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MUSCLE INJURY GUIDE:
PREVENTION AND TREATMENT
OF MUSCLE INJURIES
MUSCLE
INJURY
GUIDE: 1
Prevention of
and return to
play from
muscle injuries
List editors: Editorial Assistants:
Ricard Pruna Steffan Griffin
Thor Einar Andersen Johann Windt
Ben Clarsen
Alan McCall
CHAPTER 1
SECTION
LEADERS
EXERCISE-BASED
MUSCLE INJURY
PREVENTION (EBMIP) Muscle Injury
Guide:
Clare Ardern GROUP (SEE SECTION
Roald Bahr 1.4.4.A)
Maurizio Fanchini
Phil Glasgow Andrea Azzalin
Tero Jarvinen Andreas Beck
Prevention
Lasse Lampeinen Andrea Belli
Andrea Mosler Martin Buchheit
James O’Brien Gregory Dupont
Tania Pizzari Maurizio Fanchini
Nicol van Dyk Duccio Ferrari Bravo
and Treatment
Markus Waldén Shad Forsythe
Arnlaug Wangensteen Marcello Iaia
Yann-Benjamin Kugel
Imanol Martin
Samuele Melotto
of Muscle
Jordan Milsom
Darcy Norman
INTERNATIONAL
Edu Pons
CONTRIBUTORS
Stefano Rapetti
Injuries
Abd-elbasset Abaidia Bernardo Requena
Natalia Bittencourt Roberto Sassi
Mario Bizzini Andreas Schlumberger
Ida Bo Steenhal Tony Strudwick
Martin Buchheit Agostino Tibaudi
Phil Coles
Aaron Coutts
Michael Davison
Gregory Dupont
Caroline Finch
Brady Green
Martin Hägglund
Shona Halson
Joar Harøy
Per Homlich
Franco Impellizzeri
Gino Kerkhoffs
Ozgur Kilic
Justin Lee
Matilda Lundblad
Nicolas Mayer
Bob McCunn
Prof. Tim Meyer
FC BARCELONA
CONTRIBUTORS
Juanjo Brau
Xavi Linde
Antonia Lizzaraga
Sandra Mecho List editors: Editorial Assistants:
Edu Pons Ricard Pruna Steffan Griffin
Jordi Puigdellivol Thor Einar Andersen Johann Windt
Xavi Valle Ben Clarsen
Xavi Yanguas Alan McCall
S
OF MUSCLE INJURIES
6 Summary 7
SUMMARY
OF MUSCLE INJURIES
EDITOR’S
BIOGRAPHIES
8 Editor’s DR. RICARD PRUNA PROF. THOR EINAR ANDERSEN DR. BEN CLARSEN DR ALAN MCCALL 9
biographies
MD, PhD MD, PT, PhD,PM&R Msc, PhD
Ricard Pruna is a specialist Thor Einar Andersen is a Ben Clarsen is a specialist Alan is Head of Research
in Sport & Exercise Medicine Professor and Head of football sports physiotherapist at & Development for Arsenal
with a Masters in both medicine research at the Oslo the Norwegian Olympic Football Club and Co-head of
‘Traumatology and Sports’ Sports Trauma Research Centre Training Center and a Research & Innovation (with
and ‘Biology and Sports’ and in the Department of Sports postdoctoral research fellow Assoc Prof Rob Duffield) at
additionally holds a PhD Medicine at the Norwegian at the Oslo Sports Trauma Football Federation Australia.
in ‘Genetics and Injury in School of Sport Sciences, Research Center (OSTRC). Alan’s background is as a fit-
Football’. Ricard has a rich and Norway. He has a master degree He has a bachelor degree ness coach and sport scientist
vast experience in top-level in health administration from in physiotherapy from the with over ten years experience
football having been the first the University of Oslo. He is a University of Sydney and working in professional club
team doctor of FC Barcelona trained physiotherapist, consul- a master degree in sports teams competing in Ligue
for over 20 years. He is also tant physician, and specialist in physiotherapy and PhD 1, English Premier League,
the Head of Medical Services Physical and Rehabilitation Me- from the Norwegian School A-League, Scottish League
at FC Barcelona, overseeing dicine. His main research areas of Sport Sciences. He is a and European competitions.
the medical strategy and staff are football injury epidemiology, director of the IOC Diploma He was Head of Sport Science
of all medical aspects in the injury mechanisms and causes, in Sports Physical Therapies and fitness coach of the Aus-
club, including X professional as well as injury prevention. He and a lecturer on the sports tralian Socceroos at the 2014
sports in addition to his first has published more than 65 physiotherapy master FIFA World Cup and the U20
team football duties. peer-reviewed articles and book program at the Norwegian Young Socceroos at the 2013
chapters. School of Sport Sciences. Ben World Cup.
Ricard’s clinical interests lie has been physiotherapist
in football medicine, muscle Thor Einar is the Chief medical for a number of professional Alan’s research interests include
injuries, genetics, return to officer of the Medical Commit- road cycling teams, and the injury prevention, recovery
play, anatomy and injury tee in The Football Association of Norwegian and Australian and performance in football.
diagnosis. He has many Norway. He has served as team national programmes. He He holds a PhD in ‘Injury
scientific publications in physician for the senior male is a senior associate editor Prevention in Elite Footballers’
the football medicine areas national team from 2002-2014. of BJSM and was the senior from Université de Lille 2 and a
and has received various He is medical director at the editor of the 5th edition of Msc in Strength & Conditioning
awards for his scientific work, Norwegian FA Medical Centre Brukner and Khan’s Clinical from Edith Cowan University,
including, the Award for and is a member of the board Sports Medicine textbook. Australia.
Medical Excellence from the and director of elite sports in
Medical College University the football department at Alan is a member of the
of Barcelona, a National and Nordstrand IF. Football Research Group, Senior
UEFA Award for research in Associate Editor at British
sports medicine. Thor Einar has a strong con- Journal of Sports Medicine,
nection with high-level football Associate Editor at Science and
having played professionally Medicine in Football and on the
winning two Norwegian cham- editorial board of Apunts which
pionships with IK Start, and is a joint publication by the
represented Norwegian interna- Conseil Catala de l’Esport and
tional youth teams (U15-U23). Barca Innovation Hub.
EDITOR’S BIOGRAPHIES
MUSCLE INJURY GUIDE: MUSCLE INJURY GUIDE:
PREVENTION AND TREATMENT PREVENTION AND TREATMENT
OF MUSCLE INJURIES OF MUSCLE INJURIES
EDITORIAL ASSISTANTS
BIOGRAPHIES
10 JOHANN WINDT DR. STEFFAN GRIFFIN WHAT WE DO? OUR FOCUS 11

PhD Candidate, MSc, CSCS MBChB BSc (Hons)
KNOWLEDGE FC Barcelona aims to help change the
Johann Windt is a Sports Steffan is a junior doctor at world through sporting excellence via
Medicine Data Analyst at Chelsea and Westminster Exchanging ideas with the greatest knowledge and innovation
the United States Olympic Hospital in London, who is minds around the world to develop
Committee. Before his passionate about pursuing a cutting edge applied research projects. We are looking to form an ecosystem to
current role at the USOC, career in Sport and Exercise We have the commitment to share this foster knowledge and innovation. This
he spent two years with Medicine. He sits on the British knowledge to the new generation of ecosystem is based on a model that
the Vancouver Whitecaps Journal of Sports Medicine’s sports industry professionals. promotes a culture of excellence and
Football Club (competing in editorial board as senior collaboration with prestigious brands,
the Major League Soccer) associate editor and helps universities, research centres, start-
as a sport science data lead the journal’s social media ups, entrepreneurs, students, athletes,
NEW PRODUCTS AND SERVICES
analyst. He is currently a PhD channels. Steffan is also a investors, and visionaries around the
candidate at the University board member of the Institute world.
Leveraging our know how to partner
of British Columbia Canada. of Sport and Exercise Medicine,
with key stakeholders and create game
Co-supervised by Professors and has active research By doing so, we aim to generate new
changing technologies, processes and
Karim Khan and Tim Gabbett, interests in concussion, return- knowledge and create new products
experiences which create value not
his doctoral work focuses to-play, and medical education. and services that will be of benefit to
only for the Club but for the whole
on athlete monitoring and our own athletes, members and fans,
society.
injury aetiology. Johann is and society in general.
also a member of the Football
Research Group, which is an A RELEVANT ECOSYSTEM
international research group
collaborating closely with the Encouraging and connecting the sports HOW?
Union of European Football business ecosystem: industry leaders,
Associations (UEFA) on various sport organizations, research centers, Our knowledge and innovation
research projects related to universities, entrepreneurs and start-up. activities are structured in 5 areas:
football player health and
performance. 1. Medical services and nutrition
2. Sports performance
3. Team sports
4. Technology
5. Social science
EDITOR’S BIOGRAPHIES EDITOR’S BIOGRAPHIES

OF MUSCLE INJURIES
0.1
PREVENTING AND TREATING

MUSCLE INJURIES IN FOOTBALL
There are many physical and mental health benefits to training and playing
football, however, there is also, unfortunately, one key adverse effect; an increased
risk of injury, with muscle injuries being one of the most common injuries we see in
elite football.
— With Ricard Pruna
12 Introduction There are many physical and mental health benefits to training and playing football,
13
to Guide
however, there is also, unfortunately, one key adverse effect; an increased risk of injury,
with muscle injuries being one of the most common injuries we see in elite football. Due
to the negative effects that we know injuries have on performance, club finances and
long-term player health, their prevention and optimal treatment (when they do occur) is
an essential part of the football medicine and performance department. In particular, at FC
Barcelona (and I am sure in many of the football clubs around the world) we see the role
of the football medicine and performance department and staff as three-fold;
1. Protect our players’ health

2. Maximise player and team performance
3. Ensure the scientific integrity of medical and performance programs delivered
in FC Barcelona
At FC Barcelona we believe that the creation, integration and delivery of an effective and
efficient medical and performance program requires an evidence led approach, using the
best of research knowledge combined with our many years of practical experience. We
also believe strongly in sharing our knowledge and experiences among the football and
sports community globally.
In 2009, we published the first FC Barcelona Muscle Injury Guide with the aim of providing
an insight into our philosophy and methods of preventing and treating muscle injuries.
Then in 2015 we released our second Muscle Injury Guide. With each Guide we strive to
progress on the last. We now have the great pleasure of launching our 2018 FC Barcelona
Muscle Injury Guide: ‘Preventing and Treating Muscle Injuries in Footballers’. We see this
Guide not as a progression on the previous two, but rather as a new concept and with a
new direction. In the true spirit of FC Barcelona, we are ‘mes que un club’ (more than a
club) and have welcomed into our football family, a number of internationally renowned
sports medicine and performance practitioners and researchers to contribute with us on
the practical recommendations that follow. We are truly grateful for the partnerships we
have formed in the production of this Guide including; the Oslo Sports Trauma Research
Centre and the Science and Medicine in Football Journal. Our aim is to provide you, the
reader/practitioner with the most up to date knowledge and experiences from 60+
worldwide experts combined with the ‘Barça Way’.
Our Muscle Injury Guide is not intended to be a ‘must follow recipe’, but rather to provide
some key ingredients that you can adapt and integrate appropriately into your own
practice. We hope you enjoy reading the combined knowledge and experiences of the
many valued contributors included throughout.
Dr Ricard Pruna
Head of Medical Services, FC Barcelona
CHAPTER 0
0.2 0.3
PARTNERSHIP WITH OSLO SPORTS SCIENCE AND MEDICINE IN

TRAUMA RESEARCH CENTRE FOOTBALL JOURNAL’S SUPPORT
The Oslo Sports Trauma Research Centre was established at the Norwegian School At Science and Medicine in Football, our mission is to advance the theoretical
of Sport Sciences in 2000 as a research collaboration between the Department knowledge, methodological approaches and professional practice associated
of Orthopaedic Surgery, Oslo University Hospital, Ullevaal, the Department of with the sport of football. In other words, we want to help bridge the gap between
Sports Medicine, Norwegian School of Sport Sciences, and The Norwegian Football science/research and the practical setting. Essentially, we are an international,
Association Medical Clinic (2015). Since 2009, the OSTRC has been recognised as a peer-reviewed journal interested in promoting evidence-based practice i.e. use of
FIFA Medical Centre of Excellence and selected as one of four IOC Research Centres quality research knowledge with current best practice.
for Prevention of Injury and Protection of Athlete Health. — With Prof Tim Meyer and Prof Franco Impellizzeri
— With Thor Einar Andersen and Roald Bahr
14 The main objective of Oslo Sports Trauma Research Centre has been to develop a long- 1. Arnason A, Andersen TE, We focus on many areas of football including, physiology, biomechanics, nutrition, training, 15
term research program on sports injury prevention (including studies on epidemiology, Holme I, Engebretsen L, testing, performance analysis, psychology and coaching. Additionally, sports science and
Bahr R. (2008) Prevention
risk factors, injury mechanisms, and interventions). The program focuses mainly on three of hamstring strains in eli- medicine in football is key for us and our readership, with injury prevention and return to
sports (football, handball, and alpine skiing/snowboarding). We have addressed the most te soccer: an intervention play current hot topics for us and our readers.
study. Scand J Med Sci
common (e.g. ankle, hamstrings) and the most serious (e.g. ACL, concussions) injuries seen Sports;18(1):40-8
in these sports. The FC Barcelona Muscle Injury Guide 4.0 corresponds to our vision of bringing research
2. Soligard T, Myklebust
G, Steffen K, Holme I, and practice together. In this resource, FC Barcelona have brought together over 60 of
In football, one focus has been on the preventive effect of eccentric hamstring training Silvers H, Bizzini M et al. some of the world’s leading applied researchers and practitioners to share and perhaps
(2008) Comprehensive
using the Nordic Hamstring exercise.1 We have, in partnership with FIFA, also developed warm-up programme to
most importantly, work together to combine their knowledge and experience into one
“The 11+”, a warm-up program with exercises focusing on core stability, neuromuscular prevent injuries in young voice.
control, strength, balance, hip control and knee alignment in football.2 In 2011, we female footballers: cluster
randomised controlled
conducted an intervention study in the Norwegian male professional league involving trial. BMJ;337:a2469 Not only will this Guide provide a great practical recommendations’ resource for football
sanctioning of two-footed tackles as well as tackles with excessive force and intentional 3. Bjørneboe J, Bahr R,
science and medicine practitioners worldwide, but should also help to drive forward
high elbow with an automatic red card to enforce the Rules of the Game.3 Dvorak J, Andersen TE. meaningful applied research to further improve our field.
(2013) Lower incidence
of arm-to-head contact
We have through several conferences, workshops, visits and meetings with FC Barcelona incidents with stricter It is with great pleasure that we support this initiative by FC Barcelona. One aspect that
(FCB) and its medical staff, been inspired by the clubs’ constant strive to implement best interpretation of the we are particularly excited about is that various contributors involved in the Guide will
medical practice and scientific knowledge into their daily practice. In particular, we have Laws of the Game in progress on some of the chapters written within, by preparing scientific articles and
Norwegian male profes-
been impressed by the FCB philosophy on training principles, diagnostic procedures and sional football. Br J Sports submitting these to enter the Science and Medicine in Football peer review process. So,
management of return to play after injury. Med;47(8):508-14 watch this space…
Both the Oslo Sports Trauma Research Centre and the FC Barcelona share a common
understanding that scientists and practitioners should collaborate closely to bridge the gap
between science and practice. We certainly believe developments in the area of football
medicine will benefit from improved on- and off-field teamwork to answer the key
research questions of the future.
Therefore, it is a great honour and pleasure for the Oslo Sports Trauma Research Centre to
contribute in an exciting partnership with FCB to produce the FC Barcelona Muscle Injury
Guide:Preventing and Treating Muscle Injuries. We are very much looking forward to this
mutual collaborative effort and to continued projects in the near future.
CHAPTER 0 CHAPTER 0
0.4 0.5
A LETTER OF SUPPORT FROM INTERNATIONAL

