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BJSM Online First, published on March 27, 2013 as 10.1136/bjsports-2013-092165
Original article

Acute hamstring injuries in Swedish elite football:

a prospective randomised controlled clinical trial
comparing two rehabilitation protocols
Carl M Askling,1,2 Magnus Tengvar,3 Alf Thorstensson1

▸ Additional material is ABSTRACT There is a lack of clinical research and consensus

published online only. To view Background Hamstring injury is the single most regarding the effectiveness of various rehabilitation
please visit the journal online
(http://dx.doi.org/10.1136/
common injury in European professional football and, protocols for acute hamstring injuries in football.
bjsports-2013-092165). therefore, time to return and secondary prevention are of The primary objective of all rehabilitation protocols
1 particular concern. is to return the player as soon as possible to the
The Swedish School of Sport
and Health Sciences, Objective To compare the effectiveness of two prior level of performance with a minimal risk of
Stockholm, Sweden rehabilitation protocols after acute hamstring injury in injury recurrence. Few studies to date have evalu-
2
The Section of Orthopaedics Swedish elite football players by evaluating time needed ated the effectiveness of different treatment proto-
and Sports Medicine, to return to full participation in football team-training cols for acute hamstring injuries in athletes.10 To
Department of Molecular
Medicine and Surgery,
and availability for match selection. our knowledge, there are no prospective, rando-
Karolinska Institutet, Study design Prospective randomised comparison of mised studies in the literature investigating the
Stockholm, Sweden two rehabilitation protocols. effectiveness of different rehabilitation protocols in
3
Department of Radiology, Methods Seventy-five football players with an acute elite football.
Karolinska Sjukhuset, hamstring injury, verified by MRI, were randomly It has been suggested that hamstring exercises
Stockholm, Sweden
assigned to one of two rehabilitation protocols. Thirty- being performed at longer muscle–tendon length,
Correspondence to seven players were assigned to a protocol emphasising preferentially mimicking movements occurring sim-
Dr Carl M Askling, lengthening exercises, L-protocol and 38 players to a ultaneously at both the knee and the hip, could be
GIH, Box 5626, 114 86 protocol consisting of conventional exercises, C-protocol. a key strategy in the management of hamstring
Stockholm, Sweden,
[email protected] The outcome measure was the number of days to return injuries.13 14
to full-team training and availability for match selection.
Accepted 26 February 2013 Reinjuries were registered during a period of 12 months Aim
after return. The main objective of this study on Swedish elite
Results Time to return was significantly shorter for the football players was to compare the effectiveness of
players in the L-protocol, mean 28 days (1SD±15, range two rehabilitation protocols for acute hamstring
8–58 days), compared with the C-protocol, mean injuries with varying emphasis on muscle–tendon
51 days (1SD±21, range 12–94 days). Irrespective of lengths by evaluating time needed to return to full
protocol, stretching-type of hamstring injury took participation in football team training and availabil-
significantly longer time to return than sprinting-type, ity for match selection. Other aims were to study
L-protocol: mean 43 vs 23 days and C-protocol: mean possible correlations between injury type, location,
74 vs 41 days, respectively. The L-protocol was size, palpation pain and time to return.
significantly more effective than the C-protocol in both
injury types. One reinjury was registered, in the MATERIAL AND METHODS
C-protocol. Male as well as female players were recruited using
Conclusions A rehabilitation protocol emphasising our extensive contacts with medical teams working
lengthening type of exercises is more effective than a with elite football in Sweden. The total recruitment
protocol containing conventional exercises in promoting time was 33 months, January 2009–September
time to return in Swedish elite football. 2011. Seventy-five players, mainly from the two
highest divisions, were included in the study, all
with clinical signs of acute hamstring injury, which
were confirmed by MRI. A randomisation process
INTRODUCTION was used to assign the players to either of the two
Hamstring injury is the single most common injury protocols, the L-protocol or the C-protocol,
in elite football.1 2 This means that a professional respectively. Stratification was carried out for
male football team with 25 players would suffer gender and injury-type, that is, sprinting-type or
about five hamstring injuries each season, equiva- stretching-type of injury (see below). In addition,
lent to more than 80 lost football days.1 11 players with clinical signs of acute hamstring
Furthermore, hamstring injuries are a heteroge- injury, but where the MRI showed no sign of
neous group consisting of different injury types, injury, were followed in parallel. These
To cite: Askling CM, locations and sizes, which makes recommendations MRI-negative players were all assigned to the
Tengvar M, Thorstensson A.
Br J Sports Med Published
regarding rehabilitation and prognosis about L-protocol. All players gave their informed consent
Online First: [ please include healing time difficult.3–7 The reinjury rate in foot- prior to their participation. Approval of the study
Day Month Year] ball is high1 8 9 which, in most cases, probably indi- was granted from the Regional Ethics Committee
doi:10.1136/bjsports-2013- cates inadequate rehabilitation programmes and/or (Dnr: 2008/1320-31/2). There were no drop-outs
092165 premature return to football.10–12 in the study.

