Eligibility Criteria

English-language articles examining management and

factors affecting RTP after acute hamstring injury were
considered for eligibility, and those meeting each of the
following criteria were included: (1) the article employed a
randomized controlled trial (RCT), cohort, case-control, or
case series design; (2) patients had sustained acute
proximal or muscular hamstring injury, defined as <6
weeks between injury and initial evaluation; (3) the
authors investigated the effects of a well-described
intervention on hamstring rehabilitation or associated
baseline clinical or MRI assessment findings with RTP; and
(4) outcome measures included time to RTP, reinjury rate,
hamstring strength, hamstring range of motion (ROM),
hamstrings-to-quadriceps (H:Q) ratio, or results of
standardized functional assessment. Studies limited to
only chronic tendinopathy or only recurrent hamstring
injuries were excluded.

Information Sources and Search

Searches of MEDLINE (1966 to present), CINAHL (1981 to

present), Cochrane Central Register of Controlled Trials
(1996 to present), and SPORTDiscus (1949 to present)
were conducted in August 2020. To identify articles
pertinent to acute hamstring injury management and
prognosis, a comprehensive search strategy was
developed using applicable Medical Subject Headings
terms and keywords (see Appendix Table A1). Subsequent
manual inspection of included article reference lists
ascertained any additional relevant articles not found via
the computerized search.

Study Selection

Two reviewers (S.S.R. and M.P.K.)independently screened

all articles on the basis of title and abstract using a
specialized systematic review software (Covidence
systematic review software; Veritas Health Innovation).
Potentially eligible articles underwent full-text review prior
to final determination of study inclusion. Any
disagreements between reviewers were resolved via
discussion.

Data Collection

Based on the Cochrane Handbook for Systematic Reviews

of Interventions recommendations for data extraction, 28 a
custom data extraction form was developed to collect
information on study design; methods; population;
intervention(s); and outcome measures, including time to
RTP, reinjury rate, hamstring strength, hamstring ROM,
H:Q ratio, and/or standardized functional assessment. All
data were extracted by a single reviewer (S.S.R.) and
verified by a second reviewer (M.P.K.).
Risk-of-Bias and Quality Assessment

A risk-of-bias assessment was performed for all included

studies. RCTs were assessed using the Revised Cochrane
Risk-of-Bias Tool for Randomized Trials, which appraises
studies based on patient randomization, assignment to
intervention, availability of outcome data, outcome
measurement, and selection of reported results. 80 Overall
risk of bias for each RCT was judged as “low,” “some
concerns,” or “high.” Nonrandomized studies were
assessed using the Methodological Index for Non-
Randomized Studies (MINORS) tool. 79 The MINORS tool
represents a 12-item assessment of methodological value,
with 8 criteria indicated for noncomparative studies and
an additional 4 criteria indicated for comparative studies.
Each criterion was scored from 0 to 2, with higher overall
scores indicating higher quality of evidence.

Statistical Analysis

Patient characteristics were quantified using descriptive

statistics, calculated as weighted means and standard
deviations across included studies. We used t tests to
identify any differences in characteristics between
patients with acute proximal and muscular hamstring
injuries. A P value < .05 was used to determine statistical
significance. Stata (Version 13.1; StataCorp) software was
used for all statistical analyses.

Results
Study Selection

The database search retrieved 1704 articles, with an

additional 22 identified via manual search as potentially
relevant. After removing duplicates, 1289 articles were
screened on the basis of title and abstract. A total of 126
articles were retained for full-text review, of which 51 were
excluded for failure to satisfy the inclusion criteria, and 75
were included (Figure 1).

Study Characteristics

A total 45 of the included studies pertained to injury

††
management,** 25 defined factors associated with RTP,
and 5 integrated both. 1,9,10,45,76 Studies investigated 3 to
360 male and female athletes engaged in various sports
of all competitive levels with a mean age of 14 to 58 years.
‡‡
Of the studies pertaining to injury management, 22
§§
concerned injuries to the proximal origin, and 28 were
specific to muscular injuries. A variety of techniques and
programs were assessed according to recovery time,
reinjury risk, and degree of functional improvement,
∥∥
including surgical and nonsurgical treatment, PRP
¶¶ ##
injection, and physiotherapeutic interventions. There
was a lack of uniformity across studies regarding
diagnostic methods, criteria for RTP, and assessment of
outcomes. Prognostic studies determined whether
baseline findings were correlated with time to RTP by
conducting clinical and/or MRI assessment shortly after
injury.

Of note, study samples were duplicated in a few articles. 5

–7,39,40,44,83,85 Specifically, injuries to the 18 sprinters and

15 dancers described in Askling et al 5 were also

investigated separately in 2 other studies by the same
authors. 6,7 Hamilton et al, 40 Jacobsen et al, 44 van der
Made et al, 83 and Wangensteen et al 85 additionally
shared considerable overlap in patient populations due to
their use of pooled data from a prior RCT. 39

Risk-of-Bias Assessment

Seventeen RCTs were included, of which 12 were

a
determined to present low risk of bias, and 5 were
judged to raise some concerns. 9,10,46,49,70
b
Nonrandomized studies comprised 11 comparative and
c
47 noncomparative designs with average scores of 18.8
± 1.3 and 11.4 ± 3.4 on MINORS assessment, respectively.

Synthesis of Results

Patient Characteristics

Acute hamstring injuries were classified according to

location within the muscle complex. Collectively, 775
patients with proximal hamstring injury and 1057 patients
with muscular hamstring injury were assessed by the
included studies. Studies investigating methods of
proximal injury management generally included younger
patients and a greater proportion of male patients
compared with studies of proximal hamstring injury
rehabilitation (Table 1).

TABLE 1

Comparison of Patient Characteristics Between Studies of

Proximal Versus Muscular Hamstring Injury a

Studies of Proximal Studies of Muscular

Hamstring Injury Hamstring Injury
Management Management
No. of
775 1057
patients
Patient
age, y,
42.4 ± 10.5 26.2 ± 6.5
mean ±
SD
Patient
sex, % 57.2 87.6
male

aBold values were statistically significantly different

between groups (P < .05).