DR MICHEL D’HOOGE COLLABORATORS
In the medical world around football, great interest is given to articular and
ligament lesions. At each medical congress, new techniques are presented in
relation with important topics as anterior cruciate ligament tears of the knee, or
posttraumatic ankle instability and others. One should, however, never forget that
the most important lesion in the world of football remains a muscle injury.
— WithDr Michel Baron D’Hooghe, Chairman Medical Commission FIFA and UEFA
16 A lot remains to be studied, as well in the sphere of prevention, diagnosis and 17

treatment of these lesions. Although the scientific world around our sport has
spectacularly improved our medical assistance to the players, the impressive
epidemiological studies of Prof Ekstrand and his team indicate that the number of
muscular lesions did not decrease over the last years.
I remain convinced that, in different aspects, our approach of muscular lesions

can be improved, and this as well in the preventive, pharmacological, surgical and
conservative sphere.
We must work together to improve our criteria for return to play, as the high number
of re-injuries confronts us sometimes with our own deficiencies.
That is why this scientific work, the great medical guide of muscle injuries, is a gift to
all practitioners, active in the field of football.
Many thanks to all the collaborators of this important book, which will greatly
improve our care for the injured player.
Countries represented Countires with

in the survey no responses/not
contacted
Australia Norway
Brazil Northern Ireland
Canada South Africa
Denmark Spain
Finland Sweden
France Switzerland
Germany UK
Holland USA
Italy
CHAPTER 0 CHAPTER 0
OF MUSCLE INJURIES
1.1.1
AN INTRODUCTION TO
REVENTING MUSCLE INJURIES
The objective of football is to win games. There are many factors (i.e. tactical,
technical, physical and mental) interacting to achieve thisobjective. However,
one key, contributing factorthat the medical and performance team can influenceis
player availability i.e. through a lower impact of injuries (incidence and severity).
— With Alan McCall and Ricard Pruna
18 General This makes sense, given that one benefits of preventative strategies to key 19
Principles of
wouldlogically agree that havingthe best stakeholders (players, coaches, board
players available to play, enhances the level administratorsetc) is essential if we
likelihood of winning. Ahigher player are to succeed in at least reducing the risk
availability means thatthe coach willhave and minimising the occurrence of injuries,
Muscle Injury
more players available to train and in and in particular muscle injuries which
turn more opportunity and time to work are one of the most common types of
on tactics, technical aspects and team injuries that we are faced with.
dynamics. There isalso strongscientific
Prevention
evidence to support this notion; less The purpose of this opening chapter
injuries have been associated with ofthe FC Barcelona Muscle Injury Guide
increased success in domestic league 4.0: ‘General Principles of Muscle Injury
competition1, 2 and UEFA Champions Prevention in Football’is to highlight,
in Football
/ Europa League.3 In addition to explain and delve intosomeof thekey
performance and success, injuriesalso general principles to consider when
carry with them a significant financial the goal is to prevent muscle injury
cost. It has been estimated that the in footballers. Specifically, wewill
financial cost of one player missing one providea new injury prevention
month due to injury equates toan average modelspecific to team sports, followed
of ~€500,000.4 Remember that this is by taking you through a journey of this
an average, imagine the costif this was model, providing practical guidelines
a star player. A third important potential along the way.
consequence of injury is an adverse
effecton players’ long term physical and
mental health.5
While in an ideal world, we would be able

to prevent all injuries from ever occurring,
this is, in reality, impossibleand our aim
is really to minimise the risk of players
suffering an injury. Life is full of risky
decisions, from mundane ones to matters
of life and death.6 Risk is something that
we must accept exists; even walking
down the street has a meaningful (albeit
small) risk for our safety.7 The fact is,that
injury is so complex, multifactorial
and dynamic8 that prevention
mustalsobecomplex, multifactorial
and dynamic. We shouldaim to
identify and minimise known risk
factors for injury while simultaneously
identifyingand maximising protective
factors. Communicating the risks and the
CHAPTER 1
1.1.2
PHASE 1: EVALUATE This second phase also involves
ONGOING RE-
A NEW MODEL FOR INJURY
identifying barriers and facilitators to
This phase involves evaluating the current implementing injury prevention strategies, EVALUATION AND
PREVENTION IN TEAM SPORTS: MODIFICATION
“state-of-play” in your team. Addressing which will strongly impact on the
the question, “What is the current injury ultimate success of a preventive strategy.
THE TEAM-SPORT INJURY

situation?” involves evaluating the type, These factors will be context-specific, Injury prevention is a dynamic,
incidence and severity/burden of injuries but recent research has highlighted a cyclical process. Having introduced
PREVENTION (TIP) CYCLE

in the team. The second question, “What is number of potential barriers/facilitators to or modified a preventive measure,
the injury prevention situation?” involves implementing injury prevention exercise ongoing evaluation is required. In
analysing which injury prevention programs.15,16 These relate either to the the re-evaluation phase, successful
Recently there has been growing interest in injury prevention for football and other strategies are currently being used (or not content and nature of the prevention implementation can be judged against
team sports, including the development of models and frameworks to guide injury used) and the reasons why. For example: program itself, or to how it is delivered metrics such as injury and physical
prevention efforts1,2 , and improve understanding of injury aetiology3,5. and supported by players, coaches and performance data, team members’
— With James O’Brien, Caroline Finch, Ricard Pruna and Alan McCall team staff members. In large, multi- perceptions and the degree of fidelity
1. Is the team implementing
disciplinary sports medicine/performance to the injury prevention strategy (e.g.
evidence-based exercises
teams there is potential for conflict among the number and quality of completed
(e.g. Nordic Hamstring13 and
staff,17,18 which can jeopardise the success injury prevention exercise sessions).
the Copenhagen Adduction
of injury prevention efforts. Identifying With continual progression through the
exercise14)?
these staff-related factors will inform the model’s three phases, the team’s injury
2. What is the team’s current subsequent intervention phase. prevention strategy can dynamically
strategy for managing high- evolve, responding to various changes
20 The most widely cited injury prevention speed running load? in the team’s environment (e.g. new 21
model, called the ‘sequence of prevention’, players, new staff members and
3. What recovery strategies are in
was introduced by van Mechelen and varying game schedules). While
WHAT IS THE CURRENT place following match-play?
colleagues in 1992.2 This model builds on
previous public health approaches6 and
WHAT IS THE CURRENT
INJURY SITUATION?
INJURY PREVENTION
SITUATION?
4. Is squad rotation being used?
PHASE 3: INTERVENE evaluation of certain metrics will
occur on a daily basis in professional
The next phase involves planning both the
consists of four key steps: teams (e.g. wellness scores, workload
5. Which other preventive strategies content (what to do) and delivery (how to
data), it is recommended that teams
E) E
VALUA
TE are currently in place, and with do it) of injury prevention strategies. This
(R also undertake more formal injury
WHAT ARE THE what rationale? process will be influenced by the team’s
1. Establishing the extent of the INTRODUCE prevention evaluation, involving all key
INJURY INJURY RISK
current situation, the identified injury
injury problem PREVENTION FACTORS AND individuals, at least two or three times
INTER
MECHANISMS? risk factors and implementation barriers/

TIF Y
STRATEGIES
A detailed understanding of all team per season.
2. Identifying the key risk factors facilitators, published injury prevention
EN
NE members’ perceptions towards injury

VE
ID
and mechanisms of injury research and the team staff members’
risk and injury prevention is important to In the following chapters of this
previous experiences from working in the
3. Introducing preventive strategies inform subsequent phases in the cycle. opening section on preventing muscle
field. Implementation research highlights
to mitigate the risk of injury PLAN THE CONTENT WHAT ARE THE BARRIERS injuries we will take you through each
ANDDELIVERY OF & FACILITATORS TO the importance of securing administrative
INJURY PREVENTION DELIVERING INJURY In addition to establishing what is being of the 3 key phases in more detail.
4. Evaluating the effectiveness support for preventive strategies10 and
STRATEGIES PREVENTION?
done, it is essential to determine precisely
of preventive strategies by engaging all key partners in the design
how these strategies are being carried
repeating Step 1 process.19 In the professional football
out. For example, in the case of exercises,
setting, this means involving club officials
^ key considerations are the number
(who decide on club policy), coaches and
In 2006, Finch1 introduced an extension of risk management approaches.11,12 Figure 1: The Team-sport Injury and frequency of sessions, the exercise
Prevention (TIP) Cycle team staff members (who deliver injury
of the van Mechelen model called Such a model should be simple, directly dose within these sessions (e.g. sets,
prevention) and key players (the targeted
the ‘Translating Research into Injury applicable to the team’s specific context Phase 1: (Re) evaluate repetitions, intensity) and also the quality
Phase 2: Identify health beneficiaries) from the onset.
Prevention Practice (TRIPP)’ framework, and also acknowledge real-world Phase 3: Intervene of exercise execution.
Through involvement of all key partners
which emphasises the key role of implementation challenges. Furthermore, These phases incorporate key in the design phase, context-specific
implementation aspects in achieving the model should reflect the cyclical aspects of previous models,1,2 along
strategies can be developed which
real-world injury prevention success. nature of injury prevention, involving with important implementation
aspects applicable to team sports have adequate support and account for
Subsequently, several further models ongoing evaluation and adaptation of such as football.
have been proposed, each aiming preventive strategies as opposed to a PHASE 2: IDENTIFY barriers/facilitators in the team’s specific
context. The multi-factorial epidemiology
to address potential limitations of linear step-by-step process.
The next phase in the cycle involves of muscle injuries in football implies the
previous models. These limitations
In the process of developing this Muscle exploring the risk factors and need for multiple preventive strategies
include linear,5,7 reductionist8 or generic
Injury Guide, it became apparent that no mechanisms of the injuries identified (e.g. load management, recovery
approaches,9 a lack of operational
existing model adequately reflects the during the evaluation. This process will strategies and specific exercise-based
steps9,10 and the failure to incorporate
everyday injury prevention approach of be primarily driven by the team’s internal interventions).
player workloads.4
sports medicine and performance staff data (e.g. injury, tracking and monitoring
The applicability of each of these working in professional football teams. data), along with consideration of
models will be context-dependent, with To remedy this, we developed a new established risk factors and mechanisms
the majority being geared towards the model, the Team-sport Injury Prevention from the published literature. It is
conduct of injury prevention research,1,2 (TIP) cycle, specifically aimed at the important to appreciate the multi-factorial
and developing etiological theory.5,8 sports team medicine/performance nature of injury epidemiology,4,8 assess
However, practitioners working at the practitioner. It involves a simple injury risk at an individual player level9
injury prevention “coalface” will be continual cycle with three key phases and consider the degree to which
better served by a model more reflective (figure 1): identified risk factors can be modified.
CHAPTER 1 CHAPTER 1
1.2.1 40
QUADRICEPS MUSCLE INJURIES
EVALUATING THE MUSCLE 35

Quadriceps injury represent 5% of
all time-loss injuries and 19% of all
INJURY SITUATION 30
muscle injuries in men’s professional
football (figure 1), which means that
(EPIDEMIOLOGY) a 25-player squad can expect about
% OF MUSCLE INJURIES
25
three quadriceps injuries each season.
Similar to the findings for hamstring
Muscle injuries are one of the biggest medical problems in modern football, 20 injuries, the injury rate during match
regardless of the playing level.1 2 Specifically, muscle injuries represent almost one
play ishigher, approximately four
third of time-loss injuries and account for more than one-quarter of the overall
15 times, than during training (table 2).
injury burden as it was shown in the largest available study involving more than
Studies involving imaging modalities
9,000 injuries in men’s professional football players in Europe.2 Numbers from this
10 have shownthat rectus femoris is the
investigation also reveal that on average, an individual player will sustain a muscle
most common injury location in the
injury every other season.2
quadriceps.2 10
— With Markus Waldén, Tim Meyer, Matilda Lundblad, Martin Hägglund 5
<
Figure 1 Muscle injury location in men’s
0
HAMSTRING ADDUCTOR QUADRICEPS CALF OTHER professional football players
(adapted from Ekstrand et al.2)
22 MUSCLE INJURY HAMSTRING MUSCLE INJURIES ADDUCTOR-RELATED MUSCLE INJURIES 23

LOCATIONS AND RATES Hamstring injury is the single most common time-loss injury Each season,a typical 25-player squad
type representing 12% of all injuries in men’s professional in men’s professional football can
Most of the muscle injuries (92%) are
football.2 In that study, 37% of all muscle injuries were in the expectfour to five muscle injuriesto the
located within the four big muscle
hamstrings (figure 1). The injury rate during match play is hipand groin.2The most relevant muscle
groups of the lower limbs (hamstrings,
almost nine times higher than during training (table 2). This groups from an injury perspective
quadriceps, adductors and calves).2
means that a typical 25-player squad in men’s professional are the adductors and the hip flexors,
A men’s professional football team,
football can expect about six hamstring injuries each season. whereas injuries in othermuscles
typically consisting of a squad of around
Studies incorporating imaging modalities have shown that a such as the abdominal, sartorius and
25 players eligible for first team match
clear majority of these injuries involve the long head of the tensor fascia latae muscles are less
play, can expect about 16 muscle injuries
biceps femoris, i.e. the typical ‘sprinting injury’.4 5 frequent,or even rare.11 12 Adductor-
leading to time-loss each season (table 1).
related injuries are the second most
Other studies on high-level male players have reported common muscle injury among men’s
MUSCLE GROUP N. OF INJURIES
similar findings as those outlined above.6 7 However, two professional players representing 23%
Hamstring 6 studies on US collegiate players found a lower rate of of all muscle injuries (figure 1),and
hamstring injuries in female players,8 9 whereas one study on 7% of all time-loss injuries.2 A typical
Quadriceps 3
Swedish elite players observed no sex-related difference in 25-player squad in men’s professional
Adductors 3 the rate of hamstring injuries.3 football can therefore expectabout
three adductor-related muscle injuries
Calf 1-2 CALF MUSCLE INJURIES
MUSCLE GROUP TRAINING N. OF INJURIES < each season (table 1). The injury rate
Table 2
Other Locations 2-3 Muscle injury rate in
during match play ismore than six There is a lack of studies on lower leg
Hamstring 0.4 per 1000 hours 3.7 per 1000 hours
men’s professional times higher than during training muscle injuries in football, especially
^ Quadriceps 0.3 per 1000 hours 1.2 per 1000 hours football players (table 2). Studies involving imaging in females and in males from non-
Table 1 Average number of muscle injuries in (adapted from
Ekstrand et al.2)
modalities have documented that most professional settings. However, one
a men’s professional team per season Adductors 0.3 per 1000 hours 2.0 per 1000 hours
(adapted from Ekstrand et al.2) of theadductor-related injuries involve or two of all muscle injuries incurred
Calf 0.2 per 1000 hours 0.2 per 1000 hours the adductor longus.12 13 Although less by a typical 25-player squad in men’s
Muscle injuries also occur at a high rate detailed, publications on male sub- professional football will be located to
among, for example, female elite players elite or amateur players have reported the calf (table 1). In this sample, calf
and male youth academy players.1 3 The similar findings on the location and rate muscle injuries represented 13% of all
muscle injury spectrum in those cohorts of muscle injuries to the hipand groin.14 15 muscle injuries (figure 1),and 4% of
is essentially similar to high-level male Finally, substantially less is known all time-loss injuries.2 The calf muscle
players, whilst quadriceps injuries may be about hipand groin muscle injuries injury rate during match play isalmost
more frequent in early adolescence than in youths andin female players, but a six times higher than during training
in adulthood.1 recent review on 34 epidemiological (table 2). The classical injury involves
studies on football players concluded the medial gastrocnemius, but less
that hipand groin injury in general is known about soleus injuries even
was twice as common in males as in thoughthese injuries probably are more
females..16 frequent than once thought.17
CHAPTER 1 CHAPTER 1
1.2.2
EVALUATING THE MUSCLE

INJURY SITUATION IN YOUR
OWN TEAM
— With Alan McCall, Markus Waldén, Martin Hägglund and Ricard Pruna
24 MUSCLE INJURY BURDEN MUSCLE GROUP 1-3 DAYS 4-7 DAYS 8-28 DAYS >28 DAYS < HAMSTRING BURDEN < 25
Table 3
AND SEVERITY
Table 3 QUAD BURDEN
Muscle injury severity Muscle injury severity
Hamstring 13 25 51 11 90,0
ADDUCTER BURDEN according to lay-off
according to lay-off
Injury severity is commonly based on Quadriceps 12 25 48 15 in men’s professional 80,0 CALF BURDEN in men’s professional
football players football players
INJURY BURDEN (DAYS LOST PER 1000 HOURS)

the number of days that the player is (adapted from Ekstrand
(adapted from Ekstrand
unable to train and compete due to Adductors 18 31 41 10 et al.2)
70,0 et al.2)
injury. The average lay-off time due to
Calf 14 25 48 13 60,0
a muscle injury is approximately two
weeks with little variation between 50,0
muscle groups.2 About 10-15% of all 40,0

injuries in the big four muscle groups MUSCLE GROUP 1-3 DAYS <
TABLE 4
are severe with a lay-off time longer 30,0
Hamstring 18.2 per 1000 hours Muscle injury burden
than four weeks (table 3). There is a in men’s professional
20,0
tendency that thigh and calf injuries are Quadriceps 10.3per 1000 hours football players
(adapted from Ekstrand
more severe than hip and groin injuries. et al.19) 10,0
Adductors 8.1 per 1000 hours
Higher grade hamstring injuries, as Calf 16.5 per 1000 hours