Copyright
Askling CM, et al. BrArticle author
J Sports Med (or their
2013;00:1–8. employer) 2013. Produced
doi:10.1136/bjsports-2013-092165 by BMJ Publishing Group Ltd under licence. 1
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Original article

Inclusion/exclusion criteria addition, the perpendicular distance between the level of the
To be included, the player had to have had an acute sudden most proximal pole of the oedema and the level of the most
pain in the posterior thigh when training football or playing a distal part of the ischial tuberosity was measured.4
match. The initial clinical examination had to reveal localised
pain when palpating the hamstring muscles, localised pain while Rehabilitation protocols
performing a passive straight leg raise test and increased pain The time from the date of injury to the date of rehabilitation
when adding an isometric hamstring contraction during that protocol initiation was 5 days for both protocols. Overall, exer-
test.3 Exclusion criteria included verified or even suspected, cises were chosen that could be performed in any place and
earlier hamstring injuries in the same leg during the last without the use of advanced equipment. The exercises of the
6 months, extrinsic trauma to the posterior thigh, ongoing or L-protocol specifically aimed at loading the hamstrings during
chronic lower back problems and pregnancy. extensive lengthening, mainly during eccentric muscle actions.
In contrast, the C-protocol consisted of conventional exercises
Injury situation—type of injury for the hamstrings with less emphasis on lengthening. Each
At the first visit, the players were interviewed about the injury rehabilitation protocol consisted of three different exercises,
situation, that is, the movements or exercises during which the where exercise 1 was aimed mainly at increasing flexibility, exer-
acute injury occurred. As the majority of the players came from cise 2 was a combined exercise for strength and trunk/pelvis sta-
the two highest football divisions in Sweden, video clips of the bilisation and exercise 3 was more of a specific strength training
injury situation were available in many cases (46 of 75). The exercise. All exercises were performed in the sagittal plane. The
video was used to confirm if the injury was a sprinting-type intensity and volume of training were made as equal as possible
injury, that is, occurred at high-speed running and/or acceler- between the two protocols. The training sessions were super-
ation or a stretching-type injury, that is, occurred during move- vised, at least once every week, during the whole rehabilitation
ments with large joint excursions, that is, high kicking, split period, and the speed and load were increased over time. No
positions and glide tackling. pain provocation was allowed at any time when performing the
exercises. All exercises included in the two rehabilitation proto-
Clinical examination cols are explained in figures 1–6 and shown in online supple-
All players were examined within 2 days after the injury. The mentary videos 1–6.
clinical examination included manual assessment of flexibility
and strength of the injured and uninjured legs. The point of Outcome
peak palpation pain was recorded and the distance between that The main outcome is time to return, that is, time needed from
point and the ischial tuberosity was measured.3 The same the incidence of injury to full participation in football team
test-leader (CMA) performed this clinical examination weekly training and availability for match selection. Also occurrence of
until there were no signs of remaining injury. The last decision reinjuries was registered during a 12 months period after return.
by the CMA had to be confirmed by an independent colleague If a reinjury occurred, the responsible medical team was to
before being finalised. immediately contact the study leader so that the same procedure
as for the original injury could be repeated. The full 1-year
Askling H-test follow-up period was completed by all players in the study.
When the clinical examination showed no signs of remaining
injury, the Askling H-test was performed.15 If the player experi- Statistical analyses
enced insecurity during this dynamic test, he/she was not All statistical analyses were conducted with SPSS V.19.0 software
allowed to go back to full team training and/or match. Instead, (SPSS Inc, Chicago, Illinois, USA). Shapiro-Wilk W tests showed
the rehabilitation period was extended and the H-test repeated that the data were not normally distributed. The Mann-Whitney
with an interval of 3–5 days until insecurity was eliminated. U test was performed to investigate differences in age, height
and mass as well as MRI and palpation measures. A χ² test was
MRI applied to investigate differences in proportions of injury type
All players underwent an MRI investigation within 5 days after
the acute injury. MRI investigations were performed on a 1.5
Tesla superconductive MRI unit (Magnetom Symphony,
Siemens, Erlangen, Germany). Briefly, longitudinal, sagittal and
frontal short tau inversion recovery (STIR) images as well as
transversal T1-weighted and STIR images (5 mm slice thickness
and 0.5 mm gap) were obtained from both legs.4 A muscle was
considered injured when it contained high signal intensity
(oedema) on the STIR images, as compared with that of the
uninjured side. If more than one muscle/tendon was injured,
the one with the greatest signal abnormality was considered the
‘primary’ injury and the second largest, the ‘secondary’ injury.
In this study, MRI parameters were quantified only for the
primary injury. The free proximal tendon (PT) was deemed
injured if two of the three following parameters were present:
the tendon was thickened, and/or had a collar of high signal Figure 1 L-1 ‘The Extender’. The player should hold and stabilise the
intensity around it and/or had high intratendinous signal inten- thigh of the injured leg with the hip flexed approximately 90° and then
sity, as compared with the uninjured side. The maximal longitu- perform slow knee extensions to a point just before pain is felt. Twice
dinal length of the muscle/tendon oedema was measured.4 In every day, three sets with 12 repetitions (online supplementary video 1).

