So when can I play again doc?! This is the first question I am usually asked by an athlete, soldier or amateur sportsperson after they injure themselves playing the sport they love. The answer to this can be challenging as so many variables are in play. Have they presented acutely after injury or some time down the line with failed attempts at rehab? What's the location of the injury? What grade is the injury? is it a re-injury? Who is going to be looking after them during their recovery? - Professional athletes have a team of experienced clinicians at their disposal but at the same time their demands are much higher. The list goes on...
When it comes to muscle injuries we have come a long way in understanding why some muscle tears take longer to recover than others. Still it's by no means an exact science and any time frame ranges need a significant sprinkle of salt. With that in mind however, I've produced a table of the rough time frames I might expect for recovery for 3 of the more common muscle injury groups I see in my practice - Hamstring (a group of 3 muscles), rectus femoris (a hip flexor and knee extensor and part of the quadriceps thigh muscle group; and soleus part of the calf muscle complex.
It all starts with the right diagnosis; but once that has been clearly established the following tables represent a rough guide and starting point to work with.
Here is a table for hamstring injuries (subdivided by muscle) using the BAMIC grading system with return to play (RTP) timeframes:
Hamstring Injuries (BAMIC Grading System)
| Muscle Involved | BAMIC Grade | Description | RTP Timeframe | Notes |
|---|---|---|---|---|
| Biceps Femoris (Long Head/Short Head) | 0 | No structural damage | 5–12 days | Includes delayed-onset muscle soreness (DOMS). |
| 1a/1b | Minor strain or tear | 2–3 weeks | Myofascial or muscle belly involvement. | |
| 2a/2b | Partial muscle tear | 3–5 weeks | Healing time depends on fascial versus intramuscular involvement. | |
| 2c | Partial tear with tendon involvement | 5–7 weeks | Prolonged recovery due to tendon injury. | |
| 3a/3b | Large muscle tear | 7–9 weeks | Significant structural damage in muscle belly or junction. | |
| 3c | Intramuscular tendon tear | >10 weeks | Higher reinjury rates; careful rehabilitation required. | |
| 4c | Complete rupture | >12 weeks | Often requires surgical repair; RTP depends on successful rehabilitation. | |
| Semimembranosus | 0–1a/1b | No to mild strain | 5–20 days | Faster recovery than biceps femoris. |
| 2a/2b | Partial tear | 4–6 weeks | Typical for injuries in the muscle belly or fascial areas. | |
| 2c–3c | Tendon involvement or extensive tear | 7–10 weeks | Gradual progressive loading essential to avoid reinjury. | |
| 4c | Complete rupture | >12 weeks | Rare for this muscle; surgical repair likely needed. | |
| Semitendinosus | 0–3c | Similar grades as semimembranosus | 5–10% shorter RTP | Recovery faster compared to other hamstrings due to less strain on the tendon |
| T-Junction (Biceps Femoris) | 2a–3c | Injury at the musculotendinous junction | 6–10+ weeks | High recurrence risk; complex anatomy involving sciatic nerve proximity |
Here is a comprehensive table categorizing the return-to-sport (RTS) timeframes for rectus femoris injuries based on the British Athletic Muscle Injury Classification (BAMIC) system, incorporating all grades and subcategories (0 through 4c):
| BAMIC Grade | Description | RTS Timeframe | Notes |
|---|---|---|---|
| 0 | MRI-negative muscle soreness or DOMS | 1–7 days | No structural damage; resolves with rest and minimal |
| 1a | Small myofascial tear | 7–14 days | Peripheral myofascial involvement; faster recovery |
| 1b | Small muscle belly tear | 10–21 days | Involves the muscle belly; slightly longer recovery due to location |
| 2a | Moderate myofascial tear | 2–4 weeks | Peripheral involvement with greater structural damage |
| 2b | Moderate muscle belly tear | 3–5 weeks | Requires structured rehabilitation to restore strength and function |
| 2c | Partial intratendinous tear (<50% tendon damage) | 4–8 weeks | Tendon involvement prolongs healing; requires progressive tendon loading |
| 3a | Large myofascial tear | 3–6 weeks | Significant structural damage but peripheral location supports faster healing |
| 3b | Large muscle belly tear | 6–12 weeks | Often involves the musculotendinous junction; demands careful rehabilitation |
| 3c | Significant intratendinous tear (>50% tendon damage) | 8–16 weeks | Extensive tendon damage with risk of reinjury; slow healing process |
| 4c | Complete rupture with tendon involvement | 3–6 months (or longer) | Surgical intervention often required; prolonged and intensive rehabilitation |
Soleus Injuries (Pedret Grading System)
| Pedret Grade | Description | RTP Timeframe | Notes |
|---|---|---|---|
| 1 | Myofascial injury | 1–2 weeks | Superficial, limited to fascia; mild symptoms. |
| 2 | Muscle belly injury | 2–4 weeks | Involves localized damage without significant structural compromise. |
| 3 | Partial-thickness muscle tear | 4–6 weeks | Moderate structural damage; progressive strengthening required. |
| 4 | Full-thickness muscle tear | >8–12 weeks | Severe damage; often requires surgical repair and prolonged rehabilitation |
Overall some key summary points for these muscle injuries are:
Grade 2c injuries involve partial tendon damage with <50% cross-sectional area affected, typically requiring 4–8 weeks for RTP. These injuries demand careful monitoring during rehabilitation to avoid re-injury.
Grade 3c injuries involve >50% cross-sectional area tendon damage, often necessitating 8–16 weeks for recovery. This longer period reflects the severity of the injury and the tendon’s slower healing properties
Intratendinous injuries, as denoted by the "c" classification, are associated with poorer prognosis due to tendon healing dynamics. Specific rehabilitation strategies, including progressive loading and addressing proximal/distal muscle support, are critical for a successful RTS.
These timeframes are approximations and vary based on the injury's exact characteristics and the athlete's individual response to treatment. Further details on management approaches can be found in relevant sports medicine journals and rehabilitation guidelines.
Semitendinosus:
- Similar to semimembranosus, though generally milder severity; RTP ~5% shorter.
T-Junction Injuries:
- Proximal musculotendinous junction injuries, particularly at the biceps femoris, tend to require longer RTP times due to high reinjury risk and complexity. RTP averages 6–10 weeks depending on severity, with "c" grades reaching >10 weeks.
Soleus RTP timeframe is influenced by injury location, grade, and presence of tendon involvement. Soleus injuries classified by Pedret grading tend to recover more slowly due to the muscle's postural function and high activity in weight-bearing
Location of Injury is key. Myofascial injuries (a) have a shorter recovery times due to reduced stress on the tendon. Muscle Belly (b) injuries have a slightly longer recovery, particularly for moderate-to-severe injuries. Intratendinous injuries generally have the longest recovery due to poor tendon healing properties.
Severity of Tear progresses from Grade 1 (mild) (or 0) to Grade 4 (complete rupture) with increasing RTS timelines as severity increases
Consider rehabilitation needs and remember that all injuries involving tendon damage (Grades 2c, 3c, 4c) require progressive loading strategies, focusing on muscle-tendon unit capacity, and careful monitoring to minimise re-injury risk.