Management

Management of hamstring injury was also dependent

upon localization to the proximal origin or muscle belly.
Time to RTP and reinjury rate at final follow-up are listed
according to intervention in Tables 2 to 4. Because of
extensive variation in the methods of measuring and
reporting hamstring strength, ROM, H:Q ratio, and
functional assessment, individual study results for these
outcomes are discussed in the text only and not
presented in the tables.

TABLE 2

Summary of Studies on Management of Acute Injuries to

the Proximal Hamstring a

Me
Lead Risk ±S
Author of Injury Type Intervention N Tim
(Year) Bias to
b
RTP
333
Arner 9 Partial proximal (ran
Surgical 64
(2019) 4 (16) hamstring avulsion 150-
1440
Complete proximal
Ayuob 12 83.3
semimembranosus Surgical 20
(2020) 11 (16) 39.9
rupture
Partial/complete
Ayuob 12 tear of proximal 93.8
Surgical 64
(2020) 12 (16) MTJ of long head 35.7
of biceps
Partial/complete
Barnett 10
proximal Surgical 38 —
(2015) 13 (16)
hamstring avulsion

Best (2019) 9 Complete proximal

Surgical 49 —
15 (16) hamstring avulsion

Biedert 9 Avulsion fracture

(2015) 17 (16) of ischial Surgical 3 —
tuberosity
294
Birmingham 11 Complete proximal (ran
Surgical 23
(2011) 18 (16) hamstring avulsion 90-
1080
Partial/complete
Blakeney 15
proximal Surgical 96 —
(2017) 19 (16)
hamstring avulsion
Bowman 10 Partial proximal
Surgical 17 —
(2013) 20 (16) hamstring avulsion
Chahal 9 Complete proximal
Surgical 13 —
(2012) 23 (16) hamstring avulsion
Hofmann 9 Complete proximal
Nonoperative 17 —
(2014) 42 (16) hamstring avulsion
180
Klingele 10 Complete proximal (ran
Surgical 11
(2002) 47 (16) hamstring avulsion 90-
300
175
Konan 12 Complete proximal (ran
Surgical 10
(2010) 48 (16) hamstring avulsion 126-
455
Partial/complete
Lefevre 18 171 ±
proximal Surgical 34
(2013) 51 (24) 48
hamstring avulsion
120
Léger-St- 12 Complete proximal (IQR
Jean (2019) Surgical 22
(16) hamstring avulsion 60-
52
240
150
Lempainen 10 Partial proximal (ran
Surgical 48
(2006) 54 (16) hamstring avulsion 30-
360
 Partial/complete (1) Surgical
Piposar 18 15
proximal (2) —
(2017) 62 (24) 10
hamstring avulsion Nonoperative

180
Sandmann 11 Complete proximal (ran
Surgical 16
(2016) 68 (16) hamstring avulsion 120-
270
(1) Surgical
Shambaugh 17 Complete proximal 14
(2) —
(2017) 72 (24) hamstring avulsion 11
Nonoperative
Skaara 9 Partial proximal
Surgical 31 —
(2013) 77 (16) hamstring avulsion
112
Subbu 12 Complete proximal (ran
Surgical 78
(2014) 81 (16) hamstring avulsion 84-
224
Partial/complete
Willinger 11
proximal Surgical 71 —
(2020) 87 (16)
hamstring avulsion

a Dashes indicate data not reported. H:Q, hamstrings-to-

quadriceps ratio; IQR, interquartile range; MTJ,
myotendinous junction; ROM, range of motion; RTP, return
to play; X, outcome(s) reported.

bReported as Methodological Index for Non-Randomized

Studies score (maximum score).

TABLE 4

Summary of Studies Managing Acute Injuries to

Hamstring Muscle With Physiotherapy a
Lead Author Risk of Injury
Intervention(s) N
(Year) Bias b Type

Primal Reflex
Albertin
10 (16) Grade 2 Release 6
(2020) 3
Technique

Sprinting
Askling (2013) Some (1) L-protocol 37
or
10 concerns (2) C-protocol 38
stretching

Sprinting
Askling (2014) Some (1) L-protocol 28
or
9 concerns (2) C-protocol 28
stretching

(1) Early rehab

Bayer (2018) Munich 20
Low (2) Delayed
14 type 3-4 22
rehab

(1) Pain-
Hickey (2020) threshold rehab 21
Low Grade 1-2
41 (2) Pain-free 22
rehab

Early,
Kilcoyne
10 (16) Grade 1-2 progressive 48
(2011) 45
rehab
 Stretching and
Some
Kim (2018) 46 Grade 2 ROM-based 13
concerns
rehab

(1) Slump
Kornberg Some stretching 12
Grade 1
(1989) 49 concerns (2) Standard 16
rehab

(1) 1× daily
Malliaropoulos stretching 40
Low Grade 2
(2004) 56 (2) 4× daily 40
stretching
(1) LLLT
Medeiros protocol 11
Low Grade 1-2
(2020) 57 (2) Standard 11
rehab
(1) Rehab
Mendiguchia algorithm 24
Low Grade 1
(2017) 58 (2) Rehab 24
protocol
(1) Cryotherapy
Sefiddhashti Some with stretching 18
Grade 1-2
(2018) 70 concerns (2) Cryotherapy 19
alone
(1) STST
Sherry (2004) protocol 11
Low Grade 1-2
73 (2) PATS 13
protocol
(1) PATS
Silder (2013) protocol 13
Low Grade 1-2
76 (2) PRES 12
protocol
 Eccentric
82 11 (16) Grade 1-3 50
Tyler (2017) strength
protocol

a Dashes indicate data not reported. C-protocol,

conventional protocol; H:Q, hamstrings-to-quadriceps
ratio; IQR, interquartile range; L-protocol, lengthening
protocol; LLLT, low-level laser therapy; PATS, progressive
agility and trunk stabilization; PRES, progressive running
and eccentric strengthening; rehab, rehabilitation; ROM,
range of motion; RTP, return to play; STST, stretching and
strengthening; X, outcome(s) reported.

b Reported as Methodological Index for Non-Randomized

Studies score (maximum score) for nonrandomized
studies or Cochrane Risk-of-Bias Tool for Randomized
Trials.

c Significant difference between interventions (P < .001).

d Significant difference between interventions (P < .05).