2 Askling CM, et al. Br J Sports Med 2013;00:1–8. doi:10.1136/bjsports-2013-092165

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Original article

Figure 2 L-2 ‘The Diver’. The exercise should be performed as a

simulated dive, that is, as a hip flexion (from an upright trunk position)
of the injured, standing leg and simultaneous stretching of the arms
forward and attempting maximal hip extension of the lifted leg while
keeping the pelvis horizontal; angles at the knee should be maintained
at 10–20° in the standing leg and at 90° in the lifted leg. Owing to
its complexity, this exercise should be performed very slowly in the
beginning. Once every other day, three sets with six repetitions
(online supplementary video 2).

and PT involvement as well as in gender and level of perform-

ance. The Mann-Whitney U test was also used to assess differ-
ences in time to return between the protocols, between Figure 4 C-1 Stretching—contract/relax. The heel of the injured leg is
placed on a stable support surface in a high position (close to
subgroups with respect to injury type and PT involvement, as
maximum) with the knee in approximately 10° flexion. The heel is
well as between MRI-negative players and players with pressed down for 10 s and then, after relaxation for 10 s, a new
sprinting-type injury within the L-protocol. Spearman rank position is assumed by flexing the upper body slowly forward for 20 s.
order correlations were calculated to investigate associations Twice every day, three sets with four repetitions (online supplementary
between time to return and MRI and palpation parameters. The video 4).
significance level was set at p≤0.05.

