Journal of Science and Medicine in Sport (2006) 9, 87—90

ORIGINAL PAPER

Assessment of player performance following

return to sport after hamstring muscle
strain injury
G.M. Verrall a, Y. Kalairajah a,∗, J.P. Slavotinek b, A.J. Spriggins a

a SPORTSMED SA Sports Medicine Clinic, 32 Payneham Road, Stepney, Adelaide, SA 5069, Australia
b Department of Medical Imaging, Flinders Medical Centre, Adelaide, Australia

KEYWORDS Summary
Hamstring muscle strain; Objective: To determine if there is any decrease in playing performance of athletes
Player performance; following return to sport after recovery from hamstring muscle strain injury.
Return to sport Design: Prospective cohort study.
Participants: One professional Australian football team over two playing seasons.
Methods: For every game, the team coach rated player performance proportional to
time spent on the ground playing (an integer score out of a maximum of 10). Player
performance ratings were compared pre- and post-hamstring muscle strain injury to
assess player performance upon return to sport.
Results: Thirteen athletes had hamstring injuries and the required player ratings
were available. The mean player performance rating for the entire playing season
in which the player was injured was 6.9. The mean player performance rating for the
two games prior to injury was 6.8 as opposed to 5.4 for the two games after return
to sport. Athletes had a significantly lower player performance rating immediately
upon return to sport when compared to ratings for the entire season (p < 0.001) and
when compared to ratings from the two games prior to injury (p < 0.001).
Conclusions: Following return to sport from hamstring injury, player performance as
assessed by the team coach is reduced. This suggests that some athletes may return
to sport prior to complete resolution of the injury.
© 2006 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.

Introduction are responsible for the greatest quantity of com-

Hamstring muscle strain injuries are common
in many sports, including the various football
codes.1,2 In Australian football, hamstring injuries
∗
Corresponding author. Tel.: +61 8 8362 8111;
fax: +61 8 8362 6635.
E-mail address: yega@orthospecialist.net (Y. Kalairajah).
petition time lost due to injury2 and have a
high recurrence rate.2,3 Athletes in professional
sports are aware of the troublesome nature
and high recurrence rate of hamstring injuries.4
Despite this there is often an expectation from
the team, coach and the athletes themselves to
return to active competition as soon as practi-
cal following this injury. Although no data have

