Semin Musculoskelet Radiol 2024; 28(02): 154-164
DOI: 10.1055/s-0043-1778022
Review Article

Reinjury Following Return to Play

1   Division of Musculoskeletal Imaging and Intervention, Department of Radiology, UMass Chan Medical School, Worcester, Massachusetts
Ryan Tai
1   Division of Musculoskeletal Imaging and Intervention, Department of Radiology, UMass Chan Medical School, Worcester, Massachusetts
Ganesh Joshi
1   Division of Musculoskeletal Imaging and Intervention, Department of Radiology, UMass Chan Medical School, Worcester, Massachusetts
Elisabeth Garwood
1   Division of Musculoskeletal Imaging and Intervention, Department of Radiology, UMass Chan Medical School, Worcester, Massachusetts
Debajyoti Saha
1   Division of Musculoskeletal Imaging and Intervention, Department of Radiology, UMass Chan Medical School, Worcester, Massachusetts
› Author Affiliations


Radiologists are frequently called on for guidance regarding return to play (RTP) for athletes and active individuals after sustaining a musculoskeletal injury. Avoidance of reinjury is of particular importance throughout the rehabilitative process and following resumption of competitive activity. Understanding reinjury risk estimation, imaging patterns, and correlation of clinical and surgical findings will help prepare the radiologist to identify reinjuries correctly on diagnostic imaging studies and optimize management for a safe RTP.

Publication History

Article published online:
14 March 2024

© 2024. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

  • References

  • 1 Maffulli N, Del Buono A, Oliva F. et al. Muscle injuries: a brief guide to classification and management. Transl Med UniSa 2014; 12: 14-18
  • 2 Guermazi A, Roemer FW, Robinson P, Tol JL, Regatte RR, Crema MD. Imaging of muscle injuries in sports medicine: sports imaging series. Radiology 2017; 282 (03) 646-663
  • 3 Shakoor D, Guermazi A, Kijowski R. et al. Diagnostic performance of three-dimensional MRI for depicting cartilage defects in the knee: a meta-analysis. Radiology 2018; 289 (01) 71-82
  • 4 Flores DV, Mejía Gómez C, Estrada-Castrillón M, Smitaman E, Pathria MN. MR imaging of muscle trauma: anatomy, biomechanics, pathophysiology, and imaging appearance. Radiographics 2018; 38 (01) 124-148
  • 5 Peetrons P. Ultrasound of muscles. Eur Radiol 2002; 12 (01) 35-43
  • 6 Pollock N, James SL, Lee JC, Chakraverty R. British athletics muscle injury classification: a new grading system. Br J Sports Med 2014; 48 (18) 1347-1351
  • 7 Chan O, Del Buono A, Best TM, Maffulli N. Acute muscle strain injuries: a proposed new classification system. Knee Surg Sports Traumatol Arthrosc 2012; 20 (11) 2356-2362
  • 8 Mueller-Wohlfahrt HW, Haensel L, Mithoefer K. et al. Terminology and classification of muscle injuries in sport: the Munich consensus statement. Br J Sports Med 2013; 47 (06) 342-350
  • 9 Hamilton B, Alonso JM, Best TM. Time for a paradigm shift in the classification of muscle injuries. J Sport Health Sci 2017; 6 (03) 255-261
  • 10 Hamilton B, Valle X, Rodas G. et al. Classification and grading of muscle injuries: a narrative review. Br J Sports Med 2015; 49 (05) 306
  • 11 van der Horst RA, Tol JL, Weir A. et al. The value of MRI STIR signal intensity on return to play prognosis and reinjury risk estimation in athletes with acute hamstring injuries. J Sci Med Sport 2021; 24 (09) 855-861