0,0
SEASON 1 SEASON 2 SEASON 3 SEASON 4 SEASON 5 SEASON 6 SEASON 7 SEASON 8 SEASON 9
classified on MRI, are associated with
longer lay-off, but there seems to
be no differences in average lay-off
between the three hamstring muscles
MUSCLE INJURY TRENDS
(semimembranosus, semitendinosus
and biceps femoris).18 Two recent studies from the UEFA Elite
EVALUATING YOUR
Club Injury Study have delineated OWN TEAM’S INJURY
The term injury burden is increasingly
used in sports injury surveillance. It is
muscle injury rates over time in men’s
professional football.20 21 In the first
SITUATION
a combined measure of frequency and report on 1614 hamstring injuries in The previous section has evaluated the As an example on why this is
severity and is usually expressed as the 36 clubs between 2001 and 2014, muscle injury situation of professional important, we illustrate in figure 1
number of days lost per 1000 hours. there was an average annual increase football in general, i.e. studies using data the injury burden at FC Barcelona
Since the percentage of injuries in the of 2%,20 and in the second report on from multiple teams and over various over 9 consecutive seasons (2008/09
severity categories and the average 1812 hip and groin injuries in 47 clubs leagues, to highlight specific average to 2016/17). You will see that in line
number of lay-off days are similar between 2001 and 2016, there was, characteristics and trends in injury with the research literature, the
for the big muscle groups, the same in some contrast, an average annual epidemiology. While this information is hamstring injury burden is generally
pattern is seen as for the rates, with decrease of 3% for adductor-related essential to help guide our knowledge the main muscle injury we are faced
hamstring injuries having the highest injuries.21 Up to now, little is known of injury in football and possible with, however, you will also see that
and calf injuries the lowest burden about the injury trends in other cohorts preventative strategies, it is essential that there are differences in the injury
(table 4). or for other muscle groups. you evaluate the injury trends within your burdens of other muscle types. So,
own team, as these can differ between with continual (re) evaluation, it is
and even within seasons. This is a key possible to follow how the burden of
focus to ensure that your evaluation of muscle injuries varies. These insights
the injury problem in your own team then allow us to continually adapt our
is accurate and that the subsequent own preventative strategies to match
strategies implemented in the Team- the most current and relevant injury
Sport Injury Prevention cycle are relevant. situation to our team.
CHAPTER 1 CHAPTER 1
1.3.1
NON-MODIFIABLE RISK In addition to the literature on senior PREVIOUS INJURY
RISK FACTORS AND FACTORS players, recent data from FC Barcelona

Leg dominance in football is usually
indicate that academy players have an
defined as the preferred kicking leg.
MECHANISMS FOR MUSCLE
SEX increased frequency of rectus femoris
Interestingly, both adductor and quadriceps
injuries compared with professional
One study on elite players showed a injury rates are higher in the kicking
INJURY IN FOOTBALL
players, whereas the reverse is seen for
significantly higher rate of muscles leg,18 which probably is due to increased
hamstring injuries.23 No effect of age was,
strains in males compared with exposure of high-risk player actions
however, seen for groin muscle injuries in
females, but no sex-related difference (shooting, passing, crossing, blocking, etc).
— With Markus Waldén, Khatija Bahdur, Matilda Lundblad, Martin Hägglund that study.
for hamstring injuries.12 Similarly, a Conversely, leg dominance has not been
study on collegiate players also found identified as a risk factor for hamstring
a higher rate of muscle strains in injuries18 28 and calf injuries,18 probably due
PREVIOUS INJURY
males, but only during match play.13 to other injury mechanisms involved.
Moreover, studies on collegiate players Previous injury is one of the most
report a lower hamstring injury rate consistent and scientifically best
in female players compared with validated risk factor for muscle injury.1 5 6 PLAYING LEVEL
their male counterparts.14-16 In one of In a large study on male professional
The influence of playing level on the muscle
these studies, male players also had players, previous injury was a significant
injury risk is currently under-studied, but it
a lower recurrence rate than their risk factor (1.4 to 3.1 times higher rate)
has been shown for hamstring injuries that
female counterparts.14 Finally, a recent for all the big four muscle groups
the injury rate is highest and the recurrence
systematic review identified that male of the lower extremities (adductors,
rate is lowest at the highest professional
26 WHY AND HOW DO injuries such as concussions, lateral
players had a more than doubled
aggregated groin injury rate compared
hamstrings, quadriceps and calf
muscles).18 Interestingly, a previous
level.29 The same pattern with higher injury 27
MUSCLE INJURIES ankle sprains and anterior cruciate
ligament injuries. Little is, however,
with female players, although this adductor and calf muscle injury also
rates and lower recurrence rates at the
professional level compared with amateur
OCCUR? known about football-relevant injury
comparison was not done for muscle
injuries exclusively.4 However, this is in
increased the quadriceps injury rate, and
a previous adductor and hamstring injury
level is seen for injuries in general,30 and
mechanisms or playing situations there are therefore good reasons to assume
Most studies on potential risk factors line with recent data showing that both increased the calf muscle injury rate in
leading up to muscle injuries, and that this would be similar also for other
for injury in football have addressed all hip flexor,17 and adductor strain rates that study. Moreover, male elite players
studies in this field are therefore muscle injuries than hamstring injuries.
injuries or injuries to the lower limbs were significantly higher in male players with previous groin and hamstring
urgently needed.
in general and not muscle injuries at the collegiate level.16 17 In summary, strains had seven and twelve times
specifically. There are, however, a the literature on sex as a risk factor for higher odds of sustaining new groin
PLAYING POSITION
number of risk factor studies on football muscle injury in football is somewhat and hamstring strains, respectively.21
players that have targeted hamstring inconclusive, but it appears that male Similarly, previous hamstring injury was Goalkeepers carry a lower injury risk in
injuries,1 whereas risk factor data on RISK FACTORS FOR players have similar or higher groin and associated with a significantly higher general compared with outfield players
quadriceps and calf muscle injuries
in football are scarce.2 3 Also, although
MUSCLE INJURY hamstring muscle injury rates compared
with female players.
hamstring muscle injury rate in another
study on male elite players,22 and in male
and this seems to be the case also for
adductor, hamstring, quadriceps and
there are many studies reporting on Risk factors in football have traditionally amateur players.20 Although not specified calf muscle injuries in male professional
groin injuries among football players,4 been divided into intrinsic (player- for muscle injuries, male amateur players football players.18 28 29 In one of these
the majority of these report on hip related), such as age and sex, and AGE with previous acute groin injury in the studies, it was also shown that forwards
and groin injuries combined and few extrinsic (environmental-related) ones.1 latter cohort had more than doubled had the highest hamstring injury rate of
Age is a frequently studied risk factor
studies on risk factors for groin injury They can, however, also be categorized odds of sustaining future groin injury.24 all player positions.29 Finally, goalkeepers
for injury per se but is also important
in sports have reported data on groin into non-modifiable (unalterable) and also had fewest muscle injuries in a study
to adjust for when analysing other
muscles separately.5 6 potentially modifiable (alterable) factors There are, however, also a few studies on male academy players aged 8-16 years
potential risk factors due to the apparent
which might be more relevant from a showing no association with previous where the highest thigh injury rate was
risk of confounding. The calf muscle
The majority of the studies with risk prevention perspective (table 1). muscle injury. One study on male seen among midfielders.31
injury rate was approximately doubled
factor data on muscle injuries in professional players showed in fact a
in male professional players older
football have been carried out on significantly increased hamstring injury
INJURED TISSUES NON-MODIFIABLE MODIFIABLE < than the average age (>26 years), but
professional or elite male senior players Table 1 rate with no previous injury,25 and two PLAYING ACTIVITY
there was no such age effect with
with considerably less literature on Intrinsic Sex Strength Examples of candidate studies on female players showed no
and non-modifiable adductor, hamstring and quadriceps It is well-known that the injury rate in
female and youth players. The findings association between previous injury
Age Flexibility risk factors for muscle injuries.18 Similar findings were found general is several-fold higher than during
on suggested risk factors are often injury and future muscle injury; for thigh
in male elite players where older training regardless of the setting and
identical or similar between studies Previous injury Fitness level muscle injuries in youth players,26 and
age (>23 years) was associated with playing level. Muscle injury rates are
but could occasionally be muscle- for hamstring injuries in elite players.27
Leg dominance Psychological factors a significantly higher percentage of also higher, of approximately the same
specific or even contradictory. Muscle In summary, a majority of studies have
calf muscle injuries, but again no magnitude, during match play; the
injuries are, however, unlikely to result Extrinsic Playing level Workload and congestion found previous injury to be a risk factor
association with adductor, hamstring adductor, hamstring, quadriceps and calf
from a single risk factor, but rather as for future muscle injuries even if there
and quadriceps injuries.19 Similarly, muscle injury rates were, for example, 4-9
a consequence of several risk factors Playing position Rules and regulations are a few exceptions.
increasing age was not associated with times higher during match play in male
interacting at the time of the inciting
Playing activity Equipment higher odds of sustaining hamstring professional players.32 A higher match
event.7
injury in male amateur players,20 but injury rate has also been shown in other
Time of season Playing time
was so in two studies on male elite studies on male elite/professional players
In addition to traditional risk factor
Weather conditions Playing surface players.21 22 The literature is also here for groin muscle injuries,21 hamstring
research, there are an emerging
somewhat inconclusive, but it appears muscle injuries,21 28 33-36 and quadriceps
number of studies, mainly using
that increasing age is associated with muscle injuries,34 35 as well as in studies
systematic video analysis, describing
similar or higher muscle injury rates in on male and female players at the
injury mechanisms for typical football
male players. collegiate level.14 15
CHAPTER 1 CHAPTER 1
<
Figure 1 FLEXIBILITY increased the odds for sustaining The influence of congested match
1,6
Seasonal distribution hamstring muscle injury,47 and the total periods on injury rates is another area
of muscle injury in Poor flexibility, sometimes also
hip rotation (internal plus external) of interest. It was recently shown that
1,4 men’s professional described as muscle tightness or
football players was lower in players who sustained high match load in male professional
reduced muscle length, has for long
(adapted from adductor strains compared with players was significantly associated
1,2 Hägglund et al.18) been suggested as a risk factor for
uninjured players.48 Finally, decreased with an increased muscle injury rate
muscle injury, but one of the first
INJURIES PER 1000 HOURS
hip abduction was a risk factor for during match play.56 In that study,
1,0 studies in the field showed that there
sustaining new groin strain in male elite the overall muscle injury rate was
was no difference in range of motion
players.21 In summary, there is some significantly higher in league matches
0,8 between male amateur players with
conflicting evidence on poor flexibility with ≤4 recovery days compared with
or without hamstring strains.44 In one
as a risk factor for muscle injuries in ≥6 recovery days; significantly higher
0,6 subsequent study on male elite players,
football and further well-designed rates were also identified for hamstring
there was no difference in muscle
studies appears to be needed. and quadriceps injuries, but not for
0,4 tightness between players with and
adductor and calf muscle injuries. This
without muscle strains, but players
tallies with previous findings where
0,2 with previous quadriceps strain had
FITNESS LEVEL the muscle injury rate in a men’s
significantly shorter rectus femoris than
professional team was more than five-
0 those without strains.33 In professional There is emerging evidence that poor
JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY fold higher in congested match periods
football, one study showed that male intermittent aerobic fitness is associated
ADDUCTORS HAMSTRINGS QUADRICEPS CALF with two matches per week compared
players with hamstring and quadriceps with an increased odds to sustain
with periods one match per week.57
muscle injuries had lower flexibility in lower limb injuries, especially muscle
Looking at individual player match
28 TIME OF SEASON MODIFIABLE RISK Male amateur players with weak
these muscles than uninjured players,
whereas no difference was seen for
injuries, in male professional players.49
50
Specifically, players with lower
loads, it seems that six days or more 29
For male professional players in teams FACTORS adductor muscles had four-fold
increased odds to sustain a future groin
adductor and gastrocnemius muscle fitness level were unable to tolerate
are needed between match exposures
to reach a baseline level of the muscle
with an autumn spring season, the rates injuries.45 Similarly, male professional acute:chronic workloads of at least
TIME OF SEASON injury.24 In addition, male elite and sub- injury rate.58
of adductor, hamstrings and calf muscle players with hip and knee flexor muscle 1.25 and had a five-fold higher odds to
elite players with ongoing adductor-
injuries are significantly higher during the Muscle weakness and strength strains had significantly lower range sustain a lower limb injury compared
related pain had lower hip adduction
competitive season, whereas the reverse imbalances are frequently suggested of motion in these muscle groups with players on a higher fitness level in
strength compared with asymptomatic RULES AND REGULATIONS
finding for quadriceps muscle injuries with risk factors in the sports injury compared with uninjured players.46 one of these studies.49 Future studies in
control players,42 a finding that was
a higher injury rate during the pre-season literature. A pioneer study carried out There is also more indirect evidence of this field and on other fitness variables The majority of all muscle injuries (>90%
also seen in male amateur players
period (figure 1).18 Another study on male on a mixed cohort of athletes, mainly muscle tightness as a risk factor in a are, however, needed. regardless of muscle group) in male
with current groin pain.43 In the latter
elite players showed that there was an consisting of high-level male football study where hamstring-injured male professional players occurred in non-
study, previous long-standing groin
accumulation of hamstring injuries in the players, with previous hamstring injury professional players had significantly contact situations with few match-related
pain (>6 weeks) during the preceding PSYCHOLOGICAL FACTORS
spring season after the winter break.36 and recurrent strains and discomfort shorter fascicles of the long head of the injuries being the result of foul play in
season was associated with lower hip
Similarly, most thigh muscle injuries in showed that muscle strength deficits biceps femoris than uninjured players.40 The literature in this field is still scarce the view of the referee.32 Consequently,
adduction strength.43
male youth players occurred in September were common and that a rehabilitation Moreover, two studies on male compared with studies on physical re-enforcements of the existing rules will
(after the summer break) and in January programme with normalisation of professional players have found that factors. A recent cross-sectional study probably have negligible impact on the
There is no published data yet on the
(after the winter break).31 the muscle strength reduced the risk found that decreased range of motion of male professional players, however, panorama and burden of muscle injuries.
potential association between muscle
of re-injury.38 Moreover, in a separate in the hip was significantly associated showed that players who had suffered However, as discussed further below,
strength deficits and/or imbalances and
study on male professional players, with muscle injury; lower hip flexion at least three severe (>28 lay-off days) muscle injuries might be associated
future calf muscle injury risk.3
WEATHER CONDITIONS the hamstring muscle injury rate was muscle injuries during their career with fatigue and regulations on reducing
increased four-fold in players with had 2.6 times higher odds of reporting individual playing time and/or increasing
Although insufficiently investigated,
thigh muscle strength imbalances distress than players without previous the recovery window between matches
there are currently no studies indicating
compared with players without any severe muscle injuries.51 might therefore be of value.
that weather conditions, such as air
muscle imbalances.39 Similarly, male
temperature and evaporation, are
professional players with eccentric
associated with increased or decreased WORKLOAD AND CONGESTION RULES AND REGULATIONS
hamstring strength asymmetries
muscle injury rates in football. However,
at pre-season had four-fold higher The influence of workload on sports Currently, there are no studies
one study on male professional players
odds of sustaining hamstring strain injury risk has received a lot of interest indicating that any particular
showed no regional differences in
during the following season.25 More in recent years with both high absolute equipment, such as taping or type of
adductor, hamstring, quadriceps and calf
recent research has shown that male and relative loads being associated footwear, are associated with increased
muscle injury rates between teams from
professional players with hamstring with increased injury risk as shown in or decreased muscle injury rates in
northern Europe compared with teams
injury were weaker during eccentric a recent review by the International football.
from southern Europe, indicating that
contractions than uninjured players, Olympic Committee.52 At the time of
weather (and pitch) conditions are not
but between-limb imbalances did the publication of that paper, there
equally important for muscle injuries as
not infer a higher rate of hamstring were only a few studies on workload
perhaps for other injuries such as ligament
injury.40 Conversely, only one of 24 and injuries in football, but thereafter a
sprains and tendinopathies.37
studied muscle strength variables was number of studies on male professional
associated with increased hamstring players have been added; these studies
muscle injury rate in a recent study on show essentially the same findings by
male professional players.41 Similarly, mainly including muscle injuries in their
hamstring strength had no association analyses.49 50 53-55
with future occurrence of hamstring
muscle injury in female elite players.27
CHAPTER 1 CHAPTER 1
1.3.2
THE COMPLEX, MULTIFACTORIAL