Proximal Injuries

To determine optimal treatment for acute proximal

hamstring injuries, 22 studies investigated the efficacy of
‡‡
surgical and nonsurgical intervention (Table 2). When
supplemented with postoperative rehabilitation, surgical
repair for partial avulsion was associated with a high rate
of RTP 13,51,87 and low levels of pain and functional
limitation. 4,20,54,77 Piposar et al 62 found no differences in
objective outcomes between operative and nonoperative
management, although subjective results were superior
after surgery. Satisfactory operative results were also
observed in the context of complete avulsion, regardless
of tendon retraction 19,48,52,81 or ischial tuberosity
fracture. 17 Mean hamstring strength recovered to 78.0%
to 94.6% within 12 months of surgery, and the rate of RTP
surpassed 75%, 11,18,47,81 although up to 45% of patients
reported decreased level of activity. 23,87 Two studies
measuring hamstring ROM demonstrated >90% recovery
within 12 months of surgical repair. 11,12 Functional
outcomes did not differ by sex in any study except that by
Chahal et al, 23 in which all 4 patients experiencing poor
outcomes were female. Comparatively, nonoperative
management of complete proximal avulsion resulted in
noticeable strength deficits and lower functional scores.
42

Muscular Injuries

Management of acute muscular hamstring injury was the

focus of 28 studies. Eleven studies evaluated the efficacy
d
of autologous PRP or autologous conditioned serum 88
injection using various injection volumes, locations, and
frequencies (Table 3). Although 3 studies found patients
receiving PRP achieved earlier RTP than controls by 10 to
15 days, 1,16,33 5 studies showed no such effect.
21,37,39,65,66 Despite finding no relationships between PRP

injection and days or practices missed because of

hamstring injury in National Football League athletes,
Bradley et al 21 reported PRP injection to be associated
with fewer games missed. Zanon et al 89 noted a
decreased reinjury rate in patients receiving PRP in the
short term; however, the long-term rate was not different
from that of controls. None observed strength differences
associated with PRP injection 1,39,66 except Gaballah et al,
33 who demonstrated a transient increase in strength 4

weeks after injection relative to controls that dissipated by

week 8. Only Reurink et al 66 measured hamstring ROM
and elucidated no effect of PRP injection on straight-leg
raise or active knee extension ROM. None of the included
studies concerning PRP or autologous conditioned serum
injection reported the H:Q ratio or standardized functional
assessment.

TABLE 3

Summary of Studies Managing Acute Muscular Hamstring

Injury Using PRP or Autologous Conditioned Serum a

Lead Risk Mean ±

of Injury
Author Intervention N SD Time
Bias Type
(Year) to RTP, d
b

(1) PRP (1 × 3-mL 26.7 ± 7.0

A Hamid Grade direct injection 5 d 14 c
Low 42.5 ±
(2014) 1 1 postinjury 14
(2) No injection 20.6 c
(1) PRP (1 × 8-mL
direct injection <48 11.4 ± 1.2
Bezuglov Low BAMIC h postinjury) 20 c
(2019) 16 2a/2b (2) Saline (1 × 8-mL 20 21.3 ± 2.7
direct injection <48 c

h postinjury)
(1) PRP (1-3 × 2- to
22.5 ±
Cohen 5-mL direct
Bradley 18 30 20.1
grade injections 1 wk
(2020) 21 (24) 39 25.7 ±
2 apart)
20.6
(2) No injection
(1) PRP (1 × 3-mL Maximum,
Gaballah Grade direct injection, 5-7 8 27 c
Low
(2018) 33 2 d postinjury) 9 Maximum,
(2) No injection 43 c
(1) PRP (1 × 3-mL 50.9 ±
Guillodo 19 Grade direct injection <8 15 10.7
(2015) 37 (24) 3 d postinjury) 19 52.8 ±
(2) No injection 15.7
(1) PRP (3 × 1-mL
injections 1 cm 21 (95%
apart, <5 d CI, 18-24)
c
postinjury) 30
Hamilton Grade 27 (95%
Low (2) PPP (3 × 1-mL 30
(2015) 39 1-2 CI, 21-33)
injections 1 cm 30 c
apart, <5 d 25 (95%
postinjury) CI, 22-29)
(3) No injection
49
Lee 12 Grade PRP (single
8 (range,
(2020) 50 (16) 1-3 injection)
10-112)
20
(1) PRP (1 × 9-mL
(range,
Rettig 18 Grade direct injection <48 5
16-30)
(2013) 65 (24) 1-2 h postinjury) 5
17 (range,
(2) No injection
8-81)
(1) PRP (3 × 1-mL
injections 1 cm
 Reurink Grade apart at 5 and 10 d 41 42 (IQR,
(2015) 66 Low 1-2 postinjury) 39 30-58)
(2) Saline (3 × 1-mL 42 (IQR,
injections 1 cm 37-56)
apart at 5 and 10 d
postinjury)
(1) Autologous
conditioned serum
(5 × 1-mL injections
over area of injury
every 2nd day
[mean, 5.4
Wright- 16.3 ± 3.1
19 Grade injections]) 6 c
Carpenter
(24) 2 (2) 5 21.8 ± 4.8
(2004) 88 c
Actovegin/Traumeel
therapy (5 × 1-mL
injections over area
of injury every
second day [mean,
8.3 injections])
PRP (2-3 × 3-mL
Zanon 12 Grade 35.1 ±
injections at 72 h 25
(2016) 89 (16) 2 18.9
and 7 d postinjury)

a Dashes indicate data not reported. BAMIC, British

Athletics Muscle Injury Classification; IQR, interquartile
range; PPP, platelet-poor plasma; PRP, platelet-rich
plasma; ROM, range of motion; RTP, return to play; X,
outcome(s) reported.

b Reported as Methodological Index for Non-Randomized

Studies score (maximum score) for nonrandomized
studies or Cochrane Risk-of-Bias Tool for Randomized
Trials.
c Significant difference between interventions (P < .05).

