Sport Medicine Journal Club

complications were reported in 9 studies. They included wound infections,

skin and tendon necrosis, sural nerve
damage, decreased ankle motion, deep
venous thrombosis, and pulmonary
embolus. Nonsurgical treatment was
associated with fewer complications
than surgery (RD, 20.16; 95% CI,
20.03 to 20.30). Differences in range
of motion (3 studies) favored surgical
intervention, but were clinically unimportant. Calf circumference (3 studies),
strength (measured variously in 6 studies), and functional outcomes (measured
by different scales in 4 studies) did not
differ between interventions.
Conclusions: Rates of rerupture were
similar among patients with acute Achilles tendon rupture who were treated surgically or nonsurgically when early
range of motion was used as a cointervention. Rates of other complications
(major and minor) were fewer after nonsurgical treatment.

Commentary
During the last decade, understanding of the treatment of Achilles
tendon injury has increased, and attention has been directed to the functional
stimulus of healing tendons. Recommendations to treat this injury either
operatively or nonoperatively have been
introduced.1 The medical and rehabilitation communities continue to seek more
information on the evolved management
of this serious injury.
In their rigorous meta-analysis of
randomized trials, Soroceanu et al add to
2 previous meta-analyses of operative
versus nonoperative treatment of Achilles tendon rupture by the inclusion of the
most recent studies and of publications
in languages other than English. Their
review concludes that nonoperative and
operative treatments of Achilles tendon
rupture yield equivalent outcomes provided that early functional rehabilitation
is used. The outcomes studied include
risk of rerupture, calf strength, calf
circumference, range of motion, return
to work, functional outcomes, and overall rate of complications. Approximately
80% of the patients in each group were
male and in most instances the injury
occurred during sport. All patients had
treatment initiated within 3 weeks of
injury.

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The reviews pooled and subgroup analyses conrm that functional

rehabilitation is a critical factor in equalizing the rate of rerupture for surgical and
nonsurgical patients. Of potential interest
to the sport medicine community are the
ndings that active plantar exion was
1 degree less in patients treated nonsurgically, and that calf circumference
and most measures of strength were
comparable between the 2 groups,
and comparable to the uninjured leg.
Although it is recognized that
Achilles tendon rupture typically occurs
during athletic activity, this study and
others do not address operative versus
nonoperative treatment in higher performance athletes. Practical knowledge
about the injury would be enhanced by
information about actual compliance
with rehabilitation protocols, the ideal
characteristics of a functional brace, and
by studies of a limited (younger) age
group. Sport-specic strength is an additional important outcome measure; for
example, rapid foot push-off is critical in
court sports, sprinting, dance, speedskating, and jumping. Willits et al2
found that rapid plantar exion (270 degrees per second) is favored after operative treatment. The characteristics of
tendon healing and tendon length may
have some bearing on the speed of plantar exion. Conrmation of end-to-end
apposition of the ruptured tendon was
not mentioned in all of the studies
included in the review by Soroceanu
et al. Magnetic resonance imaging or
ultrasound can be used to judge satisfactory tendon apposition in nonsurgical
cases, whereas, during surgery, direct
visualization of the tendon ends is possible. A tendon can be shortened intentionally or unintentionally during
surgical procedures, but this can not
occur to the same degree without surgery,
although over lengthening can occur in
either group. Practical measurement of
physiologic Achilles tendon length has
been described by Rosso et al3 and may
be useful in future studies.
Because there are several relevant
endpoints in recovery from this injury,
development of a decision-making algorithm would be helpful to determine
which patients would benet from operative or nonoperative management of
Achilles tendon rupture.

Gwyneth deVries, MD, MSc

Department of Orthopedic Surgery
Horizon Health,
Fredericton, New Brunswick, Canada

REFERENCES
1. Chiodo CP; the AAOS Work Group. The Diagnosis and treatment of acute Achilles tendon
rupture. Guideline and Evidence Report. 1st
ed. Rosemont, IL: American Academy of
Orthopedic Surgeons; 2009.
2. Willits K, Amendola A, Bryant D, et al. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized
trial using accelerated functional rehabilitation.
J Bone Joint Surg Am. 2010;92:27672775.
3. Rosso C, Schuetz P, Polzer C, et al. Physiological Achilles tendon length and its relation
to tibia length. Clin J Sport Med. 2012;22:
483487.

What Are the Most

Important Risk Factors for
Hamstring Muscle Injury?
This CJSM Journal Club contribution
provides a commentary on the
following article:
Freckleton G, Pizzari T. Risk factors
for hamstring muscle strain injury
in sport: a systematic review and
meta-analysis. Br J Sports Med.
2013;47:351358.

Overview of Original Article

Objective: To identify the intrinsic and
extrinsic risk factors associated with
sport-related hamstring muscle injuries.
Data Sources: MEDLINE, the Cochrane
Library of Systematic Reviews up to
August 2011, and 6 other databases were
searched using words related to the study
objective. Google Scholar was used to
track citations, and reference lists of
included studies were scanned to nd
additional relevant studies.
Study Selection: The selected prospective, full-text studies in humans, published in the English language, could
include either rst-time or recurrent
hamstring muscle injuries that were
sport-related. Discrete data for the hamstring injury outcome had to assess
intrinsic or extrinsic risk factors. Tendon
Source of funding for the original study: No
external funding.
Correspondence about the original article: Tania
Pizzari, PhD, La Trobe University, Department
of Physiotherapy, Bundoora, Mebourne, Victoria
3086, Australia (t.pizzari@latrobe.edu.au).