  • 12 Isern-Kebschull J, Tomas X, García-Díez AI, Morata L, Ríos J, Soriano A. Accuracy of computed tomography-guided joint aspiration and computed tomography findings for prediction of infected hip prosthesis. J Arthroplasty 2019; 34 (08) 1776-1782
  • 13 Reurink G, Goudswaard GJ, Tol JL. et al. MRI observations at return to play of clinically recovered hamstring injuries. Br J Sports Med 2014; 48 (18) 1370-1376
  • 14 Paoletta M, Moretti A, Liguori S. et al. Ultrasound imaging in sport-related muscle injuries: pitfalls and opportunities. Medicina (Kaunas) 2021; 57 (10) 1040
  • 15 Cruz J, Mascarenhas V. Adult thigh muscle injuries-from diagnosis to treatment: what the radiologist should know. Skeletal Radiol 2018; 47 (08) 1087-1098
  • 16 DeWitt J, Vidale T. Recurrent hamstring injury: consideration following operative and non-operative management. Int J Sports Phys Ther 2014; 9 (06) 798-812
  • 17 Malliaropoulos N, Isinkaye T, Tsitas K, Maffulli N. Reinjury after acute posterior thigh muscle injuries in elite track and field athletes. Am J Sports Med 2011; 39 (02) 304-310
  • 18 Rudisill SS, Kucharik MP, Varady NH, Martin SD. Evidence-based management and factors associated with return to play after acute hamstring injury in athletes: a systematic review. Orthop J Sports Med 2021; 9 (11) 23 259671211053833
  • 19 Wangensteen A, Tol JL, Witvrouw E. et al. Hamstring reinjuries occur at the same location and early after return to sport: a descriptive study of MRI-confirmed reinjuries. Am J Sports Med 2016; 44 (08) 2112-2121
  • 20 Gabbe BJ, Finch CF, Wajswelner H, Bennell KL. Predictors of lower extremity injuries at the community level of Australian football. Clin J Sport Med 2004; 14 (02) 56-63
  • 21 Verrall GM, Slavotinek JP, Barnes PG, Fon GT, Esterman A. Assessment of physical examination and magnetic resonance imaging findings of hamstring injury as predictors for recurrent injury. J Orthop Sports Phys Ther 2006; 36 (04) 215-224
  • 22 Woods C, Hawkins RD, Maltby S, Hulse M, Thomas A, Hodson A. Football Association Medical Research Programme. The Football Association Medical Research Programme: an audit of injuries in professional football—analysis of hamstring injuries. Br J Sports Med 2004; 38 (01) 36-41
  • 23 Verrall GM, Slavotinek JP, Barnes PG, Fon GT, Spriggins AJ. Clinical risk factors for hamstring muscle strain injury: a prospective study with correlation of injury by magnetic resonance imaging. Br J Sports Med 2001; 35 (06) 435-439 ; discussion 440
  • 24 Hägglund M, Waldén M, Ekstrand J. Previous injury as a risk factor for injury in elite football: a prospective study over two consecutive seasons. Br J Sports Med 2006; 40 (09) 767-772
  • 25 Warren P, Gabbe BJ, Schneider-Kolsky M, Bennell KL. Clinical predictors of time to return to competition and of recurrence following hamstring strain in elite Australian footballers. Br J Sports Med 2010; 44 (06) 415-419
  • 26 Greenky M, Cohen SB. Magnetic resonance imaging for assessing hamstring injuries: clinical benefits and pitfalls—a review of the current literature. Open Access J Sports Med 2017; 8: 167-170
  • 27 De Vos RJ, Reurink G, Goudswaard GJ, Moen MH, Weir A, Tol JL. Clinical findings just after return to play predict hamstring re-injury, but baseline MRI findings do not. Br J Sports Med 2014; 48 (18) 1377-1384
  • 28 Greig M, Siegler JC. Soccer-specific fatigue and eccentric hamstrings muscle strength. J Athl Train 2009; 44 (02) 180-184