Physiotherapeutic programs for acute hamstring muscular

e
injuries were assessed in 15 studies (Table 4). Eccentric
training enabled faster RTP for elite soccer 10 and track
and field 9 athletes compared with conventional training
regardless of whether the injury was of sprinting or
stretching type. Reinjury rate did not differ between
eccentric and conventional rehabilitation protocols. 9,10
However, athletes fully compliant with an eccentric
training program experienced fewer reinjuries and
reduced strength deficits compared with noncompliant
patients. 82 Reinjury risk was further reduced via an
individualized rehabilitation algorithm designed to address
risk factors, although this approach resulted in possibly
slower RTP. 58

Kim et al 46 found stretching and ROM exercises were

effective in restoring passive ROM and reducing pain in
athletes with grade 2 injury, but active ROM and strength
were not improved. 46 Active ROM was increased by
increasing the frequency of stretching from 1 to 4 daily
sessions, however, as patients were quicker to normalize
flexibility between injured and uninjured limbs and RTP. 56
Stretching after icing (“cryostretching”) yielded greater
increases in active knee extension and lower extremity
functional scale scores compared with icing alone. 70 A
stretching and strengthening (STST) intervention was
compared with progressive agility and trunk stabilization
(PATS) by Sherry and Best, 73 who reported similar time to
RTP between groups but a significantly greater reinjury
rate in the 12 months after STST. Silder et al 76 compared
a progressive running and eccentric strengthening
program with PATS and found no benefit in RTP, reinjury
risk, strength, or ROM. Notably, all 25 athletes in this
study displayed residual injury markers on MRI scans at
RTP, and half of those who experienced reinjury did so
within 2 weeks.

Two studies demonstrated the benefit of early

intervention. 45,14 After 24 hours of immobilization, a
progressive rehabilitation program developed by Kilcoyne
et al 45 returned patients with grade 1 to 2 injury to activity
in an average of <2 weeks with a 6-month reinjury rate of
6.3%. Athletes who began physiotherapy 2 days after
grade 3 to 4 injury achieved faster RTP than athletes
beginning at 9 days, with no difference in reinjury rate
within 1 year. 14 Peak hamstring strength was increased in
the early group 13 weeks after injury, but this difference
disappeared by 26 weeks. Both early and late groups
exhibited decreased H:Q ratios compared with the
uninjured leg. Hickey et al 41 determined that pain
threshold—based rehabilitation failed to accelerate RTP or
influence reinjury rate relative to pain-free therapy.
However, isometric hamstring strength was 15% greater
after 2 months of training in the pain-threshold group. The
Primal Reflex Release Technique, a method of
downregulating the autonomic nervous system to reset
reflexes via reciprocal inhibition, was shown to
significantly increase active and passive ROM as well as
functional scores. 3 A neurologically based approach was
also examined by Kornberg and Lew, 49 who reported that
slump stretching resulted in fewer games missed after
grade 2 injury in Australian Rules football players. Last, an
RCT by Medeiros et al 57 investigating low-level laser
therapy revealed no effect in any reported outcome
measure.

Surgical intervention for muscular injury was examined in

2 studies. Lempainen et al 53 (MINORS score, 10/16)
assessed outcomes of surgical repair for muscular injury
with concomitant complete rupture of the central
hamstring tendon, reporting RTP within 4 months and no
reinjuries by 1 year for the 2 patients with nonrecurrent
injury included in the study. In addition, Cooper and
Conway 26 (MINORS score, 18/24) compared surgical and
nonoperative treatments for complete distal
semitendinosus rupture and found no difference in time to
RTP. However, 42% of patients treated nonoperatively did
not achieve acceptable results and required subsequent
surgical intervention.

Prognostic Factors

Characteristics and findings of studies correlating

baseline clinical and/or MRI findings with time to RTP are
summarized in Tables 5 and 6.

TABLE 5
Summary of Studies Assessing Prognostic Value of
Baseline Assessment a

Assessment

Lead Author (Year) Risk of Bias N Clinical MRI

b

A Hamid (2014) 1 Low 28 X

A Hamid (2013) 2 10 (16) 360 X
Askling (2006) 5 12 (16) 33 X
Askling (2007) 6 14 (16) 15 X X
Askling (2007) 7 14 (16) 18 X X
Askling (2008) 8 11 (16) 30 X X
Some
Askling (2014) 9 56 X X
concerns
Some
Askling (2013) 10 75 X X
concerns
Cohen (2011) 24 14 (16) 38 X
Comin (2013) 25 20 (24) 62 X
Crema (2018) 27 11 (16) 22 X
Ekstrand (2012) 29 12 (16) 207 X
Ekstrand (2016) 30 12 (16) 255 X
Gibbs (2004) 33 12 (16) 31 X
Guillodo (2014) 36 12 (16) 128 X
Hallen (2014) 37 13 (16) 386 X
Hamilton (2018) 40 13 (16) 110 X
Jacobsen (2016) 44 14 (16) 90 X X
Kilcoyne (2011) 45 10 (16) 48 X
Malliaropoulos (2010) 21 (24) 165 X
55
 Moen (2014) 59 13 (16) 74 X X
Pollock (2016) 63 11 (16) 44 X
Pomeranz (1993) 64 10 (16) 14 X
Schneider-Kolsky
21 (24) 58 X X
(2006) 69
Silder (2013) 76 Low 25 X
Slavotinek (2002) 75 12 (16) 30 X
van der Made (2018) 14 (16) 70 X
80

Verrall (2003) 81 12 (16) 83 X X

Wangensteen (2015) 11 (16) 180 X X
82

Warren (2010) 83 13 (16) 59 X

a MRI, magnetic resonance imaging; X, outcome(s)

reported.

b Reported as Methodological Index for Non-Randomized

Studies score (maximum score) for nonrandomized
studies or Cochrane Risk-of-Bias Tool for Randomized
Trials.