AND DYNAMIC NATURE OF
MUSCLE INJURY
While risk factor identification is important, athletic injuries do not occur because of
any single risk factor. Rather, injuries (muscle injuries included) occur as several risk
factors interact at the time of an inciting event during training or competition (Figure
1). 1, 2 In other words, athletic injury etiology is complex, dynamic, multifactorial, and
context dependent.
— With Natalia Bittencourt, Mario Bizzini, Johann Windt and Alan McCall
30 PLAYING TIME Repeat participation with modified internal risk factors based 31
on positive and negative effects of prescribed workload.
Muscle injuries in male professional
players tend to occur less frequently
in the beginning of a match (or match Previus Injury
halves);32 there were fewer quadriceps
injuries in the first quarter of the Modifable Factors
first half, fewer groin muscle injuries Internal (E.G. Aerobic capacity, “Fitness”
strength, neuromuscular
in the first quarter of the first and Risk control, tissue resilence)
Positive Training Effects
second halves, and more calf muscle Factors

injuries during the last quarter of the Rehabilitation/
second half, whereas there was no Non-Modifable Factors “Fatigue” Return-to-play
(E.G. Age, Gender, Negative Training Effects
differences between the six quarters Anatomy)
for hamstring injuries. Other studies
on male professional players have,
however, shown that there could be a No
fatigue effect also for hamstring injuries Injury
with more injuries occurring in the in
the final quarter of the first and second Predisposed Application of
halves (Woods et al., 2004), and in the Athlete Workload
later parts of training sessions and Inciting Event Injury
Exposure to External Risk
matches (Dadebo et al., 2004). Finally, (E.G. Cumulative tisuue
Factors = Susceptible Athlete
overload, collision, fall,
thigh muscle injuries in male youth (E.G. Human factors, Equipment,
non-contact actue event)
players have been shown to be more enviroment)
frequent in the end of the first half and No Recovery
then persisting throughout the second female players. In that study, the rates
60
INJURY MECHANISMS
half (Cloke et al., 2012). of calf strain and quadriceps strain in Removed from
There is yet no published study that
male players were significantly lower Participation
has used systematic video analysis for
on artificial turf during training and
describing different injury mechanisms
PLAYING SURFACE match play, respectively. Other studies
for or playing situations leading up ^
on male professional players showed,
Studies comparing artificial turf with to muscle injuries in football. From The complex, multifactorial nature of The dynamic nature of etiology means Figure 1
however, neither a difference in the The workload—injury etiology
natural grass have yielded conflicting epidemiological studies, however, it muscle injuries means that a given risk that in the ever-changing football
overall muscle strain rate,61-63 nor for model.2 According to the model, every
findings. The first study comparing appears that a majority of hamstring factor – e.g. low eccentric hamstring environment, many risk factors player will have a given internal
sub-analyses of the big muscle groups
play on so-called third-generation injuries occur during sprinting or high- strength 4 – may only result in injury if constantly change within- and between- predisposition to injury based on
between third-generation artificial their collection of internal risk factors.
artificial turf with natural grass, speed running also in football.28 32 40 accompanied by other risk factors, such days, months, and seasons. 1, 2 Muscle injuries will occur during
turf and natural grass.61 62 Finally, in
showed a significantly lower rate of Conversely, many quadriceps injuries as a previous hamstring injury and the training or competition workloads
a study on male and female players during which they are exposed to
lower extremity strains on artificial occur when shooting or kicking the presence of fatigue. Even this collection To better understand muscle injury
at the collegiate level, there was no external risk factors for injury, and
turf, but not for groin and hamstrings ball and therefore mainly affects the of risk factors may never cause injury risk in our players, adopting a complex potential inciting events. However,
between-surface difference in the
strains.59 In a subsequent follow-up, dominant leg.32 Kicking is also the most if a player isn’t exposed to activities systems approach has been proposed. 3 whether or not they experience an
rate of lower extremity strains during injury, the player’s predisposition for
also including female elite players, frequently reported injury mechanism (e.g. high-speed running and sprinting), Namely, this approach will allow us to
match play and training for either sex, injury dynamically changes with each
the same pattern was seen with a for adductor longus injuries, which which can trigger the inciting event. identify ‘risk profiles’ associated with training or competition session, as
respectively.16 64
significantly lower muscle strain rate reaches its highest muscle activity and injuries, rather than individual risk both positive (e.g. improved fitness)
and negative (e.g. neuromuscular
on artificial turf in male players, but maximal rate of stretch in the swing factors alone. fatigue) occur.
with no difference between surfaces in phase of kicking.65 Redesigned by FC Barcelona
CHAPTER 1 CHAPTER 1
Figure 2
Complex systems
approach to muscle
injuries in football.
Factors associated
with injuries
form a web of
determinants, and
certain associations
between these factors
will be regularities Figure 3
that contribute to an Theoretical web
emerged pattern/ of determinants
outcome (in this case for muscle injury
muscle injury). in football.
Redesigned by FC Redesigned by FC
Barcelona Barcelona
v v
32 MODIFIABLE RISK For football players, the main factors 33

Muscle Injury Muscle Injury
FACTORS (Emerged Pattern)
within our web of determinants (thicker
nodes) are: 1) previous muscle injury; (Emerged Pattern)
A complex patterns model considers 2) fatigue and 3) strength qualities. The

patterns in risk factor relationships that second level of nodes include: external and
Recursive Loop
Recursive Loop
Recursive Loop
Recursive Loop
may increase injury likelihood. 3 internal workload, movement efficiency,
In this model, risk factors and potential and psychological aspects. Within this
interactions result in a ‘web of theoretical web of determinants, players
determinants’ (figure 2). In each sporting who exhibit a profile including a previous
Regularities Regularities
context, one may use the model to muscle injury, high fatigue levels and (Football - Muscle Injury Risk Profile)
determine patterns of relationships low strength are considered to be at an
(interactions) between factors increased risk for muscle injury. Further,
Internal
(regularities), what certain interactions these three factors may interact, as Workload
Fatigue
produce (emerged patterns), as well as the previous muscle injuries will change the Age
regularities that may lead to injury (risk level of fitness, strength qualities, and External Previus
Workload Muscle Strength
profile). 3 Notably, multiple risk profiles may may alter the fatigue process. FATIGUE Injury Level Qualities
exist for the same outcome (i.e. injury), is the global result of the relationship of
Fitness
since individual risk factors within the between external and internal workload. Congested
Match
web of determinants may have varying The player’s external workload (work Reduced Schedule
Level of
Movement Joint
Wellness
effects, depending on other factors. For completed) is modulated by factors such Recovery
and Efficiency Mobility
Time
example, the consequences of factor A (i.e. as reduced recovery time and congested Stress
weak eccentric muscle strength) will differ match schedule, which increase workload
if it interacts with factor B (i.e., congested density and may add stress to the players,
match schedule), factor C (i.e., previous indirectly altering internal workload.
injury), or both. Ultimately, identifying these Internal workload is influenced by player’s
regularities (i.e. risk profiles) may improve internal characteristics, including physical
our understanding of injury etiology and fitness, strength qualities, and stress.
inform future preventative interventions. PREVIOUS MUSCLE INJURY can change
muscle tissue (e.g., scar and angle of peak
To our knowledge, there is currently torque), 5 which may produce muscle
no web of determinants that exists for weakness and imbalance. Movement
muscle injury in football. Until future efficiency could therefore be altered,
robust statistical analyses are carried out with other factors like joint mobility
that identify the relevant factors and risk contributing. Finally, several of these
profiles, we encourage a critical thought previous factors, along with age, have the
process and the creation of potential potential to modify STRENGTH QUALITIES.
webs of determinants. Below, we created
an initial example of what a web of
determinants for muscle injury in football
may look like. Whilst not validated, our
web is based on a combination of known
evidence in the scientific literature and our
practical experience, with the purpose of
illustrating this concept.
CHAPTER 1 CHAPTER 1
1.3.3
BUILDING THE PRACTITIONER-PLAYER MAIN COMPONENTS OF or training, and other external factors
MUSCULOSKELETAL SCREENING
RELATIONSHIP
SCREENING should be considered whenever possible
to ensure that the screening measures
IN FOOTBALL The relationship between the player Screening is usually performed at the used are consistent, and comparison with
and the medical team is essential beginning of a season, although additional previous results are meaningful.
to build trust and create a safe screening opportunities should be sought,
It is common practice in professional sport to perform some manner of periodic health environment where the player will such as a mid year review, or at the end Ideally, the entire medical team should be
evaluation (PHE), commonly referred to as “screening”. In elite football, 90% of the openly and honestly share his/her of the season to establish off-season involved in screening. Although the testing
teams do some form of screening throughout the season.1 Professional teams and concerns and physical information. programs. We recommend end-of- might be performed by specific members,
football governing bodies aim to protect the health of the player through screening and This allows an optimal shared season screening, which allows for the it is important to have the team doctor,
monitoring to identify potential risk of injury, which, if possible, could positively impact decision making process.9 It is also identification of ongoing musculoskeletal physiotherapist, and even manager present
performance, economical aspects at the club, and the health of players.2,3 an opportunity to provide education issues to receive attention before players to emphasize the value and importance
— With Nicol van Dyk, Robert McCunn, Phil Coles, Roald Bahr regarding certain health policies or resume training at the start of the next of the testing. Furthermore, it makes
injury prevention strategies and to season. direct and immediate communication
receive both subjective and objective and interpretation of the results possible,
feedback from the players on their Although the most comprehensive allowing greater transfer of the results in a
current health status. screening will likely still happen during the practically meaningful way.
pre-season, musculoskeletal screening
should sensibly be repeated throughout Screening includes both a review
the season to determine how variables and consideration of non-modifiable
respond to training and competition for information (age, previous injury, etc),
34 INTRODUCTION WHY DO WE SCREEN? DETECTING CURRENT each individual player, as well as at a team as well as modifiable potential risk 35
MUSCULOSKELETAL CONDITIONS level. This might assist the medical and factors (e.g. strength, flexbility, fitness,
Organisations such as the International At present, none of the tests used to
performance team to make better informed psychological status, workload, movement
Olympic Committee (IOC) and Fédération perform the musculoskeletal screening or Screening performed for each
decisions regarding the health of the quality, and performance tests). Although
Internationale de Football Association monitoring appropriately separate players individual player should focus on
players, as well as reducing their injury risk. many options are available, we have
(FIFA) have released guidelines on who are at high risk of injury from the rest early identification of current health
summarized some key components and
the screening of athletes and players, of the group.6 These tests simply do not problems and assessing the status
Once a battery of tests has been selected, their characteristics in table 1. Workload
attempting to set a standard of care that have the appropriate properties to perform of ‘old’ injuries to prevent their
it is important that tests are standardized monitoring will be explained in detail in
would assist in the early detection of such a function, and we continue to see recurrence.7,8 Of course not every player
and if repeated, done so in the same way. the upcoming `Preventative Strategies’
cardiovascular and other potential health the injuries that occur across all the players would need an individual follow-up
Time of day, influence of practice sessions section.
(medical) risks.4 Typically, this consists in the team, irrespective of their screening after screening. Value may be found in
of (i) a comprehensive cardiovascular results. For injury prevention in elite simply reassuring a player regarding
examination, (ii) a general medical football, large group based interventions the rehabilitation from a previous injury
evaluation (including blood tests) and are likely still key. or management of physical symptoms. TESTS AVAILABLE ADVANTAGES DISADVANTAGES CONSIDERATIONS
(iii) musculoskeletal assessment to be However, we might introduce a specific
Strength10-14 Isokinetic dynamometer (eccentric strength, side-to-side Moderate accuracy and Player buy-in, When interpreting Nordbord
performed on all players. Here, we will However, the interventions that we apply program for selected players, in imbalances, functional ratios e.g. hamstring:quadriceps) validity for all these tests difficult for players strength results, it may be important
focus on the musculoskeletal component should ideally be monitored for each particular those that have returned from Strength competing in 2 to normalise it to body mass
Field devices (Nordbord®)14 (eccentric strength, side-to-side Testing can be
of screening. individual player, as adaptation and previous injury, to ensure they reach imbalances) performed as part of
matches per week
Isometric testing might be a safe
reaction to these interventions might differ their optimal level of performance after Hand held dynamometer (HHD) (isometric strength)
training Cost alternative during congested
periods in the season and form part
Scientific evidence demonstrating how between players, and individualization return to play. Force platform (isometric strength, concentric power and/
Requires expertise
of recovery monitoring
valuable musculoskeletal testing is, which of these exercises might be necessary to to interpret the data
or eccentric duration e.g. during countermovement reactive
outputs e.g. graphs
are the best tests to use, and whether ensure effectiveness is maximised. strength e.g. from drop jump and between leg functional
imbalances
these test results are actually associated ESTABLISH PERFORMANCE BASELINE
with muscle injury is unfortunately, scarce. The complex, multifactorial and dynamic AND HEALTHY STATE Flexibility3,16,17 Straight leg raise test Moderate accuracy and Player buy-in, When is the best time to perform
This section contains important factors to nature of muscle injuries is becoming more Sit and reach test
validity for all these tests difficult for players the test? Before or after training
Another reason to conduct screening Active & passive competing in 2
consider when building your own battery and more accepted by practitioners, 5 range of motion Passive and active knee extension test
Low cost, easy to
matches per week
Might be useful in return to sport
is to establish a performance baseline perform decision making
of tests where the objective is to screen for and explained in the previous section.
for the player in the absence of injury Bent knee fall out (BKFO)
Simple tests to inform Could form part of recovery
some of the potential risk factors such as Although screening to predict future injury
or illness. For example, if a player Hip internal/external range of motion daily physiotherapy monitoring battery
those identified in section 1.3.1. Importantly, is not possible,6 we screen each individual interventions e.g.
sustains a hamstring injury during Dorsiflexion lunge test Can form part of a simple daily
these test results should be interpreted player to detect ongoing musculoskeletal manual therapies
‚general medical screen’
the season, the strength or functional Thomas test
for the individual player, which allows conditions, identify health issues that
tests performed during screening can Standing forward flexion test
Selection - can’t use all of them
appropriate intervention and decision- may require intervention, create a rapport
represent a useful reference point
making by the medical staff, based on between practitioner and player, and Knee-to-wall
for the practitioner to determine
a combination of research evidence identify how these aspects may impact
responses/success throughout the Movement Functional Movement Screen (FMS) Low to moderate Large season to If used, consider the same assessors
and current best practice. Although no team performance. quality18-24 accuracy season variability in at minimum performing the scoring
return to play process, and can Functional movement test 9+
emperical evidence exists, there is a Holistic view of
scores
Careful interpetation of the results
assist in decision making during Determine how Landing Error Scoring System (LESS)
growing consensus among practitioners well (controlled)
athleticism and Subjective (i.e. many of these have shown no
this period. Alternatively, if the club Soccer Injury Movement Screen (SIMS) movement patterns (excluding association with injury, and none of
that regular monitoring of risk factors movements are
decides to add a specific training/ performed23,24 Laboratory based jump-landing assessments Easy to administer
laboratory tests) shown predictive accuracy)
will allow more appropriate and timely
strengthening programme during the (once trained and Questionable link to
interventions. players familiarised) injury risk
season, a baseline test can assist the
performance team to establish whether
or not the program has been successful ^
Table 1. A summary of potential modifiable factors
and where to target future injury to consider when screening/monitoring for muscle
prevention programs. injury risk
CHAPTER 1 CHAPTER 1
1.3.4
INTERPRETATION OF THE
RESULTS
1. Overview of the
players risk profile, BARRIERS AND FACILITATORS
TO DELIVERING INJURY
and health status.
FOR THE INDIVIDUAL
2. Compare to previous
PREVENTION STRATEGIES
The test results for each individual player
status or test results
may be compiled to form an overview or
holistic impression of the players’ current 3. Determinate specific
status. Ideally, previous data on a particular interventions Published information on barriers and facilitators to delivering injury prevention
player exists and allows comparison to a needed to address strategies is scarce,1 but initial research on injury prevention exercise programs has
previous time point, or a moving average any identified identified a wide range of factors, relating either to the content and nature of the
of ongoing monitoring of these factors, musculoskeletal program itself, or how the program is delivered and supported by players, coaches and
this may be used to determine whether a issues or risk factors team staff members.2 3
player has improved, worsened or stayed — With James O’Brien and Caroline Finch
the same. Alternatively, the player may
be compared with the rest of the team
or data on the entire league, if available.
This would indicate whether specific
action or intervention may be needed on
an individual level to improve his current
status to be on par with the rest of the
36 team (or league). In relation to the program, TARGET GROUP KEY MESSAGES < 37
examples of barriers include lack of Table 1
Club officials Injuries are expensive. The costs to a Key messages for
individualisation, progression, variation professional club for a player being injured promoting injury
and football specificity, along with for one month can reach 500 000 Euros.4 prevention strategies
in professional teams
the program being too long or too Teams with fewer injuries are more
FOR THE TEAM monotonous. Example of barriers successful in both their national league
and in UEFA competitons.5
1. Overview of the team relating to players include lack of
The results from the different screening
status and health acceptance/motivation regarding Coaches and team staff members Avoiding injury increases player availability
measurements may allow the medical for training and matches
the program, fatigue, absences (e.g.
team to identify trends throughout the 2. Identify trends that
national team, illness) and muscle Having more players available can help
season. For instance, if the entire squad develop during a in managing the physical demands on all
soreness. In the case of coaches and
displays lower strength compared to season. (i.e, lower players.6
team staff members, acceptance and
the previous season, coupled with an strenght compared to Injury prevention exercises can be easily
support of the prevention program is incorporated into team training (e.g. warm-
increase in muscle injury, it might indicate the previous season,
a key factor. Other factors, relating to up and cool-down) with minimal time cost.
effects of a pre-season training camp or coupled with an
the team staff members who design Lower injury rates correlate with team
inappropriate training methods. Such increase in muscle success5
and deliver preventive exercise
findings may help the overall management injury). Large randomised-controlled trials support
programs (e.g. fitness coaches and
of the squad to protect the players from the effect of injury prevention exercise
3. Design group physiotherapists), include lack of staff programs in elite and sub-elite teams.7-9
injury and avoid larger scale injury
based prevention continuity, teamwork, communication
patterns. Avoiding injury can protect players from
programmes that are and planning.2 both the short- and long-term negative
aimed at the entire effects of injuries.10
Furthermore, it might assist in the design
squad. Acceptance of and active support Players
of group-based prevention programmes Injury prevention is important to keep you
for injury prevention strategies on the pitch, extend your career and invest
that are aimed at the entire squad. Certain 4. Certain key areas in your long-term health.
are particularly important factors,
key areas may be identified that need may be identified
applicable to several different
priority. Although a prevention programme that is given higher
groups (e.g. players, coaches and
would still contain all the elements needed priority
administrators). Successfully addressing
to provide holistic prevention, some test
these factors in order to increase “buy-
data may help to tailor it to the team
in” may require tailoring messages to
profile, which may improve the overall
each of these different groups. Table 1
effectiveness of the intervention. It is
outlines some tips on what you could
important to present this information in a
do to overcome some of the barriers
way that is understandable to the medical,
that can limit the effectiveness of injury
performance and management team.25
prevention programs.
TAKE HOME MESSAGE

