In-Season Management of Hamstring Tendon Injuries in Elite Athletes

In-Season Management of Hamstring Tendon Injuries in Elite Athletes

A 2026 forward-thinking, evidence-based perspective from the global stage

At the January Global Knee Summit in Dubai, in-season hamstring injuries were a central topic during the World Cup of Soccer session, where Dr. Jazayeri was selected as an expert speaker and moderator alongside world leaders in sports medicine caring for professional and high-level athletes.

The message was clear: hamstring injuries in elite sport demand precision, restraint, and strategy. The goal is not simply healing, but safe, high-performance return to play (RTP), often within the same season, while protecting long-term career longevity.


Why Hamstring Injuries Are Uniquely Difficult In-Season

Hamstring injuries are not one diagnosis. They include:

  • Intramuscular strains
  • Myotendinous junction injuries
  • Tendon insertional pathology
  • Partial or complete proximal avulsions

Elite athletes face additional pressures:

  • Dense competition schedules
  • High sprint and acceleration demands
  • Elevated reinjury risk with premature RTP
  • Contractual and career implications

As emphasized in Dubai, a nuanced, anatomy-driven approach is mandatory.

First Principles: Conservative Care as the In-Season Foundation

Load Management & High-Performance Rehabilitation

Modern in-season rehab prioritizes:

  • Early controlled loading, not rest
  • Progressive eccentric strengthening
  • Lumbopelvic control and sprint mechanics
  • GPS-guided running exposure and objective RTP metrics

This approach preserves conditioning while reducing recurrence risk.

 

Orthobiologics in 2026: Matching Biology to Injury Location

Orthobiologics are adjuncts, not replacements, for rehab, and their success depends on tear location, tissue biology, and delivery accuracy.


*LEARN MORE IN THIS BLOG: Use of orthobiologics for hamstring injuries 


PRP vs PPP: Not All Hamstring Injuries Are the Same

Platelet-Rich Plasma (PRP)

  • High platelet and growth-factor concentration
  • Stronger inflammatory and remodeling signal
  • Best suited for tendon-dominant pathology, including:
    • Proximal hamstring tendinopathy
    • Partial insertional tendon tears

Recent high-quality data show that ultrasound-guided PRP combined with structured rehab shortens RTP and may reduce reinjury risk, particularly in grade-2 injuries and tendon-based pathology (1,2).

Platelet-Poor Plasma (PPP)

  • Lower platelet concentration
  • Reduced inflammatory response
  • Increasing evidence supports PPP for intramuscular hamstring strains

A 2024 cohort study in collegiate football athletes demonstrated rapid RTP (~29 days), early pain improvement, and zero reinjuries at 12 months, positioning PPP as a compelling in-season option for muscle-belly injuries (3). Mechanistically, PPP may better support native muscle regeneration without excessive fibrosis (4).

BMAC (Bone Marrow Aspirate Concentrate)

  • Rich in mesenchymal signaling cells and cytokines
  • Considered for:
    • Recalcitrant tendon injuries
    • High-grade partial tears when surgery is being deferred
  • More commonly used out of season or in complex cases rather than acute in-season management

 

The Importance of Ultrasound Guidance

Across biologic modalities, ultrasound-guided delivery is now standard of care:

  • Confirms exact tear location
  • Optimizes biologic placement
  • Reduces complications
  • Improves consistency and outcomes (5)

When Conservative Care Is Not Enough

Understanding Tear Patterns That Require Surgery

While non-operative care is preferred in-season, immediate surgery is indicated when it offers the best long-term outcome, including:

  • Complete proximal hamstring avulsions
  • Multi-tendon involvement
  • Significant tendon retraction
  • Failure of high-level conservative management

In many elite athletes, symptoms are managed conservatively through the season, with definitive surgery planned in the off-season, unless anatomy dictates otherwise.


Surgical Strategy: Repair vs Reconstruction

  • Primary Repair
    • Acute proximal avulsions
    • Better tissue quality
    • Faster neuromuscular recovery
  • Reconstruction
    • Chronic tears or poor tissue quality
    • Often combined with biologic augmentation

Surgical timing and technique must align with sport demands, season timing, and career trajectory.


Return to Play: Criteria Over Calendars

Elite RTP decisions are performance-based, not time-based:

  • Pain-free sprinting and deceleration
  • Eccentric strength symmetry
  • Sport-specific workload tolerance
  • Psychological readiness

Imaging supports decisions, but does not dictate clearance.


Why Expertise Matters

Managing hamstring injuries in elite athletes is high-stakes medicine requiring:

  • Advanced imaging interpretation
  • Deep understanding of tissue biology
  • Mastery of orthobiologic indications
  • Integration with high-performance rehab teams

Evaluation by experts such as Dr. Jazayeri, who operate at the intersection of science, elite sport, and clinical judgment, is essential to deliver safe, season-preserving, and career-protecting outcomes.


References 

  1. Desouza C, Shetty V. (2025). Efficacy of PRP in grade-2 hamstring injuries: randomized controlled trial. (Desouza & Shetty, 2025)
  2. Liu M, et al. (2025). PRP injection for hamstring injury: systematic review and meta-analysis. (Liu et al., 2025)
  3. Kruse RC, Volfson E. (2024). Platelet-poor plasma for acute hamstring muscle injuries in collegiate football athletes. (Kruse & Volfson, 2024)
  4. Raum GM, et al. (2024). Platelet-poor versus platelet-rich plasma for muscle injuries. (Raum et al., 2024)
  5. Masiello F, et al. (2022). Ultrasound-guided PRP injections for tendinopathies: systematic review. (Masiello et al., 2022)




 

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