TABLE 6

Baseline Assessment Findings and Prognostic

Relationships With RTP Times a

Clinical Factors MRI Factors

RTP Prognosis: Accelerated
Pain during outer-range
strength test 42 BAMIC grade 0 61

Midrange strength as % of Shorter radiologist-predicted

uninjured leg 42 time to RTP 66
SLR flexibility of uninjured
Shorter length of lesion 66
leg 42
Greater physiotherapy
Smaller injury CSA 66
attendance 42
Shorter clinician-predicted
MRI-negative injury 9,10,33,37,62
time to RTP 66
Single muscle/tendon
Lower grade of injury 66
involvement 23
Sprinting-type vs Lower % of muscle/tendon
stretching-type injury 10 involvement 23
Lower radiologic grade of
injury 23,29
Lower Cohen MRI score 23
Injuries not involving proximal
tendon 9
RTP Prognosis: No Effect

Sex 43 Craniocaudal length of injury

6,7,8,26,42,57

Dominant vs nondominant Mediolateral width of injury

limb 2,42,43 6,7,42

Sudden vs gradual pain

Depth of injury 7,30
onset 42
Injury during game vs
Volume of edema 7,26,57
training 42
Forced to cease activity
Tendon involvement 30,42
within 5 min 42
Ability to walk/jog pain-free Myofascial involvement 30,42
42
No. of days to walk pain- Muscle (most) involved
free 42,57 24,29,30,37,42,57,61,75,82

No. of days to ascend stairs Injury CSA as % of total

pain-free 83 muscle CSA 26,42,57
Mechanism of injury Distance of injury from ischium
2,42,57,82,83 7,8,42,57,82

History of low back pain Intra- or intermuscular

42,82 hemorrhage 66
History of lower limb injury Site of injury within the muscle
42 23,30,61,75

History of lower limb

Grade 1 vs grade 2 injury 29,61
surgery 42
Pain on 1- or 2-leg squat 42 MRI grade of injury 57
Pain on palpation of injured Presence of extramuscular
area 35,42 fluid 57
Craniocaudal length of Partial disruption of the central
palpated pain 1,6,7,42,57 tendon 80
Mediolateral width of Amount of central tendon
palpated pain 42 retraction 80
Distance of palpated pain
BAMIC type a vs b 61
from ischium 35,42,57
Location of point of highest
palpated pain 7,8
Site of injury within the
muscle 43,55,81,83
No. of muscles injured 2
Positive vs negative slump
test 82,83
Frequency of physiotherapy
2

Grade of injury 2,43

Level of play/intensity of
sport 2,57
Delay in seeking
physiotherapy 1
Active knee extension
deficit 1,57,83
Pain upon active knee
extension 57
Pain upon PKE 35
Pain on passive SLR 57
Pain upon isometric
contraction 35,83
Previous ACL graft
harvesting 57
Isometric knee flexion
strength 5,57
Hip ROM 5,83
Use of NSAIDs within 72 h
of injury 83
RTP Prognosis: Delayed
Female sex 2 Volume of injury 6,42,75
Greater PKE range of Greater craniocaudal length of
uninjured leg 42 injury 9,10,23,30,66,73
Greater peak torque angle in
Greater width of edema 30
knee extension 42
Greater length of lesion as %
Higher grade of injury 66
of height 33
Injury to biceps femoris 66 Greater depth of injury 6
Shorter distance of pain to Longer radiologist-predicted
ischium 7,9,10 time to RTP 66
Stretching-type vs
Larger injury CSA 6,33,62,66,75
sprinting-type injury 5,10
Greater maximum pain at Involvement of proximal
time of injury 42,82 tendon 6,10
Worst VAS pain score >6 35 Proximal vs distal injuries 6
Higher VAS pain score at Shorter distance of injury to
initial examination 81 ischium 6,9,10
“Popping” sound at time of Higher Cohen MRI score 23
injury 35 /score >10 39
Bruising 35 MRI-positive injury 81
Greater deficit in passive Greater % of muscle/tendon
SLR 57 involvement 23
Complete
Longer clinician-predicted
tendinous/myotendinous
time to RTP 66,81
rupture 62
Forced to cease activity Complete central tendon
within 5 min 82 disruption 24,80
Greater length of palpated Presence of central tendon
pain 82 waviness 80

Pain on resisted knee flexion Greater central tendon

82 retraction 23
Higher radiologic grade of
>1 wk to initial consultation 2
injury 23,29,30,37,61,82
Greater No. of muscles
Recurrent muscle injury 2
involved 39
Greater active knee ROM Distal tendinous or
deficit 35,53 myotendinous injury 62
Longer self-predicted time Peritendinous fluid collection
to RTP 57 62

Lower level of sport 8

>1 d to walk pain-free 83
a ACL, anterior cruciate ligament; BAMIC, British Athletics
Muscle Injury Classification; CSA, cross-sectional area;
MRI, magnetic resonance imaging; NSAID, nonsteroidal
anti-inflammatory drug; PKE, passive knee extension;
ROM, range of motion; RTP, return to play; SLR, straight-
leg raise; VAS, visual analog scale.