RESULTS
Injury type and location
Fifty-four (72%) of all 75 MRI-verified hamstring injuries were
sprinting-type and 21 (28%) were stretching-type injuries. In 52

Figure 3 L-3 ‘The Glider’. The exercise is started from a position with
upright trunk, one hand holding on to a support and legs slightly split.
All the body weight should be on the heel of the injured (here left) leg
with approximately 10–20° flexion in the knee. The motion is started Figure 5 C-2 Cable-pendulum. A stationary cable-machine or
by gliding backward on the other leg (note low friction sock) and expander is used. With the uninjured leg as standing leg,
stopped before pain is reached. The movement back to the starting forward-backward hip motions are performed with the injured leg with
position should be performed by the help of both arms, not using the the knee in approximately 20–30° flexion. This exercise involves the
injured leg. Progression is achieved by increasing the gliding distance whole body and should be performed slowly in the beginning of the
and performing the exercise faster. Once every third day, three sets rehabilitation period. Once every other day, three sets with six
with four repetitions (online supplementary video 3). repetitions (online supplementary video 5).

Askling CM, et al. Br J Sports Med 2013;00:1–8. doi:10.1136/bjsports-2013-092165 3

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Original article

was prolonged by 7.5 days (1SD±2.8, range 3–12) and 6.7 days
(1SD±2.7, range 3–14) in the L-protocol and C-protocol,
respectively.

Time to return
Time to return was significantly shorter in the L-protocol
compared with the C-protocol, mean 28 days (1SD±15, range
8–58 days) and 51 days (1SD±21, range 12–94 days), respect-
ively (figure 7). Time to return was also significantly shorter in
the L-protocol than in the C-protocol for injuries of both
Figure 6 C-3 Pelvic lift. This exercise is started in a supine position sprinting-type and stretching-type (figure 8), as well as for injur-
with the body weight on both heels and then the pelvis is lifted up ies not involving and involving the PT (figure 9). The sprinting-
and down slowly. Start with the knee in 90° of flexion. The load is type of injuries, per se, showed significantly shorter time to
increased by putting more of the body weight on the injured leg and return compared with stretching-type injuries (figure 8). Also,
by having a greater extension in the knee. Ultimately, only the slightly injuries not involving PT showed significantly shorter time to
bent injured leg is carrying the load. Every third day, three sets with return than those involving the PT (figure 9). Correlation ana-
eight repetitions (online supplementary video 6).
lysis showed that the shorter the distance to tuber was from the
most proximal pole of the injury measured by MRI or peak pal-
of the 75 players (69%), the primary injury was located in the pation pain, the longer the time was to return (table 2).
long head of biceps femoris (BFlh) and in 25 of those 52 (48%) A longer length of the oedema was also correlated with a signifi-
there was a secondary injury commonly (80%) located in the cantly longer time to return (table 2).
semitendinosus (ST). In 16 of the 75 players (21%), the primary
injury was located in semimembranosus (SM) and in 7 of those Reinjuries
16 (44%) there was a secondary injury. A clear majority (94%) There was one reinjury registered during the 12-month
of the primary injuries of sprinting-type was located in the follow-up period. This reinjury occurred in the C-protocol
BFlh, whereas SM was the most common (76%) location for 6 months after the initial injury. Both injuries were of sprinting-
the stretching-type injury. type and located in the BFlh. The reinjury took 12 days to
return compared with 16 days for the initial injury.

Characterisation of protocol participants MRI-negative group

There were no significant differences between the groups of All of the injuries in the MRI-negative group were of sprinting-
players in the L-protocol and the C-protocol with respect to the type. The characteristics of the MRI-negative group were similar
age, height, mass, gender, performance level, type of injury, to the corresponding group of players with sprint injuries in the
involvement of proximal free tendon (table 1). Neither were L-protocol (table 3). The MRI negative group had significantly
there any differences in distance between the most proximal shorter time to return, mean 6 days (1SD±3, range 3–14 days),
pole of the oedema and the ischial tuberosity, length of the than the corresponding group of players, that is, the sprinting-
oedema and distance between the point of peak palpation pain type of injuries within the L-protocol, mean 23 days (1SD±11,
and the ischial tuberosity (table 1). range 8–44 days; figure 10).

