Hamstring T-Junction Surgical Repair: An Elite Footballer's Return to Play Journey Through a New Football-Centered Complex Approach

Abstract

Background: Hamstring strain injuries have a significant impact in football, with a high re-injury rate, particularly when the distal musculotendinous T-junction (DMTJ) is involved. In some cases, surgical repair is necessary to reduce the risk of re-injury and ensure return to play (RTP) at the pre-injury level.

Study design: Case Report.

Case description: A 24-year-old male football (soccer) player, playing in the Swiss first division, with recidivate hamstring injury, who undercame to surgical repair of DMTJ and returned to play through after 19 weeks. This case report introduces a new football-centered model divided into four main phases, showing how it guided the clinical reasoning used through the RTP process, along with MRI evaluations, clinical outcomes, global positioning system (GPS) data, and strength and power (S&P) neuromuscular testing.

Outcomes: The subject gradually returned to team training after 12 weeks and successfully returned to play after 19 weeks. The player participated in 26 official matches throughout the season, accumulating 1.323 minutes of play without reporting any symptoms at the injury site.

Conclusions: The subject had a successful return to play following the rehab model proposed in this case report, as he was involved in all the matches, and he played without any symptoms or new injuries.

Level of evidence: 5.

Keywords: Football; Return to Play; distal musculotendinous T-Junction; hamstring; surgery.

Figure 1.. MRI imaging at four different timepoints.

1A-B. 48h after injury. Distal musculotendinous T-Junction injury with diffused hematoma. 2A-B. After re-injury, pre-surgery evaluation. Chronic rupture, small seroma and gap identified at the biceps femoris (BF) T-Junction area with loss of tension of the musculotendinous structure. 3A-B. Week 9 after surgery. Healing and maturation of injured area, regular tension of the structures restored. 4A-B. Week 16 after surgery. Complete healing of the surgery site.

Figure 2.. Surgical incision, identification of the T-junction injury site and surgical repair.

Figure 3.. Hamstring rehabilitation and return to play process based on a football-centered model (Credits to Marco Carletta).

S&C: Strength and conditioning; HSR: High-speed running; MSS: maximal sprinting speed

Figure 4.. Example of a knee-based hamstring exercise.

With this kind of exercise, we place more tension on the distal part of the hamstring. By using a flywheel inertial device, eccentric overload is emphasized.

Figure 5.. Example of a ball possession game during the return to partial team training phase.

Figure 6.. Concentric and eccentric mean and peak torque during Isokinetic testing at three different timepoints during the return to play (RTP) process.

ISO test 1: Isokinetic test before returning to high-speed running (at week 12); player performed 5 concentric and 5 eccentric repetitions at 60°/s. ISO test 2: before return to full training (at week 16); player performed 5 concentric and 5 eccentric repetitions at 60°/s and 180º/s. ISO test 3 at the beginning of the next season (8 months after RTP); player performed 5 concentric and 5 eccentric repetitions at 60°/s, and 5 eccentric repetitions at 180°/s (normal protocol in the club). Since the player’s bodyweight did not change throughout process (fluctuating by only 1 kg), normalized values were not provided. All the tests were performed using an Easytech Genplus Isokinetic Dynamometer (Easytech s.r.l., Borgo San Lorenzo (FI), Italia).

Figure 7.. Countermovement Jump (CMJ) tests at three different timepoints.

Pre-injury(1), Pre-return to High-Speed Running & Sprint phase (week 12) (2) and Post-return to play (week 24)(3). At each timepoint, three CMJs were performed on force platforms at 1000 Hz (FD4000, Vald Performance, Brisbane, Australia). UL:Uninjured Limb; IL: Injured Limb

Figure 8.. Example of a situational high speed running drill during the return to HSR and Sprint phase.

Figure 9.. High-speed running distance (HSR, distance between 20 – 25 km/h) and sprint distance (distance > 25 km/h) covered during the microcycle training with the team before and after the injury.

Figure 10.. Comparison between external loads accumulated during three full microcycles training with the team before and after the injury.

HSR: High Speed Running distance, between 20 – 25 km/h; Sprint: distance > 25 km/h. *Cohen effect size: small difference.