Clinical Factors

Seventeen studies investigated relationships between

f
clinical assessment findings and time to RTP . Pain during
outer-range strength testing, 44 greater midrange strength
as a percentage of uninjured leg strength, 44 and shorter
clinician-predicted recovery 69 were associated with
accelerated RTP. In contrast, factors associated with
delayed RTP included greater passive knee extension of
the uninjured leg, 44 greater peak torque angle in knee
extension, 44 injury to the biceps femoris, 69 greater
maximum pain at injury, 44,85 worst visual analog scale
(VAS) pain score >6, 36 higher VAS pain score at initial
examination, 84 popping sound at injury, 36 bruising, 36
pain on resisted knee flexion, 85 and longer clinician- 69,84
and self-predicted time to RTP. 59 Several examined
factors had contradictory results across studies. Two
studies by Askling et al 5,10 noted stretching-type injuries
took longer to recover than did sprinting-type ones, while
others found injury mechanism to have no effect on
recovery time. 2,44,59,85,86 There was no consensus
regarding the effect on time to RTP for sex, 2,45 injury
grade, 2,45,69 physiotherapy attendance, 1,2,44 hip ROM,
5,44,59,86 number of days to walk pain-free, 44,59,86 history

of ipsilateral or contralateral lower limb injury,

1,2,44,45,59,85,86 craniocaudal length of pain, 1,6,7,44,59,85

need to cease activity within 5 minutes of injury, 44,85 level

of play, 2,8,59 or active knee extension deficit. 1,36,55,59,86

MRI Factors

Twenty-three studies evaluated the role of MRI in

g
predicting time to RTP. Accelerated RTP was associated
with MRI-negative injury, 9,10,34,38,64 lower percentage of
muscle/tendon involvement, 24 and shorter radiologist-
predicted recovery. 69 Conversely, the following were
associated with prolonged recovery time: MRI-positive
injury, 84 greater normalized length of lesion, 34 greater
percentage of muscle/tendon involvement, 24 complete
tendinous/myotendinous rupture, 63,64 complete central
tendon disruption, 25,83 central tendon waviness, 83
greater number of muscles involved, 40 and longer
radiologist-predicted recovery. 69 Studies reported
conflicting results for injury grade, 24,29,30,38,59,63,85
h
length, width, 6,7,30,44 depth, 6,7,30 cross-sectional area,
6,27,34,44,59,64,69,78
volume, 6,7,27,44,59,78 tendon
involvement, 6,9,10,24,30,44 amount of tendon retraction,
24,83
site of injury within the muscle, 6,24,30,63,64,78
presence of extramuscular fluid, 59,64 distance from
ischium, 6 –10,44,59,85 and the Cohen MRI score. 24,40 Of
note, the Cohen MRI score refers to an assessment tool
designed to evaluate hamstring injuries on the basis of
patient age, muscles involved, injury location, extent of
injury, and retraction. 24

Discussion
This review assessed management of acute proximal and
muscular hamstring injuries by reviewing interventions
and prognostic factors associated with RTP. According to
the literature, patients undergoing surgical treatment for
partial or complete proximal hamstring ruptures achieved
consistently better outcomes compared with those
managed nonoperatively. 11,12,15,19,68 For patients with
acute muscular injuries, physiotherapy incorporating
eccentric training 9,10,82 and PATS 73,76 attained favorable
outcomes in time to RTP, reinjury rate, and restoration of
strength. Stretching-based protocols increased ROM but
failed to reduce reinjury risk or improve strength. 46,56,73
Supported by findings that rehabilitation with pain-
threshold limits does not predispose to adverse effects, 41
early initiation of rehabilitation enabled faster RTP. 14,45
Slump stretching 49 and reflexive release techniques 3 also
offered functional benefit by addressing neurological
components of hamstring strain. Regarding the efficacy of
PRP injection, results were inconclusive, confounded by a
lack of standardization in PRP formulation and injection
protocol. Similar inconsistencies have been reported in
recent meta-analyses, 35,61,71,75 emphasizing the need to
determine the optimal injection protocol for standard use
in future research investigating the effect of PRP on time
to RTP. Overall, although the quality of evidence of
included studies varied, the diverse methods and
predictive factors examined warrant consideration by
clinicians seeking to optimize injury recovery.

Studies quantifying the prognostic value of baseline

assessments have indicated that certain clinical and MRI
findings are correlated with time to RTP. Clinical factors
associated with accelerated RTP included lesser deficit in
strength of the injured leg relative to the uninjured leg 44
and shorter physician-predicted recovery time, 69
whereas prolonged time to RTP was observed in patients
with greater pain, 36,44,84,85 injury to the biceps femoris,
69 and longer physician- 69,84 and self-predicted 59

recovery times. It is possible that patients with greater

strength and decreased pain in the injured leg at baseline
may be able to begin physiotherapeutic activity and
facilitate rehabilitation sooner after injury, resulting in
earlier RTP. On MRI scans, findings indicating greater
injury severity at initial presentation, such as greater
lesion size, 24,34,84 tendinous/myotendinous rupture,
25,63,64,83 and greater number of muscles affected, 40

were correlated with prolonged RTP. Despite associations

of initial examination and MRI findings with time to RTP,
accurate prognostication of recovery time remains
difficult. In a multivariate analysis of 180 patients,
Wangensteen et al 85 determined that a single clinical
examination at initial presentation accounted for 29% of
variance in time to RTP, whereas supplementation with
MRI findings explained only an additional 2.8%. Jacobsen
et al 44 likewise reported that 59.0% and 8.6% of variance
in RTP was accounted for by clinical and MRI examination,
respectively, suggesting the added benefit of MRI findings
in prognosticating RTP is less pronounced.

