Current concepts in acute hamstring injury management: diagnosis, rehabilitation, return to sport, and surgical treatment

Hamstring injuries are common in sports and frequently recur.This review synthesizes contemporary evidence on the management of acute hamstring injuries, integrating the London International Hamstring Consensus with recent literature on anatomy, diagnosis and imaging, classification, rehabilitation and return to sport, nonoperative treatment, and surgery.Clinical examination remains central; magnetic resonance imaging is most useful when high-grade tendon involvement or avulsion is suspected, and ultrasound is an accessible tool for initial assessment.The British Athletics Muscle Injury Classification is associated with recovery time in cohorts of elite athletes but cannot reliably predict individual outcomes.Rehabilitation should be individualized and criteria-based, although no single validated return-tosport test or established strength threshold exists, and several adjunctive treatments remain under investigation.Surgery may benefit selected patients with high functional demands or refractory injuries, but most surgical indications are based on observational evidence, and a recent randomized trial found that nonoperative treatment was noninferior to surgery for proximal avulsions in moderately active adults.We propose phenotype-informed frameworks in which the injured structure and its healing characteristics guide loading progression, return-to-sport timing, and surgical decision-making.