1440-2440/$ — see front matter © 2006 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.jsams.2006.03.007
88
Table 1 Summary of player performance ratings in injured players
For entire season
For two games prior to injury
For two games after return to sport
Data is presented for the 13 players where comparisons could be made. Comparing all three columns a Friedman test demonstrated
significant difference between the three periods p < 0.001. A pairwise Exact Wilcoxon Signed Ranks Test demonstrated significant
differences between player ratings for the entire season compared to player ratings for the two games after return to sport
p < 0.001 and player ratings for the two games prior to injury compared to player ratings for the two games after return to sport
p < 0.001.
been presented about player performance after
return to sport from hamstring injury, evidence
from magnetic resonance imaging (MRI) studies,5
laboratory studies of muscle stretch injury6,7
and the observed high recurrence rate3 sug-
gests that the injury in many cases has not
fully resolved at the time of return to sport.
Accordingly, the aim of this study was to deter-
mine if athlete performance is poorer following
return to sport after recovery from hamstring
injury.
Method
All athletes were male and played professional Aus-
tralian football for an elite level team consisting of
first and reserve grade teams. The study was con-
ducted over two full playing seasons with the team
playing weekly for 25 competition matches in each
season.
Hamstring muscle strain injury was noted when
a player developed pain localised to the posterior
thigh during the course of playing or training and
subsequent MRI scan detected focal intramuscular
hyperintensity within the hamstring muscle(s) on T2
images.8—10
For every first grade game the club coach rated
player performance proportional to time spent on
the ground. Players who had limited on-field time
(less than one-quarter) were not rated. This rating
was an integer score to a maximum of 10. Player
ratings for the two games prior to injury and for
the entire playing season in which the player was
injured were compared to player ratings for the
first two games played after return to sport. Play-
ers were included in the study if they played at
least two matches out of a possible two in the
first grade team after return to sport following
injury.
An exact Friedman test was performed compar-
ing all data followed by pairwise Exact Wilcoxon
Signed Rank Tests if the Friedman test was signifi-
cant. Thus, we compared player performance rat-
G.M. Verrall et al.
Mean Median Range S.D.
6.8 6.7 5.7—7.8 0.56
6.8 7.0 5.5—8.0 0.70
5.1 5.0 4.0—6.5 0.87
ings from the two matches after returning to com-
petition to the player performance ratings of the
player for the entire season and to the player per-
formance ratings for the player in the two matches
prior to injury.
Results
Across the two seasons, a total of 20 hamstring
injuries were recorded. Thirteen of these injuries
had relevant player ratings and were therefore
included in the analyses. Seven athletes were
excluded (three had insufficient pre-injury ratings,
four had insufficient post-injury ratings). Three
of the 13 returned to play in the reserve grade
and played one match there, before being pro-
moted to the first grade team, whereas the other
10 played in the first grade team for their return
from injury match. Only first grade matches were
rated. Player ratings are summarised in Table 1.
There was significantly reduced performance in
the first two games after return to sport com-
pared to performance during the entire season
(p < 0.001) and the two games prior to the injury
(p < 0.001).
Discussion
This study demonstrates that player performance
in Australian football is reduced in the immediate
return to play period following hamstring injury.
This is consistent with the hypothesis that ath-
letes often return to sport prior to complete res-
olution, with respect to muscle healing, of injury.3
As obtaining direct histological evidence is difficult
in the study of athletic hamstring injuries, indirect
evidence, such as player performance or persis-
tent MRI abnormalities may provide support for the
proposition of incomplete resolution of injury prior
to return to sport. Other studies also support this
proposition.
Player performance after hamstring muscle strain injury
It has been demonstrated that at six weeks post-
hamstring injury 36% of athletes still had signal
intensity changes on MRI, despite nearly all of these
athletes having returned to competition sport by
this time.5 Laboratory studies that analyse mus-
cle stretch injury and subsequent healing6,7 also
suggest that the injury may take many weeks to
heal, longer than the average 28-day2 hamstring
injury convalescent interval. Finally, it has been
shown that there is an increased susceptibility for
re-injury that lasts up to eight weeks after return
to sport.3
How incomplete resolution of injury impacts
negatively upon player performance upon return to
sport is not clear. It is possible that the hamstring
muscle has reduced capacity to perform follow-
ing rehabilitation and that this would be impor-
tant in a sport, such as Australian football, that
requires a large amount of high-intensity interval
running. Other factors that could be responsible
include a decreased level of fitness of the play-
ers upon return to sport because of their time out
of match-playing, reduction in confidence that may
result in the athlete not ‘‘risking’’ their hamstring
as players are aware of the high re-injury rate,
reduced skill level because of significant absence
from match-playing, and finally a perceived neg-
ative assessment (bias) of performance by the
coach as he may place the player under more
rigorous assessment than would normally be the
case.
When considering the impact that decreased
performance of a player may have on team perfor-
mance, it may be reasonable to suggest that players
should have a longer convalescence interval before
returning to sport following hamstring injury. It
is not clear whether or not a longer convalescent
interval would improve player performance upon
returning to sport. With the recurrence rate in the
first week upon returning to sport in Australian
football being relatively low (13%)3 , by justifying
the timing of return to sport, there may be long-
term benefit to the team for the player returning
from injury gaining match conditioning that
may allow improved performance in subsequent
matches.
When interpreting the findings of this study it
is important to consider its inherent weaknesses.
The most obvious weakness of this study is the lim-
ited size of the injured group. Another weakness
was the failure to look at return to sport perfor-
mance following other injuries as these athletes
may demonstrate a similar trend. Furthermore, the
validity and reliability of the player performance
ratings could not be assessed. Finally, direct com-
parisons from the literature are also not possible
89
as to our knowledge no study has looked at player
performance criteria after return from any injury
in any sport.
Conclusions
This study demonstrates that player performance
as assessed by the team coach is reduced following
return to play after hamstring injury. This is con-
sistent with the proposition from other studies that
some athletes may return to sport prior to complete
resolution of injury.
Practical implications
• Player performance is reduced following
return to play after hamstring injury.
• Some athletes return to play prior to complete
resolution of the hamstring injury.
• Coaches, players and the medical team should
be aware for the potential for player perfor-
mance to be impaired when making decisions
on the timing of return to play for hamstring
injured athletes.
Acknowledgements
The authors wish to thank Dr. Adrian Esterman for
his statistical analysis. The coach of the Norwood
football club, Mr. Peter Rhode is also thanked.
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