This study has several important limitations. First, the

strength of any systematic review is dependent upon the
quality of evidence of included studies. This review
included 17 RCTs, of which 5 were determined as raising
“some concerns” on risk-of-bias assessment. The
remaining 58 studies consisted of cohort, case-control,
and case series study designs included in an effort to be
comprehensive in evaluating rehabilitative techniques.
When critically appraised, comparative nonrandomized
studies achieved a mean MINORS score of 18.8 ± 1.3, and
noncomparative nonrandomized studies achieved a score
of 11.4 ± 3.4. These scores indicate a reasonable risk of
bias and are mainly attributable to a lack of prospective
data collection, blinding, and/or prospective calculation of
sample size. Differences in study design, patient
population, and outcome measures limited direct
comparisons between studies and precluded data pooling
for meta-analyses, making it difficult to draw concrete
conclusions in circumstances of conflicting results. This
was particularly apparent when analyzing the efficacy of
PRP injection for treatment of hamstring muscular injury,
as studies varied in terms of volume, location, and number
of injections. With regard to studies examining the
prognostic value of clinical and MRI examination, the
majority conducted only univariate analyses correlating
baseline findings with RTP. Furthermore, criteria for RTP
and methods of functional assessment were inconsistent,
likely explaining some of the variance in time to RTP
across studies. Future large-scale research using
standardized RTP criteria and outcome measures are
required to determine reliable associations between
baseline findings and RTP prognosis via multivariate
analysis.

Conclusion
Surgical intervention offers substantial benefits over
nonoperative care for treatment of acute partial and
complete proximal hamstring ruptures, while muscular
injuries are effectively treated with physiotherapy
encompassing eccentric training and PATS. The efficacy
of PRP, however, remains controversial. Prognostication of
RTP is of great importance, and the ability to accurately
predict recovery time can be improved with a thorough
clinical examination shortly after injury. Although the
added benefit may be limited, structural factors observed
on MRI scans can also inform RTP prognosis. Future high-
quality research evaluating novel therapeutic protocols
and prognostic determinants of RTP is needed to further
enhance rehabilitation and better predict recovery
timelines for athletes with acute hamstring injury.
APPENDIX
TABLE A1

MEDLINE (Ovid)
1. Exp Hamstring muscles/

2. ((hamstring* or (biceps adj2 femoris) or

semimembranosus or semitendinosus or thigh or
(posterior adj2 thigh)) not ACL not cruciate).tw, kw

3. 1 or 2

4. Exp “Wounds and Injuries”/

5. Exp “Sprains and Strains”/

6. Exp Pain/

7. (injur* or (leg adj2 injur*) or (sports adj2 injur*) or

(athletic adj2 injur*) or strain* or sprain* or tear* or
ruptur* or trauma* or pain* or dysfunction*).tw, kw

8. 4 or 5 or 6 or 7

9. Exp Therapeutics/

10. Exp Rehabilitation/

11. Exp Diagnostic Imaging/

12. (therap* or rehab* or manag* or interven* or imag*).tw,

kw

13. 9 or 10 or 11 or 12 or 13

14. Exp “Recovery of Function”/

15. Exp Sports Medicine/

16. (recover* or progress* or convalescen* or outcome* or
“return to play” or “return to sport” or “return to
competition” or “return to participation” or “return to
training” or “return-to-play” or “return-to-sport” or
“return-to-competition” or “return-to-participation” or
“return-to-training”).tw, kw

17. (re-occur* or recur* or reoccur* or re-inj* or reinj*).tw,

kw

18. 14 or 15 or 16 or 17

19. 3 and 8 and 13 and 18

20. Limit 19 to (English language and full text)

21. Limit 20 to MEDLINE

CINAHL (EBSCO)
1. (MH “hamstring muscles” OR MH thigh OR TI
((hamstring* or (biceps N2 femoris) or
semimembranosus or semitendinosus or thigh or
(posterior N2 thigh))) OR AB ((hamstring* or (biceps N2
femoris) or semimembranosus or semitendinosus or
thigh or (posterior N2 thigh)))) NOT TI ACL NOT TI
cruciate

2. MH (“Wounds and Injuries”) OR MH (“Sprains and

Strains”) OR MH “Pain” or TI ((injur* or (leg N2 injur*) or
(sports N2 injur*) or (athletic N2 injur*) or strain* or
sprain* or tear* or rupture* or trauma* or pain* or
dysfunction*)) OR AB ((injur* or (leg N2 injur*) or (sports
N2 injur*) or (athletic N2 injur*) or strain* or sprain* or
tear* or rupture* or trauma* or pain* or dysfunction*))

3. MH Therapeutics OR MH Rehabilitation OR MH
“Diagnostic Imaging” OR TI ((therap* or rehab* or
manag* or interven* or imag*)) OR AB ((therap* or
rehab* or manag* or interven* or imag*))
 4. MH “Recovery of Function” OR MH “Sports Medicine”
OR TI ((recover* or progress* or convalescen* or
outcome* or “return to play” or “return to sport” or
“return to competition” or “return to participat*” or
“return to train*” or “return-to-play” or “return-to-
sport” or “return-to-competition” or “return-to-
participat*” or “return-to-train*”)) OR AB ((recover* or
progress* or convalescen* or outcome* or “return to
play” or “return to sport” or “return to competition” or
“return to participat*” or “return to train*” or “return-
to-play” or “return-to-sport” or “return-to-
competition” or “return-to-participat*” or “return-to-
train*”))

5. S1 AND S2 AND S3 AND S4

6. Narrow by language – English

7. Limiters – full text

Cochrane Central Register for Controlled Trials (EBSCO)

1. (MH “hamstring muscles” OR MH thigh OR TI
((hamstring* or (biceps N2 femoris) or
semimembranosus or semitendinosus or thigh or
(posterior N2 thigh))) OR AB ((hamstring* or (biceps N2
femoris) or semimembranosus or semitendinosus or
thigh or (posterior N2 thigh)))) NOT TI ACL NOT TI
cruciate

2. MH (“Wounds and Injuries”) OR MH (“Sprains and

Strains”) OR MH “Pain” or TI ((injur* or (leg N2 injur*) or
(sports N2 injur*) or (athletic N2 injur*) or strain* or
sprain* or tear* or rupture* or trauma* or pain* or
dysfunction*)) OR AB ((injur* or (leg N2 injur*) or (sports
N2 injur*) or (athletic N2 injur*) or strain* or sprain* or
tear* or rupture* or trauma* or pain* or dysfunction*))