Askling H-test DISUSSION

Thirteen players (35%) in the L-protocol and 27 in the Outcome—time to return
C-protocol (71%) experienced insecurity while performing the The time to return to full training and match selection availabil-
test and therefore needed to extend the rehabilitation period. ity in elite football players after acute hamstring injury can be
In mean, the rehabilitation period was prolonged by 7 days considerably affected by the choice of rehabilitation protocol. In
(1SD±2.7, range 3–14). On average, the rehabilitation period this study on Swedish elite football players, the average time to

Table 1 Descriptive, MRI and palpation data, as means±1SD (median and range) or ratios (%) for players in the L-protocol and the C-protocol,
respectively
L-protocol (n=37) C-protocol (n=38) p Value

Age (years) 25±5 (24, 16 to 37) 25±6 (25, 15 to 37) 0.738*

Height (cm) 180±5 (180, 170 to 198) 181±7 (180, 160 to 196) 0.278*
Mass (kg) 77±6 (76, 64 to 90) 79±10 (78, 50 to 113) 0.310*
Female (%)/male (%) 8/92 8/92 0.973**
Elite (%)/non-elite (%) 89/11 90/10 0.968**
Sprinting-type (%)/stretching-type (%) 73/27 71/29 0.853**
Proximal free tendon (PT) not involved (%)/PT involved (%) 68/32 74/26 0.561**
Distance from proximal injury pole to tuber, mm 60±72 (40, −30 to 240) 67±80 (40, −40 to 280) 0.738*
Injury length, mm 176±99 (190, 30 to 400) 169±78 (180, 15 to 325) 0.865*
Peak palpation pain, distance to tuber, cm 10±7 (8, 1 to 26) 10±8 (8, 1 to 32) 0.903*
*Mann-Whitney U test.
**χ² test. The level of significance was set at p≤0.05.

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Figure 7 Time to return, in days, in either the L-protocol (n=37)

or C-protocol (n=38). The boxes represent IQRs; in the boxes the
horizontal lines represent median values and black squares represent
mean values; whiskers=mean±1 SD. *** Denotes significant difference
( p<0.001, Mann-Whitney U test).
Figure 9 Time to return, in days, for players with injuries either
involving or not involving the proximal free tendon (PT) in either the
return was shortened with 23 days, from 51 to 28 days (45%) L-protocol (n=25 and 12, respectively) or the C-protocol (n=28 and 10,
by replacing conventional exercises (C-protocol) with exercises respectively). The boxes represent IQRs; in the boxes the horizontal
emphasising loading of the hamstring muscles at lengths near lines represent median values and black squares represent mean
the maximal (L-protocol). It should be noted that included in values; whiskers=mean±1 SD. **=p<0.01; ***=p<0.001 denote
significant differences (Mann-Whitney U test).

these numbers are extra days caused by the inclusion of the

extracriterion test, Askling H-test. On average, the rehabilitation
period was prolonged by 7 days (1SD±2.7, range 3–14 days).
Without this extratest the time to return would have been
shorter but the difference between the L-protocol and
C-protocol would still have remained highly significant, mean
25 and 46 days, respectively. Since earlier similar intervention
studies are lacking, no directly comparable numbers for times to
return are available. As a comparison it can be mentioned that
Petersen et al9 in a hamstring injury prevention study of Danish
elite and subelite football players, reported mean ‘recovery
times’ of 30 (range 7–64 days) and 26 days (range 4–89 days).

Exercise characteristics—possible differential effects

between protocols
The exercises in both protocols were selected based on practical
experience and applied anatomy, not on biomechanical analysis.