Although we cannot eliminate risk of
injury, the goal of screening is to aid in the
protection of our players, minimize risk,
and contribute to their overall well-being,
ultimately contributing to team success.
CHAPTER 1 CHAPTER 1
1.4.1
STRATEGIES TO PREVENT
MUSCLE INJURY
When we think of prevention strategies for muscle injuries, we typically think of
exercises targeted at strengthening the muscles and related modifiable risk factors
that exercise can influence. However, in contemporary professional football, we are
moving away from the thought that preventing muscle injury means implementing
specific exercises and looking at it as a more holistic strategy that is multifaceted.
— With Alan McCall and Ricard Pruna
38 We only need to look at the playing During the process of putting the PREVENTATIVE STRATEGY EFFECTIVENESS RATING 39
2 COMPETITIONS PER WEEK

schedule of elite level football teams FC Barcelona Muscle Injury Guide
to understand why we need to think 4.0 together, we realised that there Overall control of load / management +++
of the training week
bigger than just exercise alone. Elite was limited scientific evidence for
football teams are regularly required to preventative strategies in the elite Exercise based strategies +++
play in periods with 2 matches per week football environment. We therefore
3 x season 14 x season 25 x season throughout the season e.g. domestic decided to perform a Delphi Survey Recovery strategies ++
league, national cups, confederation of 18 elite teams from the Big 5 Consideration of previous injury ++
competitions etc. Figure 1 illustrates Leagues (England, France, Spain, Italy
EXTRA LONG CYCLE LONG CYCLE SHORT CYCLE the congested match schedule that FC and Germany) to ask performance Team communication and ability ++
to work together
Barcelona are typically exposed to. You practitioners what they do and
will see that the majority (25 matches) are what they consider to be important
MACH DAY MACH DAY MACH DAY ^
played with only 2 full days recovery, 14 strategies to prevent muscle injury
THE BARÇA WAY Table 1 Perceived
with 3 full days and only 3 where the in their players. The Delphi survey effectiveness of
MD+1 / MD-4 MD+1 / MD-3 MD+1 / MD-2 recovery between matches is considered process involves various rounds of strategies to prevent
‘extra long’ i.e. 4 full days. With such a questionnaires in which we ultimately At FC Barcelona, we do not consider muscle injury in elite
footballers (EBMIP
congested match schedule it is difficult come to a consensus among the injury prevention to be made up of
MD+2 / MD-3 MD+2 / MD-2 MD -2 one specific strategy, but rather the
Delphi Survey results)
to plan any focussed, high-intensity respondents as to the most effective
exercise programs that may be able to strategies to prevent muscle injury simultaneous integration of many
MD -2 MD -2 MACH DAY help prevent muscle injury, at least for the and how to integrate these into strategies, which alone, cannot
regular playing squad. As such we need the football program. The following ‘prevent’ an injury.
MD -1 MACH DAY to look at other ways to minimise the risk chapters are based on the results of
Instead it is most likely, the combi-
of muscle injury and this calls for other this Delphi process in addition to what
‘preventative strategies’. Even for the non- we know from the scientific literature nation of many strategies inclu-
MACH DAY playing or substitute squad, preventative and our own practical experience. ding, controlling the training load,
strategies other than exercise-based maximising recovery, optimising
should be beneficial to optimise The overall results of our Delphi communication in addition to per-
the training process i.e. maximise survey1 of the Big 5 leagues revealed forming a variety of specific exer-
performance and minimise injury. the most effectively perceived cises etc as the best way to reduce
preventative strategies to prevent the risk of our players incurring a
muscle injury (table 1). We will now go muscle injury.
through each of these in more detail,
providing practical recommendations
on implementation in practice.
<
Figure 1.
Typical match schedule of FC Barcelona during an
in-season period
CHAPTER 1 CHAPTER 1
1.4.2
CONTROLLING TRAININGLOAD
Athlete monitoring is now common practice in high performance football.
Fundamentally, athlete monitoring involves quantifying the players training load and
their responses to that training. The main reasons for monitoring athletes are that it
can provide information to refine the training process, increase athlete performance
readiness and reduce risk of injury and illness. Through a systematic approach to
data collection and analysis an improved understanding of the complex relationships
between training, performance and injury can be obtained.
— With Aaron J Coutts
“Fitness”
40 Response 41
thresholds7. To overcome this limitation, Heart rate measures may also be used
Injury it is recommended that averaging the to assess the internal training load
Risk acceleration/deceleration demands during football, but due to the technical
during training and match play may be a and practical issues such as the high
more appropriate method compared to risk of technical issues and data loss
Training Training Athlete Performance threshold-based methods.8 and a low level of player compliance in
Plan Dose Responses measurement, the session-RPE method
The internal training load is the response is the most widely recommended
Performance
of the player to the external load applied approach.12 An additional advantage of
Readiness and is usually measured using heart rate the session-RPE method over heart-rate
or the session-RPE method.9,10 The session derived approaches is that loads can
“Fiatigue” RPE-method requires players to rate their easily be obtained from all types of
Response perceived intensity of a session according training, including cross training and
to a standard rating of perceived exertion resistance training which are common
(RPE) scale (see Figure 2). The load for a in football. However, despite this a
^ session is then determined as the product recent report showed that heart rate
THEORETICAL BASIS OF TRAINING LOAD Table 1 Conceptual
model for athlete
of the session duration and the players was more widely adopted in top level
ATHLETE MONITORING MEASURES monitoring systems
(modified from Coutts,
RPE. For example, a 40-minute session
rated as being ‘hard’ by a player would
clubs than the session-RPE method,
likely due to the reservations of players
Crowcroft, Kempton 1).
The main aim of athletic training is to The training dose applied and experienced provide a load of 200 arbitrary units (i.e. 5 and coaches in providing RPE following
provide a stimulus that is effective in by athletes - commonly referred to as the x 40 min = 200 AU). match play.13
improving the players’ capacity to perform. training load – can be measured using
For positive training adaptations to occur, a variety of methods and is typically 0 Nothing at all “No I” Many performance practitioners
the balance between training dose categorised as either an internal or are many other variables that can be 0.3 measure these variables during each
and recovery (i.e. rest and/or recovery external training load 3. The external load obtained from various athlete tracking 0.5 Extremely weak Just noticeable training session use this information
interventions) needs to be obtained. At is the training dose applied to the athletes devices (e.g. estimated metabolic power, 0.7 to assess player output during training
simplest level, the performance responses and is commonly using microtechnology accelerometer loads, etc.), an approach 1 Very weak Light and to understand longitudinal changes
can be explained by the fitness-fatigue devices (e.g. GPS) and athlete tracking with relatively few variables that have 1.5 in training load for individual players.
model first described by Banister, Calvert, systems whilst the internal training load good measurement precision are 2 Weak However, the best use of these data is
Savage, Bach 2. The fitness-fatigue model is the load experienced by the athlete supported by a strong proof of concept are 2.5 when they are stored and the historical
is a simple approach to quantify a dose- and is measured using physiological recommended for load monitoring. 3 Moderate data are used to understand the loads
response relationship of training load (e.g. heart rate) and/or perceptual (e.g. 4 applied to players over the short and
to fitness, fatigue and performance. In perception of effort) tools. Due to the Unfortunately, the important activities that 5 Strong Heavy longer-term and this information can
its simplest form, the model estimates nature of the physical demands of football require high speeds and/or accelerations – 6 be used to identify risks of players who
performance outcomes as a result of the (i.e. it required players to complete high- which have been reported to be important 7 Very strong may be at risk of injury or reduced
fitness and fatigue responses that result of intensity, intermittent exercise), total constructs of load in football4 - tend to 8 performance.
the training dose applied through training. distance travelled, distances covered at be more difficult to accurately quantify 9
According to the model, fitness was higher running speeds (e.g. >14.5 km/h, with current technology. Indeed, despite 10 Extremely strong “Strongest I”
referred to as the average weekly training sprint efforts (i.e. efforts > 23 km/h) recent improvements with increased 11
dose completed in the previous 4 weeks and the number of accelerations and sampling rate and improved chipsets,5,6
whilst the fatigue was determined as the decelerations are the most commonly GPS devices cannot yet precisely assess ^
Figure 2 The category-ratio (CR10) scale
training load completed during the most used metrics used to quantify the external players accelerations/decelerations of perceived exertion 11 commonly used in
recent week. training load in football. Whilst there characteristics using intensity-based determination of the session-RPE training load.
CHAPTER 1 CHAPTER 1
Load monitoring systems can also be HIGH RISK SCENARIOS <

used to help ensure players are being Table 1 Example of
increased risk metrics
prepared for the demands of match play. Overload available from player
In particular, frequent exposure to higher ACWR spike Very high ACWR as determined by sessions
monitoring systems
(adapted from Colby,
sprint speeds and distances have been categorized in the top 20% Dawson, Peeling,
shown to reduce injury risk in both Gaelic Heasman, Rogalski,
Week-to-week change Previous (2-weeks ago) to current week (last 7 Drew, Stares 23)
football22 and professional Australian days) change >15%
Rules football players.23 As a general
rules, exposing players to speeds >90% Very high chronic load Very high 4-week chronic load for current season
maximum sprint speeds 1-2 per week
Acute workload ceiling Individual’s highest 1-week acute load for the
along with providing sufficient long term current season
exposure to sprint speed distances may
provide a prophylactic effect against Chronic workload Individual’s highest 4-week chronic load for the
ceiling current season
injury.22 Similar variables could be
included in a football player monitoring Over expose to speed >4 sessions in a week with exposure to high sprint
system to ensure are prepared for the high speeds >90% maximum speed
speed demands of match play. Underload / Under

prepared
Making decisions to intervene on training
ACWR trough Very low ACWR as categorized by sessions in the
for a player is usually a collective decision lowest 20%
between sport science, medical and
42 MEASURING THE Recent research has shown for avoiding training errors follow coaching staff using data from monitoring Very low chronic load Very low 4-week chronic load as determined by
sessions in the lowest 20%
43
PLAYER’S RESPONSE that systems that consist of
multidimensional measures of load
the Goldilocks’ approach to training
prescription such that we should avoid
systems but also the collective expertise
on the group. Specific risk markers need Exposure to maximal Week with low exposure to maximal speed (<85%
Measuring the players response and response are most appropriate players completing too much work to be developed for each group or athletes speed maximum sprint) prior to intense speed session or
match
to training is also a basic aspect for monitoring athletes.18 Moreover, (increasing fatigue), avoid players and according to the specific system and
of athlete monitoring systems in these monitoring systems should completing too little training (under markers that are available. However, the Acute Response Alerts
football.14 Common responses that consist of valid and reliable measures prepared) or changing workloads too common scenarios for risk are elevated
Increased soreness Elevated muscle soreness >1.5 standard deviation
are of interest to scientists is player that are simple to collect and of quickly (acute stress-response). loads, spikes in load following periods of from usual levels, combing with plan for high speed
fatigue, sleep and soreness, although low invasiveness to players. When low or high chronic loads, in appropriate or high load session
other factors (e.g. mood, stress etc.) training load and response data are Through monitoring of the load data, we recovery/rest periods from previous
Multiple wellness alerts Sustained period for reporting multiple response
are also commonly assessed. These interpreted in the context of each can assess for acute changes in these intense efforts. Table 1 below provides markers > 1.5 standard deviation from usual levels.
factors are often assessed using short other and with the current training load metrics during the previous week or examples of alters that may be used
customised questionnaires which goals, performance practitioners are longer-term changes over the past month to identify players at risk with a player Perfect Storm Low chronic loads, elevated ACWR with increased
report of soreness, fatigue and/or sleep
are relatively simple to administer able to make training decisions at (i.e. chronic load). Indeed, increases in monitoring system in football.
to players, often using cloud-based the individual level of the player that week-to-week training load of more than
computing applications.15 Notably, it can inform performance and reduce 15% from the preceding week increases
has recently been shown that various injury risk. injury risk ~50%.19 Another simple
TAKE HOME MESSAGE
customised single item psychometric check commonly used by performance
measures - such as perceptions of practitioners is to check how the recent Athlete monitoring systems are now
fatigue, mood, soreness and fatigue
have greater sensitivity to acute and
USING TRAINING LOAD change in training load compares to the
chronic load. Now commonly referred
common-place in football. The goal
of these systems is to monitor how
chronic training loads than commonly DATA TO MAKE DECISIONS to as the acute-to-chronic workload individual players are responding to
used objective measures.14
ABOUT FUTURE TRAINING load ratio (ACWR),20 this measure has
recently been associated with elevated
training. Fundamental measures that
should be incorporated in these systems
Objective response markers (e.g. Recent research has shown that systems with increased injury risk when the include quantifying training load,
heart rate and biochemical markers) that consist of multidimensional measures ACWR exceeds 1.50 or is less than 0.80.21 and the players response to this load.
have also been suggested as useful of load and response are most appropriate Importantly however, performance Following this, correct interpretation of
components of athlete monitoring for monitoring athletes.18 Moreover, these practitioners should be aware that this the data requires that all changes be
systems. Specifically, markers such as monitoring systems should consist of valid measure cannot be used to predict injury, contextualised in relation to the actual
muscle damage markers, heart rate and reliable measures that are simple to but used as a rule of thumb to when training load completed by the athlete,
variability hormonal and immune collect and of low invasiveness to players. making decisions about future training whilst accounting for the magnitude of
measures have shown to respond When training load and response data decisions. change required for practical importance
to changes in training intensity and are interpreted in the context of each in monitoring the training response. In
dose and have been associated other and with the current training goals, These data can also be used to ensure practice, these measures can be used to
with overreaching in a variety of performance practitioners are able to we build robust athletes through inform coaches and sport science staff on
athletes.16,17 However, due to logistical make training decisions at the individual appropriate exposure to training loads, individual players. If collected carefully
issues such as the invasiveness of level of the player that can inform with the general goal for players to and interpreted effectively, important
drawing blood or obtaining saliva performance and reduce injury risk. maintain moderate-to-high workloads, feedback can be provided to players and
samples from players, along with whilst minimising high variation in the coaches that enhances their readiness to
the costs and time for analysis, these Common training or periodisation errors ACWR. Conversely, we should also avoid perform and reduces their injury risk.
measures are not suited for daily can be avoided using a systematic having players being underprepared by
monitoring. approach to load monitoring and by completing low chronic loads, combined
following some common-sense rules with extreme ACWRs as this has been
in prescribing training. Basic heuristics associated with high injury risk.
CHAPTER 1 CHAPTER 1
1.4.3
RECOVERY STRATEGIES
Our Delphi survey revealed recovery as an effective strategy to prevent muscle
injury in elite footballers. Although fatigue has been highlighted by football
practitioners as one of the most important non-contact injury risk factors in
elite players, 1 it is surprising that the actual scientific level of evidence for
fatigue and injury is currently weak. 2
— With Abd-Elbasset Abaidia, Gregory Dupont, Antonia Lizarraga and Shona Halson
Day after the match:

Wearing compression upper limb strength
Hydration + foods Cold Bath garments training
End of with high glycemic *if 2 matches Massage
Have a good night sleep
the match index and proteins per week
^
44 However, there are several, indirect ACCELERATING factors (bright light, travel requirement, COMPRESSION GARMENTS MASSAGE Figure 1
Schematic representation of a
45
sources of evidence that can be
extrapolated to suggest a plausible link
RECOVERY: WHAT room environment). Optimizing sleep
may be possible by sleeping at least 8 to
Wearing compression garments following Massage can have a beneficial effect recovery protocol following a
football match
between fatigue and injury in footballers. RECOVERY STRATEGIES 10 hours, and increasing sleep hygiene
a match may have beneficial effects
on recovery kinetics. The effectiveness
on decreasing muscle soreness and on
increasing the perception of recovery. 12
For example, injuries are more common
at the end of each half during professional
TO USE (AND WHY) by measures such as switching-off lights,
decreasing the temperature of the room,
of compression garments on muscle The best results on muscle soreness are
force and power is underpinned by a obtained with a combination of effleurage,
matches, 3, 4, 5 whilst there is also a known limiting screen time and social media
TAKE HOME MESSAGE high level of scientific evidence. 18-20 It petrissage, tapotement, friction and
significant reduction in muscle force at use, and adapting the food ingested in
is recommended to wear compression vibration techniques and for a duration of 5
the end of matches. 4 A study of a French Consuming proteins after a match enables the afternoon by avoiding drinks such
garments with a high level of pressure to 12 minutes.
Ligue 1 professional football team 6 also repair of muscle damage following as coffee or tea. If the first night’s sleep
(for example: 15mm Hg at the thigh level
provides indirect evidence to support exercise. Scientific evidence has shown a is poor, it should be compensated with a
and 25 mm Hg at the calf level) until bed
the fatigue-injury belief of practitioners, beneficial effect of a protein dose of 20–40 nap the following day. 13
time and the days following the match. 21
in which the authors observed that a g, including 10–12 g of essential amino
Some individuals may prefer to sleep in the
significantly lower than normal recovery
time between high-intensity actions prior
acids and 1–3 g of leucine on muscle
protein synthesis rates. 10 Optimization
garments for additional recovery benefits, IMPORTANT
COLD-WATER IMMERSION
to injury was evident (35.6+/-16.8 s vs. of the resynthesis of muscle glycogen
however they should not be worn if sleep
is disturbed.
CONSIDERATIONS
98.8+/-17.5s). stores is effective when consuming Immersing the body into water with
carbohydrates with a high glycemic index. a temperature of 10°C for an exposure INDIVIDUAL VARIATION
Finally, further support lends itself with the An intake of 1.2 g carbohydrate per kg period of 10 minutes immediately after
Due to the fact that individuals will
widely accepted and established finding per hour immediately after a match, at muscle-damaging exercise session is
that, periods of match congestion (e.g. 15-60 min intervals for up to 5h, enables beneficial for recovery. 14 Results have THE DAY AFTER THE likely have different levels of fatigue/
soreness, a different time course of
weeks with multiple matches) significantly
increases the risk of injury. 7, 8 Elite football
maximum resynthesis of muscle glycogen
stores.11 Post-game re-hydration is an
consistently shown a beneficial effect of
this strategy on force, sprint and jump
MATCH recovery and respond differently
to specific recovery strategies, an
teams are regularly exposed to periods of important issue, it is recommended to recovery. 15, 16 While the use of acute cold-
UPPER LIMB STRENGTH TRAINING individualized approach to recovery
match congestion (e.g. 2 to 3 matches per consume a fluid (150% of body mass lost) water immersion is supported by research,
may be necessary. Some players may
week with typically 3 to 4 days recovery with a high amount of sodium (500 to 700 the effect of chronic use of immersion Scientific evidence for effective recovery
respond positively or negatively to
between) in which the time allowed mg.l-1 of water). 12 has been questioned. 17 This is due to the strategies the day following a match
different strategies, and therefore
between matches may be insufficient to potential role that cold water immersion is scarce. Teams typically perform low
consideration should be given to
restore normal homeostasis within players may play in reducing adaptation. Therefore, intensity and low volume exercise based
finding the optimal strategy for each
9
i.e. to fully recover. A recent multi-team, a periodised approach is likely best, strategies such as active recovery run,
SLEEP player based on performance and
multi-year study performed by the UEFA whereby cold water immersion is used pool session, or bike and tend to avoid
perceptual data if possible.
Football Research Group 7 showed that The recovery process may be affected acutely to influence performance (for rigorous intense activities. While only
muscle injury rates were 21% lower and recovery kinetics slowed following a example during congested schedules) preliminary evidence, performing an
when there were 6 days or more recovery perturbed sleep at night.14 Indeed sleep and limited or reduced at other times (pre- upper-limb strength training session the
THE FUTURE OF RECOVERY
compared to 3 or less days. These results is often considered the best recovery season or weeks with only one match). day after fatiguing and muscle damaging
show that a recovery period from 48h to strategy available to athletes, and it is lower-limb exercise may accelerate the While the area of recovery research is
96h between two matches is associated critical to manage sleep disturbances recovery kinetics of concentric force. 22 This relatively new in comparison to other fields
with an increased injury risk, suggesting when playing multiple games per week. strategy may be implemented the day after in physiology and nutrition, future areas of
insufficient time to fully recover. Recovery Many elite footballers complain of sleep a match. It also represents a time-efficient interest include periodisation of recovery,
strategies aimed at accelerating the time difficulties after night matches, which may modality to enhance upper-limb strength individualisation of recovery, psychological
for players to fully recover may therefore be due to physiological factors (fatigue, in players that may not be possible later in recovery (meditation, relaxation,
be useful in the overall injury prevention soreness, temperature), psychological the week or allows an additional exposure mindfulness) and how athletes recovery
strategy. factors (arousal, stress) or environmental to such training. from mental fatigue.
CHAPTER 1 CHAPTER 1
1.4.4
EXERCISE-BASED STRATEGIES
TO PREVENT MUSCLE INJURIES
Exercise is one of the most common preventative strategies implemented by football
teams to prevent muscle injury. 1 The following summary and recommendations are a
combination of relevant scientific research findings with current best practice.
— With Maurizio Fanchini, Eduard Pons, Franco Impellizzeri, Gregory Dupont, Martin
Buchheit and Alan McCall
*Special contribution from Nick van der Horst, Ida Bo Steendhal and the EBMIP Delphi Group
46 Specifically, this chapter is based on PREVENTATIVE STRATEGY EFFECTIVENESS RATING < HIGH-SPEED RUNNING 47
Table 1
the results of a systematic review and
our expert led Delphi survey of key High-speed running / sprinting +++
Perceived AND SPRINTING (HSR)
effectiveness of
football performance practitioners exercise strategies to During running and sprinting i.e. at high
Eccentric ++ prevent muscle injury
operating in teams from the Big 5 in elite footballers
velocities (HSR), lower limb muscles
Leagues (Bundesliga, English Premier Concentric + (EBMIP Delphi Survey experience high values of torque at
League, La Liga, Ligue 1, Serie A) and results) stance and late swing phases. During
Isometric +
combined with the philosophy and the stance phase, muscles of the hip
practices of FC Barcelona medical and Plyometrics (Horizontal & vertical orientations) + and knee work to counteract the ground
performance staff. reaction force. Muscles of the ankle
Activation / coordination (e.g. sprint +
movements & mechanic drills contract eccentrically and concentrically
Our systematic review showed that (with higher power compared to knee
there is no convincing evidence for Flexibility (dynamic & static) + and hip joints muscles) to absorb the recommended within the muscle injury producing moderate (> 6 to 10) exposures
many exercise-based strategies to Core stability +
ground reaction force and to push the prevention strategy. Exposure to targeted (i.e. the number of activity performed) of
prevent muscle injury in elite football body forward in the swing phase. 2 HSR and HIA can have the additional ≥95% of their maximal running velocity
players. Our results highlighted a Multi-joint exercises (e.g. Olympic lifting, Between + to +++ (no During the swing phase, muscles control benefit of developing physical qualities within the week were at reduced risk of
squats, functional strength) consensus as to precise
low quality of studies (systematic effectiveness)
the movement direction of the limb such as intermittent aerobic fitness that lower limb injury, while both low (<5) and
reviews and randomized control extremity with hamstrings muscles has been shown to protect players from high (>10) exposures increased the risk of
trials) and overall weak scientific Single leg strength and stability Between + to +++ (no responsible for both hip extension and lower limb injury. 7 injury. Importantly, a high chronic overall
consensus as to precise
evidence supporting eccentric exercise effectiveness)
knee flexion. 2 The high power expressed training load (all trainings) allowed players
to prevent hamstring injuries. The by the muscles results in high horizontal to tolerate higher exposures (between 10
HOW TO INTEGRATE HSR AND HIA INTO
Delphi survey revealed (Table 1) the Agility Between + to +++ (no force that maximize the forward and 15) ≥95% without increasing the risk
consensus as to precise THE FOOTBALL TRAINING PROGRAM?
perceptions of elite level practitioners effectiveness)
propulsion. 2 A lower contribution of of injury. Additionally, minimal exposure
regarding the effectiveness of various horizontal force during sprinting has The nature of football as a running based to HSR efforts (i.e. maximum speed and
exercise types to prevent muscle Kicking (shooting, crossing, long passes) Between + to +++ (no been proposed as a risk factor and sport means that the coaches’ normal sprint volume) has been shown to be a
injuries in footballers. The following effectiveness)
mechanism for hamstring muscle football training sessions inevitably risk factor for injury in Australian Rules
piece will focus primarily on the two injury in football. 3 Specific focus on involve a varied amount of contribution Footballers. Our chapter on‘controlling
most highly rated exercise types; Resisted sprints (e.g. sleds, parachutes) Between + to +++ (no HSR within the training program should of HSR and HIA depending on the load’with Professor Aaron Coutts will
high-speed / sprint running and effectiveness) therefore be considered important to type and duration of the session. We cover this in more detail.
eccentric exercise. A secondary expose and condition the lower limb recommend that wherever possible,
emphasis highlights the importance muscles in a specific manner to cope HSR and HIA should be integrated into Position specific HSR and HIA should be
of a multi-dimensional approach to with the demands of football training the coaches’ typical football drills. While, developed to contextualize running bouts
exercises based prevention and other and match-play. Importantly, reaching ideally HSR and HIA targeted sessions in relation to tactical activities, the work to
potentially effective exercises that can HSR velocities requires the player to are integrated seamlessly into normal rest ratio and method of recovery can be
be incorporated into the prevention accelerate and given the nature of training, it is also appropriate to prescribe manipulated as well as the introductions
program. football, then decelerate and change separate football specific drills and of change of direction and turns to
direction and change intensity with generic running (e.g. maximal aerobic simulate specific match patterns. 9 10 An
and without the ball (e.g. dribbling, speed, repeated straight line sprints integrated approach of physical, tactical
passing, shooting) according to the etc) to ensure players are exposed data and technical elements is also time
context of the game. 4 5 These situations, to sufficient amounts of this type of efficient and well accepted and liked by
requiring neuromuscular load 6 can preventative training. players and coaches. It is important to
present potentially injurious situations individualise the prescription of HSR and
and therefore exposing players to these While not in football (soccer), it has been HIA according to each player, there is not
high-intensity actions (HIA) is also shown in Gaelic Football 8 that players one size to fit all.
CHAPTER 1 CHAPTER 1
48 WHEN IN THE TRAINING WEEK, We recommended in general, (based on NON-STARTERS / SUBSTITUTES # Full days 49
between matches @M+3/+4 or M-3
TO PERFORM HSR AND HIA? our expert led Delphi survey) that during @M+3/+4 or M-3
periods of 1 match per week (i.e. >5 days It is important to remember that while the 1. Type #4 HIA 1. Type #6 Speed
There is no strong scientific evidence full recovery between matches), HSR and playing squad is 11 players, the typical elite >5 days SSGs 3-5 x 3-4min 5v5 + GKs* (Sprints via Football Sessions)
2. Type #2 HSR
to guide when the optimal time HIA specific exercise is performed on football squad comprises ~ 25 + players and HIIT Short 2 x 4-6 min 10s (110%)/20s (rest)*
is in the training week to perform Matchday -3 (M+4). During periods with not all can play. It is imperative that players Next match?
specifically focussed HSR and HIA ≤4 days recovery between matches, it is not playing regularly are also prepared for
training and there are likely various generally considered to perform football the rigorous demands of a match not only <5 days Football sessions only
possibilities depending on a number training only as the targets will most likely from an injury perspective but also from
of factors, including but not limited be achieved during the games. Within a performance standpoint. Carling and @M+1 @M+3/+4 or M-3 @M-2/-1
to; the number of days from the last even a congested fixture list, coaches colleagues 11 found that substitutes directly >60 min
1. Type #4 HIA 1. Type #6 Speed 1. Type #6 Speed
match and the next match (e.g. 2 to 6 normal training will involve higher winning more games was one of the <5 days SSGs 3-4 x 3-4min 4v4 + GKs Same as* (Sprints via Football Sessions)
+ days), starters versus non-starters/ running intensities (including sprints), potential contributors to a championship 2. Type #4 HSR
Played HIIT Short 1-2 x 4 min 20s (95%)/20s (rest)
substitutes, loads performed and and therefore it is likely not necessary to winning compared to 4 other non-winning last match?
experienced during the match, the perform any additional work. It is even seasons. Therefore careful consideration
planned content of the coaches possible to perform HIA drills i.e. short should be given to these players and @M+1/+2 (depending on rest day)
football session, individual players acceleration, deceleration and change although involved in the same main training Did not play /
played <35 min 1. Type #4 HIA
3-4 days
needs, strengths, weaknesses, likes of direction drills (typically coined speed sessions as the starting players, they will SSGs 3-4 x 2-3min 5v5 + GKs
or HIIT Short 2 x 4min 15s (95% passing, kicking, sharp CODs)/15s (rest)
and dislikes, current and on-going & agility by players) on the M-1 as long likely require additional and supplemental 2. Type #6 Speed:
medical issues, whether or not they as a low volume and adequate recovery HSR and HIA to ensure they are prepared if Next match? 4-6 progressive 40/60-m runs (build up to 90-95% MSS), r = >45s
are accustomed and adequately times between repetitions are respected. called upon. Specifically, it is recommended
prepared to be exposed to and tolerate Anecdotally, many players actually enjoy that non-starters and substitutes perform @M+1
such demanding exercise. performing these types of activities on the additional HSR and HIA exercise on M+1 or 1. Type #1
M-1 (e.g. as part of the warm up or after M+2 (but not on both), depending on the 2 days HIIT Short 1 x 4min 10s (105%, 45° CODs)/20s (rest)
2. Type #6 Speed
the session) as it makes them feel “sharp” training schedule e.g. days off, upcoming 4 progressive 40-m runs (build up to 90-95% MSS), r = >45s
for the match the next day. match etc.
^
Figure 1
Decision process when it comes to programming the different running e.g. High-intensity intermittent
training (i.e. HSR & HIA) drills with respect to competition participation and matches macrocycles.
Note that only HIIT sequences are shown – most sessions would also include technical and tactical
components and possession games. SSGs: small-sided games. HIA: high-intensity activities (> 2ms2
accelerations, decelerations and changes of directions). HSR: high-speed running (>19.8 km/h). The
different HIIT types are the following: Type #1) aerobic metabolic, with large demands placed on
the oxygen (O2) transport and utilization systems (cardiopulmonary system and oxidative muscle
fibers), Type #2) metabolic as 1) but with a greater degree of neuromuscular strain, Type #3) metabolic
as 1) with a large anaerobic large glycolytic energy contribution but limited neuromuscular strain,
Type #4) metabolic as with 3) but with both a large anaerobic glycolytic energy contribution and a
high neuromuscular strain, Type #5) a session with limited aerobic demands but with a anaerobic
glycolytic energy contribution and high neuromuscular strain Type #6)not considered as HIIT) with a
high neuromuscular strain only, which refers to typical speed and strength training for example. Note
for all HIIT Types including a high neuromuscular strain, possible variations exist in the form of this
neuromuscular strain, i.e. more oriented toward HSR (likely associated with a greater strain on hamstring
muscles) or HIA (acceleration, decelerations and changes of directions, likely associated with a greater
strain of quadriceps and gluteus muscles). Note for example that Type #1 can be achieved while using
45°-CODs, is likely the best option to reduce overall neuromuscular load (decreased absolute running
velocity and no need to apply great force to change of direction, resulting in a neuromuscular strain lower
than straight line or COD-runs with sharper CODs.) Reference (for both HIIT types and Figure): Science
and Application of High Intensity Interval Training, Laursen P, Buchheit M. Human Kinetics, In Press.
CHAPTER 1 CHAPTER 1
WHEN IN THE TRAINING WEEK TO BEFORE THE SESSION PLYOMETRICS, CORE AND MULTI-JOINT
50 ECCENTRIC EXERCISE PERFORM THE MAIN ECCENTRIC
estimation. It is also vital to consider if
players are accustomed to performing
of performing such exercises before or
after the session. This is best done at the EXERCISES
51
One potentially modifiable risk factor
In our expert led Delphi survey, exercises EXERCISES? eccentric exercise as this may allow individual player level also. It has been
for muscle injury are increases in Plyometric exercises are commonly used
with an eccentric focus were rated as the them to perform such exercise on a M-3 recommended that eccentric exercise
fascicle.19 Performing eccentric exercise to improve sprint and jump performance
2nd most important exercise mode to As with high-speed running and in a 5 day week without experiencing performed both before (fresh) and after
before the training session has revealed in team sport in addition to increasing
prevent muscle injury in elite footballers. sprinting exercise, there is no clear any muscle soreness. (fatigued) are likely optimal to the injury
fascicle length increases but not when the neuromuscular control and lead to
This is in line with the perceptions of scientific evidence as to when is the best prevention program.23 This is in line
performed after the session. 20 Similar less torque working on the knee.24 The
worldwide Premier League,1 UEFA period to perform the main eccentric During periods with ≤4 days it is with the actual practices of the expert
chronic adaptation of peak torque introduction of plyometric exercises into
Champions League12 and National teams exercises during the football training generally considered that specific practitioners from the Big 5 leagues.
production of the hamstring muscles has the injury prevention program could be
competing in the FIFA World Cups.13 week. There are a number of similar high-intensity type eccentric exercise
been shown to be similar when eccentric promising however several parameters
Eccentric exercise may be particularly contextual factors running based training is not necessary. There may however
exercise is performed before and after of load (volume, intensity, frequency)
useful as it targets various modifiable that need to be considered surrounding be options to include low intensity, low
the training session.20 should be accurately evaluated during
risk factors including; eccentric strength,
optimal angle of peak torque and
the decision of when is most appropriate
to include eccentric exercise.
volume eccentric type exercises coined
as ‘activation’ exercises.. The specific
EXERCISE-BASED INJURY the design of the training program.
muscle architecture e.g. fascicle length14. muscle section of this Guide will provide
AFTER THE SESSION
PREVENTION STRATEGIES Specific exercises targeting the motor
control of the core muscles have been
It is likely that these reasons explain
why this exercise mode is favoured by
In general, when playing 1 match per
week and 6 days recovery between
further details on specific eccentric
exercise types e.g. for the hamstring, A training intervention where eccentric
SHOULD BE MULTI- found to result in fewer games missed in
practitioners not only in football but also matches, the most appropriate day is adductor, quadriceps and calf. exercise is performed after the session DIMENSIONAL Australian Footballers,25 however, multi-
joint exercises such as the squat and
in many other team sports.15 Importantly, perceived to be on M+ 3 (M-4 from the has shown to increase muscle thickness
deadlift are at least and in some cases
player buy in and the quality to which next match). This timescale likely allows and pennation angle21 as well as a While this section has focussed
more effective in the activation of core
the exercises are performed are likely opportunity for muscles to recover from PERFORMING ECCENTRIC EXERCISES chronic adaptation towards an improved on running and eccentric exercise
muscles.26 An important consideration
key to ensuring optimal adaptations and the previous match and enough time BEFORE OR AFTER THE FOOTBALL ability of players to maintain their specifically, in reality, the injury
for the practitioner is that the inclusion
beneficial effects on muscle injuries.12-16 for them to recover again before the SESSION? eccentric strength at half-time and upon prevention program is and should be
of other exercise modes such as
As such, exercise with an eccentric focus next match 4 days later e.g. Saturday – cessation of a simulated football match multi-dimensional that includes various
Once we have decided on the day to plyometrics and multi-joint exercises
should be considered in the overall Tuesday – Saturday. versus those performing in a fresh state other exercise modes. Therefore, the
perform the eccentric session, another should be performed in both vertical
injury prevention program for footballers before training.22 global injury prevention program should
key question for practitioners is when to and horizontal orientations. Using both
and buy in and quality execution of When the recovery between matches not be limited to high-speed running /
implement it i.e. before (non-fatigued) orientations in the football training
these should be encouraged and is 5 full days (e.g. Saturday – Friday) sprinting or eccentric exercise alone but
or after (fatigued) football training? program has been shown to improve
monitored by practitioners. the preferred day is again on the M+3, CONSIDERATIONS WHEN DECIDING involve the addition of other exercises
While scientific evidence is limited neuromuscular performance of players
however this will also correspond to a BEFORE OR AFTER THE FOOTBALL targeting modifiable risk factors. Table
currently, there are some preliminary in comparison to vertically oriented only
M-3 i.e. 3 days before the next match. SESSION 1 illustrates the wide array of exercise
findings suggesting that specific timing exercises.27
While only preliminary evidence, it types available to the practitioner
of the eccentric exercise around the An important consideration when
has been shown in semi-professional who wants to reduce injury in his/her
football session may result in different planning the timing of the eccentric
football players that performing eccentric team. While there is limited evidence
adaptations that could contribute to exercise session is that an acute effect
exercise on the M+3 i.e. M-3 during a for many of these exercise types e.g.
reducing muscle injury risk. of eccentric exercise performed before
week with 5 full days recovery resulted plyometrics, flexibility, core stability, static
the training session may result in muscle
in elevated levels of creatine kinase and and dynamic flexibility, activation etc
fatigue that could actually increase
hamstring muscle soreness 24h before to prevent muscle injuries of the lower
the probability to sustain an injury in
the next match.17 However, perhaps limbs in footballers, they should also
the subsequent session.21 Therefore,
importantly was that muscle function (i.e. be considered due to their perceived
as a practitioner you should consider
muscle force) was not affected. Muscle effectiveness and widespread use in elite
carefully the context surrounding the
force is considered the gold standard football teams i.e. current best practice.
planned eccentric exercise; in particular
measure of muscle damage18 and may
consideration of the coaches training
be more useful to inform injury risk
session and determine the risk:benefit
CHAPTER 1 CHAPTER 1
52 FLEXIBILITY KEY PROGRAM PREVENTATIVE STRATEGY EFFECTIVENESS RATING <