3. MH Therapeutics OR MH Rehabilitation OR MH
“Diagnostic Imaging” OR TI ((therap* or rehab* or
 manag* or interven* or imag*)) OR AB ((therap* or
rehab* or manag* or interven* or imag*))

4. MH “Recovery of Function” OR MH “Sports Medicine”

OR TI ((recover* or progress* or convalescen* or
outcome* or “return to play” or “return to sport” or
“return to competition” or “return to participat*” or
“return to train*” or “return-to-play” or “return-to-
sport” or “return-to-competition” or “return-to-
participat*” or “return-to-train*”)) OR AB ((recover* or
progress* or convalescen* or outcome* or “return to
play” or “return to sport” or “return to competition” or
“return to participat*” or “return to train*” or “return-
to-play” or “return-to-sport” or “return-to-
competition” or “return-to-participat*” or “return-to-
train*”))

5. S1 AND S2 AND S3 AND S4

6. Narrow by language – English

SPORTDiscus (EBSCO)
1. (MH “hamstring muscles” OR MH thigh OR TI
((hamstring* or (biceps N2 femoris) or
semimembranosus or semitendinosus or thigh or
(posterior N2 thigh))) OR AB ((hamstring* or (biceps N2
femoris) or semimembranosus or semitendinosus or
thigh or (posterior N2 thigh)))) NOT TI ACL NOT TI
cruciate

2. MH (“Wounds and Injuries”) OR MH (“Sprains and

Strains”) OR MH “Pain” or TI ((injur* or (leg N2 injur*) or
(sports N2 injur*) or (athletic N2 injur*) or strain* or
sprain* or tear* or rupture* or trauma* or pain* or
dysfunction*)) OR AB ((injur* or (leg N2 injur*) or (sports
N2 injur*) or (athletic N2 injur*) or strain* or sprain* or
tear* or rupture* or trauma* or pain* or dysfunction*))

3. MH Therapeutics OR MH Rehabilitation OR MH
 “Diagnostic Imaging” OR TI ((therap* or rehab* or
manag* or interven* or imag*)) OR AB ((therap* or
rehab* or manag* or interven* or imag*))

4. MH “Recovery of Function” OR MH “Sports Medicine”

OR TI ((recover* or progress* or convalescen* or
outcome* or “return to play” or “return to sport” or
“return to competition” or “return to participat*” or
“return to train*” or “return-to-play” or “return-to-
sport” or “return-to-competition” or “return-to-
participat*” or “return-to-train*”)) OR AB ((recover* or
progress* or convalescen* or outcome* or “return to
play” or “return to sport” or “return to competition” or
“return to participat*” or “return to train*” or “return-
to-play” or “return-to-sport” or “return-to-
competition” or “return-to-participat*” or “return-to-
train*”))

5. S1 AND S2 AND S3 AND S4

6. Narrow by Language – English

7. Limiters – Full Text

Notes
∥References 3, 9, 10, 14, 41, 45, 46, 49, 56 –58, 70, 73,
76, 82.

¶References 4, 11 –13, 15, 17 –20, 23, 26, 47, 48, 51 –54,

62, 68, 72, 77, 81, 87.

＃References 1, 16, 21, 33, 37, 39, 50, 65, 66, 88, 89.

**References 3, 4, 11 –21, 23, 26, 33, 37, 39, 41, 42, 46 –

54, 56 –58, 62, 65, 66, 68, 70, 72, 73, 77, 81, 82, 87 –89.
††References 2, 5 –8, 24, 25, 27, 29, 30, 34, 36, 38, 40,
44, 55, 59, 63, 64, 69, 78, 83 –86.

‡‡References 4, 11 –13, 15, 17 –20, 23, 42, 47, 48, 51, 52,
54, 62, 68, 72, 77, 81, 87.

§§References 1, 3, 9, 10, 14, 16, 21, 26, 33, 37, 39, 41, 45,
46, 49, 50, 53, 56 –58, 65, 66, 70, 73, 76, 82, 88, 89.

∥∥References 4, 11 –13, 15, 17 –20, 23, 26, 42, 47, 48, 51 –

54, 62, 68, 72, 77, 81, 87.

¶¶References 1, 16, 21, 33, 37, 39, 50, 65, 66, 88, 89.

##References 3, 9, 10, 14, 41, 45, 46, 49, 56 –58, 70, 73,
76, 82.

aReferences 1, 14, 16, 33, 39, 41, 56 –58, 66, 73, 76.

bReferences 21, 25, 26, 37, 51, 55, 62, 65, 69, 72, 88.

c
References 2 –8, 11 –13, 15, 17 –20, 23, 24, 27, 29, 30,
34, 36, 38, 40, 42,44, 45, 47, 48, 50, 52 –54, 59, 63, 64,
68, 77, 78, 81 –87, 89.

dReferences 1, 16, 21, 33, 37, 39, 50, 65, 66, 89.

eReferences 3, 9, 10, 14, 41, 45, 46, 49, 56 –58, 70, 73,
76, 82.

fReferences 1, 2, 5 –10, 36, 44, 45, 55, 59, 69, 84 –86.

gReferences 6 –10, 24, 25, 27, 29, 30, 34, 38, 40, 44, 59,
63, 64, 69, 76, 78, 83 –85.

hReferences 6 –10, 24, 27, 30, 44, 59, 69, 76.

Footnotes
Final revision submitted July 5, 2021; accepted August 10,
2021.

One or more of the authors has declared the following

potential conflict of interest or source of funding: Funding
was provided by the Conine Family Fund for Joint
Preservation. S.D.M. has received education payments
from Kairos Surgical and honoraria from Allergan. AOSSM
checks author disclosures against the Open Payments
Database (OPD). AOSSM has not conducted an
independent investigation on the OPD and disclaims any
liability or responsibility relating thereto.

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