Table 2 Correlations between time to return and MRI and

palpation parameters in players in the L-protocol and C-protocol,
respectively
L-protocol C-protocol
Figure 8 Time to return, in days, for players with either Spearman’s r p Value Spearman’s r p Value
sprinting-type or stretching-type injuries in either the L-protocol (n=27
and 10, respectively) or C-protocol (n=27 and 11, respectively). The Distance to tuber (mm) −0.736 <0.001 −0.717 <0.001
boxes represent IQRs; in the boxes the horizontal lines represent Length (mm) 0.817 <0.001 0.320 <0.05
median values and black squares represent mean values; Palpation (cm) −0.832 <0.001 −0.859 <0.001
whiskers=mean±1 SD. *** Denotes significant difference ( p<0.001, Significant (p≤0.05) correlations are in italics.
Mann-Whitney U test).

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Table 3 Descriptive data, as means±1SD (median and range) or (%) for players in the MRI-negative group and the sprinting-type injury within
the L-protocol, respectively
MRI-negative (n=11) L-protocol (n=27) sprinting-type p Value

Age (years) 23±7 (21, 15 to 36) 25±5 (26, 16 to 37) 0.302*

Height (cm) 181±6 (179, 174 to 192) 180±4 (179, 170 to 189) 0.961*
Mass (kg) 75±7 (76, 60 to 86) 77±6 (76, 64 to 90) 0.759*
Female (%)/male (%) 9/91 11/89 0.854**
Sprinting-type (%)/Stretching-type (%) 100/0 100/0
Elite (%)/non-elite (%) 100/0 96/4
*Mann-Whitney U test.
**χ² test. The level of significance was set at p≤0.05.

Lacking objective data we cannot pinpoint the factors causing should build on attaining eccentric loading at as long muscle
the remarkable difference in outcome between the two proto- lengths as possible.17–19
cols. The most conspicuous characteristics of the more success-
ful L-protocol were the systematic attempts to put load on the Factors predicting time to return irrespective of
hamstrings during maximal dynamic lengthening, the latter rehabilitation protocol
involving movements at both the hip and the knee. The contri- Earlier investigations of ours have identified two main types of
bution of eccentric actions might also have been greater in the acute hamstring injuries, one occurring at high-speed running,
L-programme, although we have no data to directly support typical for sprinters4 the other occurring during slow stretching
such a statement. Otherwise, the two protocols were made as to extreme muscle lengths, typical for dancers5 but also occur-
similar as possible in terms of early start after injury, thorough ring in other athletes.6 These types of injuries are best distin-
instruction and regular follow-up and progression in load/speed/ guished by identifying these typical injury situations, either
excursion based on the avoidance of the pain criterion. relying on players’ report or on other forms of documentation,
The selection of these properties of the L-protocol was based for example, videos from elite football matches as used here.
on the common assumption of specificity, that is, the rehabilita- Ekstrand et al7 showed that 70% of hamstring injuries in elite
tion training, within reasonable limits, should attempt to mirror football players occur during high-speed running and the rest
the particular situation that lead to the injury. Even though the with stretching, sliding, twisting, turning, passing, jumping and
exact mechanisms behind different types of hamstring injuries overuse. Their numbers are close to ours based on the number
are unknown, several pieces of indirect evidence point to the of players reported to us by the medical teams, 72% of the
aforementioned factors to be important14 16 and several authors injuries were high-speed running and 28% stretching-injuries,
have suggested that rehabilitating acute hamstring injuries occurring during, for example, high kicking, sliding tackle and
split motions. Establishing type of injury provides essential prog-
nostic information since stretching-type of injury has, on the
average, 84% longer times (59 vs 32 days) to return than
sprinting-type of injury in the present study. Other measure-
ments with similar prognostic value, that is, prolonging or short-
ening the time to return, are position of peak pain upon
palpation and position of the proximal pole of the oedema in
relation the ischial tuberosity as well as oedema length upon
MRI. Correlation analysis showed that the shorter the distance
to tuber and the longer length of the oedema the longer the
time to return. The latter two findings are in accordance with
earlier studies.4 20 21 Interestingly, these effects on time to
return were all independent of the two rehabilitation protocols
applied here. So, there seems to be room for developing exer-
cises that are more specific with respect to injury type and
location.