Table 2 Perceived 53
There is no clear evidence for lower

VARIABLES FOR EXERCISE High-speed running / sprinting +++ effectiveness of
exercise strategies to
limb flexibility alone to reduce muscle BASED STRATEGIES Eccentric ++
prevent muscle injury
in elite footballers
injuries, however they have been Concentric +
(EBMIP Delphi Survey
results)
integrated into global prevention Although scarce, there is some
programs that have shown beneficial scientific evidence for the use of multi- Isometric +
effects on muscle injury.28-29 Static and dimensional injury prevention programs
Plyometrics (Horizontal & vertical orientations) +
dynamic lower limb flexibility training in elite footballers. In 2005, Verrall
may logically be useful to allow the and colleagues30 found that a global Activation / coordination (e.g. sprint +
hip and knee muscle to move within prevention program incorporating sport movements & mechanic drills
ranges of motion necessary during specific running drills, high-intensity Flexibility (dynamic & static) +
kicking and sprinting. interval anaerobic training, strength
training and flexibility resulted in a Core stability +
significant reduction in hamstring Multi-joint exercises (e.g. Olympic lifting, Between + to +++ (no
muscle injuries and the number of squats, functional strength) consensus as to precise
EFFECTIVENESS OF competition games missed. Owen effectiveness)
MULTI-DIMENSIONAL et al. (2015)28 implemented a multi-

dimensional prevention program in
Single leg strength and stability Between + to +++ (no
INJURY PREVENTION elite European footballers incorporating effectiveness)
PROGRAMS ON MUSCLE eccentric, general strengthening

exercises, dynamic flexibility, core,
Agility Between + to +++ (no
INJURY IN FOOTBALLERS balance, coordination and agility based effectiveness)
runs into the overall football training Kicking (shooting, crossing, long passes) Between + to +++ (no
Although scarce, there is some program resulting in significantly less consensus as to precise
scientific evidence for the use of multi- muscle injuries in players. effectiveness)
dimensional injury prevention programs Resisted sprints (e.g. sleds, parachutes) Between + to +++ (no
in elite footballers. In 2005, Verrall consensus as to precise
and colleagues30 found that a global effectiveness)
prevention program incorporating sport
specific running drills, high-intensity
interval anaerobic training, strength
training and flexibility resulted in a
significant reduction in hamstring muscle
injuries and the number of competition
games missed. Owen et al. (2015)28
implemented a multi-dimensional
prevention program in elite European
footballers incorporating eccentric,
general strengthening exercises, dynamic
flexibility, core, balance, coordination and
agility based runs into the overall football
training program resulting in significantly
less muscle injuries in players.
CHAPTER 1 CHAPTER 1
1.4.5
COMMUNICATION
Another of the most important injury prevention strategies as highlighted by elite
football practitioners from the ‘Big 5’ Leagues in our Delphi Survey was ‘communication’.
A common opinion among football practitioners is that, to maximise the preventative
effects of strategies such as controlling load and implementing exercise and recovery
strategies, we must be able to communicate effectively with key stakeholders such as
players and coaching staff, as well as among ourselves.
— With Mike Davison and Ricard Pruna
54 Good internal communication WHAT IS Professor Albert Mehrabian is WHY IS IT LIKELY TO different clubs, where the workplace
can change from one day to another, THE BARÇA WAY
55
should help in the implementation of
preventative strategies and perhaps
COMMUNICATION? internationally well known for
his publications on the relative
BE IMPORTANT IN there are common cultural as well
The Medical and Performance team
more importantly, gain the ‘buy in’ of Communication is simply the act of importance of verbal and nonverbal FOOTBALL? as communication challenges to
overcome. have to be confident as well as
players and coaches. Whilst there is transferring information from one messages. Some of the key findings
willing and able to communicate
currently no scientific evidence for place to another. Although this is a from Mehrabian’s work,2-5include; Simply put, communication is at the
It is therefore crucial for the Football their recommendations using simple
the effectiveness of communication simple definition, in a high-pressure (i) 7% of the understanding of the heart of every successful organisation.
Medicine team to try to maintain language and even drawings to
to prevent muscle injury in elite environment such as that in elite football, message comes from the feelings and It disseminates the information
consistency and high quality levels of clearly illustrate their points and
football specifically, it makes sense it becomes a lot more complex. Successful attitudes in the words that are spoken needed to get things done, and builds
internal communication irrespective of recommendations.
that effective communication could communication can be considered as a (verbal communication), (ii) 38% of relationships of trust and commitment.
organisational change, in order to avoid
be beneficial to maximise injury combination of several important factors. the understanding of the message Without it, team members end
a potential deleterious effect on injury We need to be patient and take
prevention strategies. A UEFA-led Firstly, the right language needs to be comes from the feelings and attitudes up working in silos with no clear
burden, and player welfare. the time to educate the players,
survey of 33 of the 34 Champions used. Secondly, it is important to know invoked by the words that are said direction, with vague goals and little
coaching staff and board members
League teams competing in the the audience, considering their own injury (paraverbal communication), (iii) 55% opportunity for improvement. A team
on key medical and performance
2014/15 season, revealed ‘internal experience, their cultural context, and their of the understanding of the message with high quality communication INTERRELATED WORK,
concepts.
communication’ as one of the most potential heuristics and biases. Finally, it is comes from the feelings and attitudes between different roles are likely to PART OF PREVENTION
important risk factors for non-contact important to evaluate and ensure that the translated in facial expression (non have good collaborations, and benefit
It is essential that we are honest
injury (muscle injury being a large desired message has reached its target, verbal communication). from multiple perspectives in making
and act in the best interests of the
component of non-contact injuries), and has been understood. informed decisions, for instance in
COACHING players, the club and fellow staff and
and successful buy in from players We have to recognise there are many those regarding players’ well-being. STAFF not concerned with our own ego.
and coaches as crucial to the success types of communication at play in a
of injury prevention strategies.1 The football club. They range in setting, in However, team morale can plummet
following is a philosophical view of CATEGORIES OF COMMUNICATION structure and in forms of interaction. when communication is ambiguous,
how effective communication may help However, it is often not the information unfocused, lacking in important details
in the elite football setting and provides There are various categories of itself that is important for the outcome, and where it does not allow for genuine
some examples of the FCB philosophy communication, of which more than it is the way it is delivered. In the two-way dialogue. A situation like SHARE &
COMMUNICATE
regarding communication. one may occur or interact at any emotionally and often paranoid setting this, where this low quality of internal INFO
time. The different categories of of a football club, the body language communications, is one where there is
communication include: and tone dominate. Thinking more increased risk of misunderstandings,
specifically about Football Medicine, one-sided decision-making and
• Spoken or Verbal Communication: e.g. the diversity and scope of potential wrongful decisions. MEDICAL &
PLAYERS PERFORMANCE
face-to-face, telephone conversations and communications STAFF
is wide. Perhaps it is the widest We know from experience that
• Non-Verbal Communication: e.g. body
in the football club environment, organisational stress can have a
language, gestures, how we dress or
and this means that the doctors, negative impact on player welfare.
act
physiotherapists, fitness coaches, An organisation with a lot of ^
• Written Communication: e.g. e-mails, sports scientists, team psychologists miscommunication, where members Figure 1
A key component
reports and medical notes need to be skilled in communication to experience a lack of or insufficient of the multi-faceted
be effective. information, and where their opinions injury prevention
• Visualisations: e.g. graphs, charts, program in FC
are not considered, might create
photos and other visualisations can Barcelona
stress on staff and players. Football
communicate messages
is a dynamic industry and with a
constant transfer of coaches and
players from different nations between
CHAPTER 1 CHAPTER 1
1.5
CONTINUOUS (RE) EVALUATION

AND MODIFICATION OF
PREVENTION STRATEGIES
A key phase of the Team Sport Injury Prevention (TIP) cycle is ongoing (re) evaluation
of the injury situation to find out whether prevention strategies are actually having an
impact. Are any new or different injury patterns emerging? This information is essential
to allow the medical and performance team to adapt to a constantly changing injury
landscape and ensure maximum prevention effectiveness over time.
— Alan McCall, Ben Clarsen, James O’Brien and Robert McCunn
• Injury severity corresponds to the

