Clinical versus radiological findings: A paradox in diagnosing minor hamstring injuries

Hamstring injuries occur commonly in athletes participating in sports that require sprinting/high velocity running, kicking a ball or agility. In the first instance, clinical assessment and management play a pivotal role in managing these injuries. Radiological investigations such as ultrasonography (US) and magnetic resonance imaging (MRI) are also recommended to confirm one or more parameters related to hamstring injury (the location, length, cross-sectional area, volume, edema, hemorrhage, etc.) and predicting return-to-play. However, hamstring injuries that are minor in nature, diagnosed clinically, may not be discernible on conventional US or MRI in some cases. Certain reasons for these paradoxical (clinical vs. radiological) findings may include pain referral to the posterior thigh from lumbosacral dysfunction or sciatic nerve pathoneurodynamics. Conversely, minor hamstring injuries might remain indiscernible within the threshold of conventional MRI sensitivity. To date, there is neither clear consensus on a standardized criteria nor strong evidence for using MRI to prognosticate return-to-play following hamstring injuries. This paper briefly discusses the controversy between contradicting clinical and radiological findings encountered by clinicians in the diagnosis of minor hamstring injuries. If posterior thigh pain appears with clinical signs and symptoms of a minor hamstring injury without pain referral from neighboring structures, but presents with negative findings on US or MRI, the diagnosis remains a challenge. However, such conditions are pragmatically treated as (nonstructural) hamstring injuries unless certain differential diagnoses can be established.