  • 29 Croisier JL, Ganteaume S, Binet J, Genty M, Ferret JM. Strength imbalances and prevention of hamstring injury in professional soccer players: a prospective study. Am J Sports Med 2008; 36 (08) 1469-1475
  • 30 Askling C, Karlsson J, Thorstensson A. Hamstring injury occurrence in elite soccer players after preseason strength training with eccentric overload. Scand J Med Sci Sports 2003; 13 (04) 244-250
  • 31 Kornberg C, Lew P. The effect of stretching neural structures on grade one hamstring injuries. J Orthop Sports Phys Ther 1989; 10 (12) 481-487
  • 32 Koulouris G, Connell DA, Brukner P, Schneider-Kolsky M. Magnetic resonance imaging parameters for assessing risk of recurrent hamstring injuries in elite athletes. Am J Sports Med 2007; 35 (09) 1500-1506
  • 33 Shamji R, James SLJ, Botchu R, Khurniawan KA, Bhogal G, Rushton A. Association of the British Athletic Muscle Injury Classification and anatomic location with return to full training and reinjury following hamstring injury in elite football. BMJ Open Sport Exerc Med 2021; 7 (02) e001010
  • 34 van der Made AD, Almusa E, Reurink G. et al. Intramuscular tendon injury is not associated with an increased hamstring reinjury rate within 12 months after return to play. Br J Sports Med 2018; 52 (19) 1261-1266
  • 35 McAuley S, Dobbin N, Morgan C, Goodwin PC. Predictors of time to return to play and re-injury following hamstring injury with and without intramuscular tendon involvement in adult professional footballers: a retrospective cohort study. J Sci Med Sport 2022; 25 (03) 216-221
  • 36 Arner JW, McClincy MP, Bradley JP. Hamstring injuries in athletes: evidence-based treatment. J Am Acad Orthop Surg 2019; 27 (23) 868-877
  • 37 Jokela A, Stenroos A, Kosola J, Valle X, Lempainen L. A systematic review of surgical intervention in the treatment of hamstring tendon ruptures: current evidence on the impact on patient outcomes. Ann Med 2022; 54 (01) 978-988
  • 38 Aujla RS, Cecchi S, Koh E, D'Alessandro P, Annear P. Surgical treatment of high-grade acute intramuscular hamstring tendon injuries in athletes leads to predictable return to sports and no re-injuries. Knee Surg Sports Traumatol Arthrosc 2023; 31 (10) 4601-4606
  • 39 van Heumen M, Tol JL, de Vos RJ. et al. The prognostic value of MRI in determining reinjury risk following acute hamstring injury: a systematic review. Br J Sports Med 2017; 51 (18) 1355-1363
  • 40 Silder A, Sherry MA, Sanfilippo J, Tuite MJ, Hetzel SJ, Heiderscheit BC. Clinical and morphological changes following 2 rehabilitation programs for acute hamstring strain injuries: a randomized clinical trial. J Orthop Sports Phys Ther 2013; 43 (05) 284-299
  • 41 Reurink G, Almusa E, Goudswaard GJ. et al. No association between fibrosis on magnetic resonance imaging at return to play and hamstring reinjury risk. Am J Sports Med 2015; 43 (05) 1228-1234
  • 42 Heiderscheit BC, Blemker SS, Opar D. et al; HAMIR Study Group. The development of a HAMstring InjuRy (HAMIR) index to mitigate injury risk through innovative imaging, biomechanics, and data analytics: protocol for an observational cohort study. BMC Sports Sci Med Rehabil 2022; 14 (01) 128
  • 43 Petersen J, Thorborg K, Nielsen MB. et al. The diagnostic and prognostic value of ultrasonography in soccer players with acute hamstring injuries. Am J Sports Med 2014; 42 (02) 399-404