MRI-negative injuries
In our study, 11 players showed typical sprinting-injury, but had
no signs of acute hamstring injury upon MRI investigation. The
clinical examination, performed within 2 days, showed all
typical signs of acute hamstring injury, for example, distinct pal-
pation pain; pain provoked by isometric contraction of the ham-
Figure 10 Time to return, in days, for MRI-negative players (n=11, all strings and reduced straight leg raise performance, compared
performing L-protocol) or for players with sprinting-type injuries within with the uninjured leg. Possible explanations for this discrep-
the L-protocol (n=27). The boxes represent IQRs; in the boxes the ancy could be that the structural defect is below the detection
horizontal lines represent median values and black squares represent limit of the MRI or radiologist, the oedema is limited and
mean values; whiskers=mean±1 SD. *** Denotes significant difference cleared away within the 5 days before MRI, or spine-related
( p<0.001, Mann-Whitney U test). and/or neuromuscular disorders have provoked the acute

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symptoms.7 22 After undergoing the L-protocol (4 of the 11

players did not perform the L-protocol since they returned How might it impact clinical practice in the near future?
within 5 days after injury occurrence), the time to return
(average 6 days) for the MRI-negative group was clearly the
▸ Improve rehabilitation efficiency after acute hamstring injury
shortest for all groups investigated here. This is in accordance
by using protocols with lengthening exercises.
with earlier studies demonstrating that MRI-negative cases have
▸ Improve prognosis by determining injury type and using
better prognosis for recovery than those showing injury signs on
palpation and MRI to establish injury pain, location and size.
MRI.7 23 This finding also points out the importance of per-
forming an MRI, not least to identify the MRI-negative ham-
string injuries with expected short times to return.
Acknowledgements The authors thank the medical staff of Swedish elite football
Reinjuries: Askling H-test clubs, who sent players to be included in the study. The authors also thank Olga
Tarassova, Swedish School of Sport and Health Sciences, Hans Larsson, Sabbatsberg
In this study only one reinjury occurred among the 75 players Sjukhus, Klas Östberg, Solnakliniken, and Ulf Gustafsson, FeelGood, for their skilful
(0.8%) during the 12 months follow-up. This is a considerably contributions to this research. The Swedish Centre for Sport Research is gratefully
lower number than the recurrence rates of 12–25% earlier acknowledged for financial support.
reported for European football.7 24 25 There may be several Contributors CMA, MT and AT designed the study, monitored data collection,
reasons for this. One could be that the rehabilitation protocols analysed the data and drafted and revised the paper.
were more rigorous and intensive than previous ones. Another Competing interests None.
might be the introduction of the Askling H-test. Notably, this Patient consent Obtained.
test must not be performed before all clinical tests at the end of
Ethics approval Karolinska Institutet.
rehabilitation, including those of passive flexibility, indicate
complete recovery. Absence of any signs of insecurity is required Provenance and peer review Not commissioned; externally peer reviewed.
before the player is allowed to return to full-team training or
match. It is not unlikely that the recurrence rate would have REFERENCES
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Askling CM, et al. Br J Sports Med 2013;00:1–8. doi:10.1136/bjsports-2013-092165 7

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Original article

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8 Askling CM, et al. Br J Sports Med 2013;00:1–8. doi:10.1136/bjsports-2013-092165

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Acute hamstring injuries in Swedish elite

football: a prospective randomised
controlled clinical trial comparing two
rehabilitation protocols
Carl M Askling, Magnus Tengvar and Alf Thorstensson

Br J Sports Med published online March 27, 2013

doi: 10.1136/bjsports-2013-092165

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