2014 Lippincott Williams & Wilkins

Clin J Sport Med  Volume 24, Number 2, March 2014

and avulsion injuries and nonspecic

musculoskeletal injuries were excluded,
as were intervention, retrospective, and
cross-sectional studies and nonsystematic reviews. Of 1649 articles identied
by the searches, 26 were included, plus
a further 8 studies identied through
citation tracking. Thus, 31 prospective
studies and 3 reviews were selected.
Data Extraction: Details of the participants, the injuries and diagnosis, the
sport involved, the risk factors investigated, and the outcomes and follow-up
were extracted by the authors, who both
assessed the studies methods. For continuous data, standardised mean differences (SMD) and 95% condence
intervals (CI), were calculated. Metaanalysis was conducted where possible
using a random effects model.
Main Results: Hamstring injuries were
investigated in 14 studies of Australian
football, 10 studies of soccer, 5 studies
of track and eld, and 2 studies of rugby.
The follow-up period varied between 3
weeks and 8 years. The study method
scores ranged from 44% to 94%, with
12 studies not adjusting appropriately
for confounding factors such as previous
injury and age. Older age was associated
with probability of injury in a metaanalysis of 7 studies (SMD, 2.5; 95%
CI, 0.78-4.15) and in a separate analysis
of 3 studies (odds ratio [OR], 2.46, 95%
CI, 0.98-6.14). Meta-analyses of 8 studies, including 2952 athletes, found previous hamstring injury to be a risk factor
for future injury (relative risk [RR], 2.68;
95% CI, 1.99-3.61 and OR, 4.06; 95%
CI, 2.39-6.89). Body mass index, weight,
and height were generally not associated
with rst or recurrent hamstring injuries.
There was little evidence from 11 studies
that the ratio of hamstring to quadriceps
strength was a risk factor for hamstring
injuries, whatever the speed and contraction type of the testing. In 4 studies, hamstring peak torque was not found to be a
risk for hamstring injuries (SMD, 20.24;
95% CI, 20.85 to 0.37). However, in
4 studies, increased quadriceps peak
torque did appear to be a risk factor for
hamstring injuries (SMD, 0.43; 95% CI,
0.05-0.81). Factors such as strength
asymmetries, limb dominance, playing
position, exibility and tness were not
consistently associated with hamstring
injuries.
2014 Lippincott Williams & Wilkins

Sport Medicine Journal Club

Conclusions: Among many risk factors that were investigated only older
age, previous hamstring injury, and
increased quadriceps peak torque were
associated with an increased risk of
sustaining a future sport-related hamstring strain injury.

Commentary
Freckleton and Pizzari are to be
commended for providing the sport
medicine community with the most
comprehensive literature search and syntheses to date of studies relating to risk
factors for hamstring muscle injury. The
topic is of interest to all sport medicine
practitioners concerned with the management of this most common muscle
injury in sport.
The greatest strengthbut also
weaknessof the review by Freckleton
and Pizzari is in the pooling of data.
The strength is that statistical power
is potentially increased by including
more injuries (events) associated with
the individual risk factors being investigated.1 However, the weakness of
pooling data that appear to be unadjusted is that important interaction
effects or confounders may be missed,
as the authors mentioned as a limitation
of their study.
The identication of risk factors
was considered a critical step in the
4-step sequence of injury prevention
that was introduced by van Mechelen
et al.2 The reason for this is that risk
factors related to a specic injury
should offer information on the underlying causes for the particular injury.1,2
Thus, information on risk factors may
suggest strategies for future injury
prevention.2 Although this idea is simple and appealing, the multifactorial
nature of injuries in sports may sometimes interfere with this approach,
especially in prospective risk factor
studies in which important factors,
known and/or unknown, are not taken
into account.1
The present systematic review
agrees with previous studies in identifying
older age and previous hamstring muscle
injuries as risk factors for subsequent
hamstring muscle injury. The role of
quadriceps and hamstring muscle strength
seems less clear. Based on the investigators statistical analyses, increased

quadriceps strength is a risk factor for

hamstring muscle injury, whereas hamstring weakness is not. Does this mean
that injury prevention should focus on
systematic quadriceps strength reduction (immobilization would be quite
effective for this) in athletes at risk of
hamstring muscle injuryinstead of
eccentric hamstring strengthening?
Probably not, especially as eccentric
hamstring strengthening has been shown
to be an effective injury-preventative
strategy.3 Although the van Mechelen
model may be theoretically useful, in reality our understanding of risk factors may
suffer from not taking the multifactorial
nature of hamstring muscle injuries into
account.1
Freckleton and Pizzari suggest that
previous injury and age should be
considered in a multivariate model
when other risk factors are investigated. However, based upon their
ndings of increased peak quadriceps
strength as a risk factor for hamstring
muscle injury it may also be relevant
to include this isolated variable in
multivariate analyses, to investigate
interaction or confounding effects.
Future studies of potential risk factors
for hamstring muscle injury should
also include adjustment for individual
athletic exposure hours,1 particularly
focusing on match-play exposure in
high-risk hamstring-injury sports such
as football, because match-play is
associated with higher rates of hamstring injuries than is similar time
spent training.3 These factors have not
been adequately accounted for in the
current literature, which limits our present understanding of risk factors for
hamstring muscle injury.
Kristian Thorborg, M Sportsphysio, PhD
Arthroscopic Centre Amager
Copenhagen University Hospital
Amager-Hvidovre, Copenhagen, Denmark

REFERENCES
1. Bahr R, Holme I. Risk factors for sports injuries
a methodological approach. Br J Sports Med.
2003;37:384392.
2. van Mechelen W, Hlobil H, Kemper H. Incidence, severity, etiology and prevention of
sports injuriesa review of concepts. Sports
Med. 1992;14:8299.
3. Thorborg K. Why hamstring eccentrics are
hamstring essentials. Br J Sports Med. 2012;
46:463465.

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