  • 44 Oladeji L, Reynolds G, Gonzales H, DeFroda S. Anterior cruciate ligament return to play: where are we now?. J Knee Surg 2023 ; August 7 (Epub ahead of print)
  • 45 Centers for Disease Control and Prevention. CDC injury research agenda 2009–2018. Available at: . Accessed December 7, 2023
  • 46 White LM, Kramer J, Recht MP. MR imaging evaluation of the postoperative knee: ligaments, menisci, and articular cartilage. Skeletal Radiol 2005; 34 (08) 431-452
  • 47 Samuelsen BT, Webster KE, Johnson NR, Hewett TE, Krych AJ. Hamstring autograft versus patellar tendon autograft for ACL reconstruction: is there a difference in graft failure rate? A meta-analysis of 47,613 patients. Clin Orthop Relat Res 2017; 475 (10) 2459-2468
  • 48 Nagelli CV, Hewett TE. Should return to sport be delayed until 2 years after anterior cruciate ligament reconstruction? Biological and functional considerations. Sports Med 2017; 47 (02) 221-232
  • 49 van Melick N, van Cingel RE, Brooijmans F. et al. Evidence-based clinical practice update: practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus. Br J Sports Med 2016; 50 (24) 1506-1515
  • 50 Schilaty ND, Bates NA, Sanders TL, Krych AJ, Stuart MJ, Hewett TE. Incidence of second anterior cruciate ligament tears (1990–2000) and associated factors in a specific geographic locale. Am J Sports Med 2017; 45 (07) 1567-1573
  • 51 Xu S, Cheema SG, Tarakemeh A. et al. Return to sport after primary anterior cruciate ligament (ACL) reconstruction: a survey of the American Orthopaedic Society for Sports Medicine. Kans J Med 2023; 16: 105-109
  • 52 Schweizer N, Strutzenberger G, Franchi MV, Farshad M, Scherr J, Spörri J. Screening tests for assessing athletes at risk of ACL injury or reinjury—a scoping review. Int J Environ Res Public Health 2022; 19 (05) 2864
  • 53 Meredith SJ, Rauer T, Chmielewski TL. et al. Return to sport after anterior cruciate ligament injury: Panther Symposium ACL Injury Return to Sport Consensus Group. J ISAKOS 2021; 6 (03) 138-146
  • 54 Meredith SJ, Rauer T, Chmielewski TL. et al; Panther Symposium ACL Injury Return to Sport Consensus Group. Return to sport after anterior cruciate ligament injury: Panther Symposium ACL Injury Return to Sport Consensus Group. Orthop J Sports Med 2020; 8 (06) 23 25967120930829
  • 55 Zappia M, Capasso R, Berritto D. et al. Anterior cruciate ligament reconstruction: MR imaging findings. Musculoskelet Surg 2017; 101 (Suppl. 01) 23-35
  • 56 Flannery SW, Murray MM, Badger GJ. et al; BEAR Trial Team. Early MRI-based quantitative outcomes are associated with a positive functional performance trajectory from 6 to 24 months post-ACL surgery. Knee Surg Sports Traumatol Arthrosc 2023; 31 (05) 1690-1698
  • 57 Reynolds SB, Dugas JR, Cain EL, McMichael CS, Andrews JR. Débridement of small partial-thickness rotator cuff tears in elite overhead throwers. Clin Orthop Relat Res 2008; 466 (03) 614-621
  • 58 Ogata K, Whiteside LA, Lesker PA, Reynolds FC. Acute effect of open joint wounds on articular cartilage and synovium in rabbits. J Trauma 1979; 19 (12) 953-956
  • 59 Anderson K, Boothby M, Aschenbrener D, van Holsbeeck M. Outcome and structural integrity after arthroscopic rotator cuff repair using 2 rows of fixation: minimum 2-year follow-up. Am J Sports Med 2006; 34 (12) 1899-1905
  • 60 Watson S, Allen B, Grant JA. A clinical review of return-to-play considerations after anterior shoulder dislocation. Sports Health 2016; 8 (04) 336-341
  • 61 Dickens JF, Rue JP, Cameron KL. et al. Successful return to sport after arthroscopic shoulder stabilization versus nonoperative management in contact athletes with anterior shoulder instability: a prospective multicenter study. Am J Sports Med 2017; 45 (11) 2540-2546
  • 62 Buss DD, Lynch GP, Meyer CP, Huber SM, Freehill MQ. Nonoperative management for in-season athletes with anterior shoulder instability. Am J Sports Med 2004; 32 (06) 1430-1433
  • 63 Denard PJ, Dai X, Burkhart SS. Increasing preoperative dislocations and total time of dislocation affect surgical management of anterior shoulder instability. Int J Shoulder Surg 2015; 9 (01) 1-5
  • 64 Nakagawa S, Ozaki R, Take Y, Mizuno N, Mae T. Enlargement of glenoid defects in traumatic anterior shoulder instability: influence of the number of recurrences and type of sport. Orthop J Sports Med 2014; 2 (04) 23 25967114529920
  • 65 Krych AJ, Sousa PL, King AH, Morgan JA, May JH, Dahm DL. The effect of cartilage injury after arthroscopic stabilization for shoulder instability. Orthopedics 2015; 38 (11) e965-e969
  • 66 Lau BC, Conway D, Curran PF, Feeley BT, Pandya NK. Bipolar bone loss in patients with anterior shoulder dislocation: a comparison of adolescents versus adult patients. Arthroscopy 2017; 33 (10) 1755-1761
  • 67 Kim DS, Yoon YS, Yi CH. Prevalence comparison of accompanying lesions between primary and recurrent anterior dislocation in the shoulder. Am J Sports Med 2010; 38 (10) 2071-2076
  • 68 Brophy RH, Marx RG. The treatment of traumatic anterior instability of the shoulder: nonoperative and surgical treatment. Arthroscopy 2009; 25 (03) 298-304
  • 69 Aydıngöz Ü, Yıldız AE, Huri G. Glenoid track assessment at imaging in anterior shoulder instability: rationale and step-by-step guide. Radiographics 2023; 43 (08) e230030
  • 70 Gyftopoulos S, Beltran LS, Bookman J, Rokito A. MRI evaluation of bipolar bone loss using the on-track off-track method: a feasibility study. AJR Am J Roentgenol 2015; 205 (04) 848-852
  • 71 Di Giacomo G, Peebles LA, Pugliese M. et al. Glenoid Track Instability Management Score: radiographic modification of the Instability Severity Index Score. Arthroscopy 2020; 36 (01) 56-67
  • 72 Hatta T, Yamamoto N, Shinagawa K, Kawakami J, Itoi E. Surgical decision making based on the on-track/off-track concept for anterior shoulder instability: a case-control study. JSES Open Access 2019; 3 (01) 25-28
  • 73 Bernhardson AS, Murphy CP, Aman ZS, LaPrade RF, Provencher MT. A Prospective analysis of patients with anterior versus posterior shoulder instability: a matched cohort examination and surgical outcome analysis of 200 patients. Am J Sports Med 2019; 47 (03) 682-687
  • 74 Frank RM, Romeo AA, Provencher MT. Posterior glenohumeral instability: evidence-based treatment. J Am Acad Orthop Surg 2017; 25 (09) 610-623
  • 75 Bradley JP, Arner JW, Jayakumar S, Vyas D. Revision arthroscopic posterior shoulder capsulolabral repair in contact athletes: risk factors and outcomes. Arthroscopy 2020; 36 (03) 660-665
  • 76 Zaremski JL, McClelland J, Vincent HK, Horodyski M. Trends in sports-related elbow ulnar collateral ligament injuries. Orthop J Sports Med 2017; 5 (10) 23 25967117731296
  • 77 Walker CM, Genuario JW, Houck DA, Murayama S, Mendez H, Noonan TJ. Return-to-play outcomes in professional baseball players after nonoperative treatment of incomplete medial ulnar collateral ligament injuries: a long-term follow-up study. Am J Sports Med 2021; 49 (05) 1137-1144
  • 78 Berk AN, Rao AJ, Ahmad CS. et al. Inconsistencies in reporting risk factors for ulnar collateral ligament reconstruction failure: a systematic review. J Shoulder Elbow Surg 2023; 32 (07) 1534-1544
  • 79 Makhni EC, Lee RW, Morrow ZS, Gualtieri AP, Gorroochurn P, Ahmad CS. Performance, return to competition, and reinjury after Tommy John surgery in major league baseball pitchers: a review of 147 cases. Am J Sports Med 2014; 42 (06) 1323-1332
  • 80 Garcia GH, Gowd AK, Cabarcas BC. et al. Magnetic resonance imaging findings of the asymptomatic elbow predict injuries and surgery in major league baseball pitchers. Orthop J Sports Med 2019; 7 (01) 23 25967118818413
  • 81 Ciccotti MC, Ciccotti MG. Ulnar collateral ligament evaluation and diagnostics. Clin Sports Med 2020; 39 (03) 503-522
  • 82 Wear SA, Thornton DD, Schwartz ML, Weissmann III RC, Cain EL, Andrews JR. MRI of the reconstructed ulnar collateral ligament. AJR Am J Roentgenol 2011; 197 (05) 1198-1204
  • 83 Brophy RH, Gill CS, Lyman S, Barnes RP, Rodeo SA, Warren RF. Effect of anterior cruciate ligament reconstruction and meniscectomy on length of career in National Football League athletes: a case control study. Am J Sports Med 2009; 37 (11) 2102-2107
  • 84 D'Ambrosi R, Meena A, Raj A. et al. In elite athletes with meniscal injuries, always repair the lateral, think about the medial! A systematic review. Knee Surg Sports Traumatol Arthrosc 2023; 31 (06) 2500-2510
  • 85 Baker JC, Friedman MV, Rubin DA. Imaging the postoperative knee meniscus: an evidence-based review. AJR Am J Roentgenol 2018; 211 (03) 519-527
  • 86 Lim PS, Schweitzer ME, Bhatia M. et al. Repeat tear of postoperative meniscus: potential MR imaging signs. Radiology 1999; 210 (01) 183-188
  • 87 Schnackenburg KE, Macdonald HM, Ferber R, Wiley JP, Boyd SK. Bone quality and muscle strength in female athletes with lower limb stress fractures. Med Sci Sports Exerc 2011; 43 (11) 2110-2119
  • 88 Patel KA, Christopher ZK, Drakos MC, O'Malley MJ. Navicular stress fractures. J Am Acad Orthop Surg 2021; 29 (04) 148-157
  • 89 Attia AK, Mahmoud K, Bariteau J, Labib SA, DiGiovanni CW, D'Hooghe P. Return to sport following navicular stress fracture: a systematic review and meta-analysis of three hundred and fifteen fractures. Int Orthop 2021; 45 (10) 2699-2710
  • 90 Glasgow MT, Naranja Jr RJ, Glasgow SG, Torg JS. Analysis of failed surgical management of fractures of the base of the fifth metatarsal distal to the tuberosity: the Jones fracture. Foot Ankle Int 1996; 17 (08) 449-457
  • 91 Lee KT, Park YU, Jegal H, Park JW, Choi JP, Kim JS. Prognostic classification of fifth metatarsal stress fracture using plantar gap. Foot Ankle Int 2013; 34 (05) 691-696
  • 92 Lee KT, Park YU, Jegal H, Kim KC, Young KW, Kim JS. Factors associated with recurrent fifth metatarsal stress fracture. Foot Ankle Int 2013; 34 (12) 1645-1653
  • 93 O'Malley M, DeSandis B, Allen A, Levitsky M, O'Malley Q, Williams R. Operative treatment of fifth metatarsal Jones fractures (zones II and III) in the NBA. Foot Ankle Int 2016; 37 (05) 488-500
  • 94 Popp KL, Ackerman KE, Rudolph SE. et al. Changes in volumetric bone mineral density over 12 Months after a tibial bone stress injury diagnosis: implications for return to sports and military duty. Am J Sports Med 2021; 49 (01) 226-235