56 RE-EVALUATING THE number of days absence due to the
WHY IS INJURY BURDEN 120
Knee < 57
Figure 1
LANDSCAPE OF MUSCLE injury. SO IMPORTANT? Injury risk matrix
showing reporting the
INJURIES IN YOUR TEAM • Individual player exposure (in 100 incidence AND severity
of various muscle
minutes) for all training sessions and Although injury incidence can be useful
SEVERITY (# OF DAYS LOST)

injury locations
The key to ongoing evaluation of matches should be recorded to allow to provide an evaluation of the how and joint injuries
the injury landscape in your team calculation of injury statistics. often injuries will occur in your team, 80 for comparison.
The yellow shading
throughout the entire season is it says nothing about how severe they represents the injury
Recording this information correctly
injury surveillance.1 The medical and are. In contrast, burden measures burden i.e. the lighter
is essential to the subsequent 60
the yellow shading,
performance team should record incorporate both injury likelihood and
interpretation and actions decided. the lower the injury
injuries consistently to ensure that data severity.1 This approach has been used Quadriceps burden and vice versa,
There are two particularly useful
is comparable within and between for many years in rugby union3 as well 40 the darker the yellow
methods to calculate, report and shading, the greater
seasons. We recommended using as in the UEFA ECIS during the last
monitor the muscle injury situation Calf
the injury burden.
well-established injury definitions decade.4,5 Hamstring
within your club (and indeed all injury 20
Ankle Adductor
from published research. In this
types can be recorded this way),
way, practitioners can compare not Burden is best illustrated using a risk
allowing accurate comparison to the
only within their own team, but also matrix illustrating injury likelihood 0
published research literature.
with data published in the scientific (incidence) and severity (time loss).1 0,0 0,5 1,0 1,5 2,0
literature. Specifically, injury definitions Figure 1 illustrates the incidence plotted
1. Injury Incidence – corresponds to INCIDENCE (# OF INJURIES/1000 PLAYER HOURS)
and collection procedures should follow against the severity of various injuries,
the rate of injuries and is calculated
the guidelines set out in the 2006 with the lighter to darker yellow
and reported as a number of injuries
Consensus Statement for the definition
and data collection procedures for
per 1000 hours of exposure (e.g.
shading representing the burden. This
figure highlights the importance of
EVALUATING CURRENT the how and the why. For example, Qualitative methods include, but
football (soccer) injuries.2 This method
match exposure, training exposure
and match + training exposure). For
evaluating both incidence and severity INJURY PREVENTION a qualitative approach is needed to
investigate why a particular preventative
are not limited to, interviews, focus
groups and surveys.7 While it may
is also used by the UEFA Elite Club
Injury Study (ECIS), which provides
example, if a team has 10 injuries
and how reporting one alone, does not
provide the full picture of the muscle
PRACTICES IN YOUR CLUB strategy might be popular with players seem unnecessarily over complicated
during 5,000 hours exposure, the and coaches, and another one unpopular. to refer to ‘qualitative data collection’
insights into the largest database of injury landscape in your team.
injury incidence is 2 injuries for every In addition to collecting injury data, A multitude of factors influence the injury instead of simply ‘talking to your
football injuries anywhere in the world.
1,000 hours.* equation: #injuries/1000 it is essential to evaluate the injury prevention behaviour of players, coaches colleagues’, incorporating scientific
The key aspects of the UEFA ECIS
hours of exposure prevention situation in your club. Are and team staff members. Even strategies rigour to the process can be valuable.
method include:
prevention strategies affecting the injury shown to be highly effective in controlled Using tools such as standardised
2. Injury Burden – corresponds to
situation? Are they being consistently research studies may not be utilised by surveys and semi-structured
• An injury is defined as any physical the cross product of severity AND
implemented? What do players and players, coaches and support staff in the interviews, and considering factors
complaint sustained by a player incidence i.e. provides a combination
coaches think of the strategies? There real world. The Nordic hamstring exercise such as how, when and where you
that results from a football match or of the rate of injury as well as a
is no gold standard for how these is a perfect example of this conundrum; ask certain questions might allow you
training and leads to the player being measure of loss i.e. days lost due
questions should be answered – it scientific evidence shows the exercise to collect more relevant, systematic
unavailable to take full part in future to the injury. Total number of days
requires combining a quantitative reduces the risk of initial hamstrings insights and present your conclusions
football training or match-play (i.e. lost per 1000h. For example, if a
(i.e. measurable, data-driven) and a injuries by 59% and recurrent injuries by with credibility. Table 1 provides
time loss). team has 10 injuries during 5,000
qualitative approach. 86%, yet a majority of UEFA Champions some suggestions for employing
hours exposure, each resulting in an
• A player is considered injured until League teams do not use it.6 Qualitative qualitative methods to evaluate the
average absence of 10 days, the injury
the club medical staff clear for In general, quantitative data tells us the research methods can be an important injury prevention situation in your
burden is 20 days for every 1,000
full participation in training and what and the when (e.g. injury types, tool for understanding the reasons team, taking the implementation of
hours. *equation: #days absence/1000
availability for match selection. locations, incidences and burdens), behind your team’s injury prevention the Nordic Hamstring Exercise (NHE)
hours of exposure
whereas qualitative data may tell us situation. program as an example:
CHAPTER 1 CHAPTER 1
58 WHO TO ASK* HOW TO ASK WHEN TO ASK WHAT TO ASK (Ex) < 59
Table 1
Suggestions for
Players Surveys As part of routine team How many of the planned NHE sessions were carried out? employing qualitative
meetings evaluation in a team
Football coaches Focus groups Were the correct number of sets and repetitions performed?
Formal injury prevention setting
Medical and Interviews What was the quality of exercise execution?
evaluation sessions
performance staff
Do you see any benefits of using the NHE program?
Individual player
Club officials
performance reviews Does the program have any negative side-effects?
Are there any barriers for using the NHE program?
Was the program modified? (Why?)
Do you use alternate strategies? (Why?)
Do you intend to continue using the NHE program?
Could the NHE program be adapted to better fit your team’s
situation?
* It is important to ask individuals from all the

groups involved in the injury prevention strategy; Acknowledging the fast and frenetic
players (who perform the program); team staff pace of football, continual evaluation
members (who deliver the program) football is crucial in this phase of the Team
coaches (who often act as “time-keepers”) and
club officials (who determine club policy and Sport Injury Prevention cycle. This will
provide resources e.g. financial). allow the medical and performance
team to audit and identify emerging
patterns in the injury situation and take
subsequent action. Although it may be
normal to discuss the injury situation in
daily and weekly medical meetings, we
recommend a more formal evaluation
performed 2 to 3 times per season,
including coaches, other support staff
and even some players. During this
evaluation, injury statistics, qualitative
analyses and reviews of injury
prevention research and innovative
strategies can be discussed in depth.
CHAPTER 1 CHAPTER 1
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15-094747 MSS.0000099107.- gth increase using the interaction of strangers
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03704.AE Copenhagen Adduction in a waiting situation.
14. Bourne MN, Timmins et al. Hamstring
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RG, Opar DA, et al. myoelectrical activity 4. Brughelli M, Mendi-
randomized controlled Research in
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CHAPTER 1 CHAPTER 1
OF MUSCLE INJURIES
2.1.1
RETURN TO PLAY FROM MUSCLE

INJURY: AN INTRODUCTION
The previous section on preventing muscle injury in football has outlined various
strategies and tools that can be adopted to minimise the risk of players incurring a
muscle injury. While in an ideal world we would be able to prevent all muscle injuries
from occurring this is unfortunately, impossible. As outlined in our ‘Injury Landscape’
article (see Section 1, Chapter 2.1.c) a professional football can expect around 16
muscle injuries in a season.
— With Ricard Pruna, Alan McCall and Thor Einar Andersen
66 General As such we need to be optimally 67
principles of
prepared to deal with muscle injuries TO RETURN
when they come. Following a muscle THE PLAYER TO
TO AVOID
injury (or any injury for that matter) MATCH-PLAY
RE-INJURY
AS SOON AS
there are 2 main objectives (and at POSSIBLE
Return to Play
the same time challenges); 1) to return
the player to match-play as soon as
^
possible and 2) to avoid re-injury. Figure 1 Objectives
There is a fine balance to this, which (and challenges) of
from Muscle
is complex depending on the context Returning a player
from injury.
of each individual player, injury and
circumstance (figure 1).
Injury
In football, the decision to progress
or delay a players’ return to play
following muscle injury, could be the
difference between having a player
back two matches earlier (increasing
the chance to win 6 points) versus
keeping the player out an extra two
weeks, lowering his/her injury risk,
but maybe gaining fewer points from
those two matches.1 Essentially, it
comes down to a decision on an
agreed ‘level of risk’ (for re-injury)
that the team is willing to accept
i.e. a shared decision of medical,
performance practitioners, the coach
and the player him/herself.
The purpose of this chapter on ‘General

Principles of Return to Play from
Muscle Injury’, as with the previous
prevention section, is to bring together
the best of research knowledge and
demonstrate how we combine this
with our practical experience and
knowledge. Providing you with general
principle to follow during the return to
play process.
CHAPTER 2
2.1.2
GUIDING PRINCIPLE 4 GUIDING PRINCIPLE 5 GUIDING PRINCIPLE 6
RETURN TO PLAY IN FOOTBALL: Use regular assessment and feedback
to reinforce and guide collaborative goal
How you communicate with the injured
player is important. Focus on using
Keep the player cognitively engaged
in football, even when off the pitch,
A DYNAMIC MODEL setting. Repeat testing and monitoring
can help the player see progress, and
language that emphasises the notion
that return to play is a progression that
to maintain the high-level cognitive
function required for football is essential.
this is often especially helpful for players begins at the time of injury. Return to The unpredictable nature of football
There is a paradigm shift occurring in the way we think about return to play.
with injuries that have extended time play is not something that automatically requires high-level cognitive function
Instead of return to play being the highly anticipated event occurring at the end of a
loss. Continual assessment of players’ happens once rehabilitation is completed. for reaction time, decision-making,
rehabilitation program, we now consider that return to play starts the moment the
performance performing, in particular Use positive language that focuses on shifting attention, pattern recognition and
injury occurs and continues beyond the point where the player making his or her
football specific actions such as repeated what the player can do – whether that is anticipation.4 Keeping the football brain
return to unrestricted match play (Figure 1). This type of progression is individual and
sprints and external running loads as modified individual field-based training, active helps the player stay engaged in
malleable, allowing for faster and slower individual progressions throughout the
well as how they are coping with these modified team training, or performing as rehabilitation. Mental fatigue can impact
return to play plan.
through internal load markers (e.g. desired in the competitive environment. on performance,5 and training cognitive
— With Clare Ardern and Ricard Pruna
perceived exertion, fatigue, soreness) and Focusing on the performance aspect function should be part of a standard
psychological readiness and confidence in each phase of the return to play football conditioning program.5 Therefore,
may help you and the player monitor the continuum is vital to helping the player it is also appropriate to include relevant
progressive restoration of strength, ability to maintain the sense of being an athlete,3 cognitive challenges throughout the
perform football actions and psychological irrespective of whether he or she has return to play continuum. Strategies to
readiness. The information gathered from achieved the goal performance, or not. consider include choosing typical football
regular testing can, in turn, guide goal movement patterns or skills where
setting about when it is safe to resume decisions have to be made randomly
68 < 69
Figure 1 restricted training, unrestricted training and and focus attention and temporo-spatial
Football return to play unrestricted match play. control.
continuum (adapted
from Ardern et al.1)
<
Figure 2
Football-specific
drill involving high
cognitive demands
while preforming
rapid changes of
direction, passing and
The concept of return to play as a

THE BARÇA WAY
GUIDING PRINCIPLE 3 shooting. The player
responds to light
continuum was introduced in the Bern signals indicating their
Appropriate loading throughout the running direction and
2016 consensus on return to sport,1 and
Working backwards from an antici- return to play continuum is important whether they need
is something familiar to FC Barcelona to pass or shoot. This
pated return to optimal performan- to stimulate satellite cells to promote challenges both their
clinicians and practitioners, who have
ce date – which is usually a specific muscle tissue healing, and (in later spatial awareness and
been practicing in this framework for reaction times. As an
game – helps motivate the player stages of the return to play plan)
the past decade. The purpose of this example, in a muscle
and facilitates effective communica- to ensure the player is adequately injury with 6-week
section is to outline 6 guiding principles
tion with the manager and perfor- prepared for the demands of return to prognosis we would
for return to football after muscle injury typically introduce
mance team. Progress towards that performance. Structuring the return to
and highlight 4 key considerations for this drill following the
goal is continuously assessed using play plan so that the player spends as second week.
the decision-making team.
the milestones in the return-to-play much time as possible doing football-
continuum. In this way we can see specific, pitch-based training (with
whether the player is on track, be-
GUIDING PRINCIPLE 1 hind, or even ahead of schedule.
appropriate modification, according to
impairments and functional limitations)
FOUR KEY CONSIDERATIONS FOR EFFECTIVE RETURN TO PLAY PLANNING
Making an accurate diagnosis is provides two important benefits. First,
the cornerstone of effective injury it facilitates appropriate and specific 1. Many factors influence the 3. Support the player to be 4. Return to play planning
management and return to play
planning. Accurate diagnosis facilitates
GUIDING PRINCIPLE 2 loading (when combined with a well-
structured impairment-focused (e.g.
return to play.1 Physical and
mental readiness to return
confident about returning
to play by keeping him
is about managing risk.7,
8 Careful planning and
an estimation of prognosis, and in turn, Return to play plans must be tailored to the strength, range of motion, effusion) to play are both important or her involved with the regular monitoring will help
shared decision-making regarding individual player, who has an individual management plan). Second, maintaining aspects, and do not always team throughout the return the decision-making team
injury management. Imaging may be injury and an individual return to play contact with the team provides the go hand-in-hand. to play plan, by regularly appropriately consider risk
used judiciously at this step, but you continuum. An individualised plan is injured player considerable psychosocial monitoring progress,6 and implement effective risk
2. Use a group of sport-
must be clear about what (if anything) responsive to the needs of the player to and motivation support. and by emphasising minimisation strategies for
specific functional tests and
imaging will do to change the return appropriately consider factors that might football-specific elements timely return to play.
player-reported outcomes
to play plan.2 At FC Barcelona, we influence prognosis, and those that could throughout.
to monitor progression and
work backwards from the anticipated influence the risk for reinjury at any stage
to judge when the player
time to return to full match-play. through the return to play. A one-size-fits-
is physically and mentally
Understanding biology will help all approach is insufficient in professional
ready to return to play.1
when estimating injury prognosis and football, given the multifactorial nature
planning a strategy for appropriate of return to play, and the need to address
loading through the return to play specific individual factors based on the
continuum. player’s needs.
CHAPTER 2 CHAPTER 2
2.1.3
RETURN TO PLAY IN FOOTBALL:

A DYNAMIC MODEL
When a footballer sustains a muscle injury, their first question is invariably: “how
long will this take to recover?” Answering this is not easy,1-5 but in elite-level football
it is vital to make an educated guess. As previously discussed, the RTP continuum
begins with the anticipated date of return to optimal performance in mind and works
backwards, defining the milestones necessary to achieve that goal. This approach
motivates the player, allows the manager to plan effectively, and facilitates good
communication and realistic expectations from all involved.
— With Ricard Pruna and Ben Clarsen
70 Recent research has shown that, when THE STARTING POINT: LOCATION AND PLAYER-SPECIFIC FACTORS FOOTBALL-SPECIFIC FACTORS POSITION KEY DEMANDS CONSEQUENCES FOR < 71
used in isolation, both MRI and clinical EXTENT OF TISSUE DAMAGE MUSCLE INJURY Table 1
Key positional
assessment findings are poor predictors Every football player has unique anatomy Each player’s unique role on the Goalkeepers, Long kicks and jumps High stress on rectus demands and their
of RTP time.1-5 That is because even Knowing the exact injury location is that will affect his or her recovery from pitch needs to be considered when central defenders femoris consequences
on muscle injury
when the same type of injury occurs, arguably the most important factor in a muscle injury. For example, due to estimating the RTP time. For example, rehabilitation
Full backs, High speed running, High stress on hamstrings
myriad individual and contextual predicting RTP time. This is why, at FC differences in free tendon length, a biceps wide defenders and wingers perform wingers rapid acceleration and
factors influence how quickly each Barcelona, clinical assessments are femoris injury located 5cm from the more high-speed running than deceleration
player will recover, and how much performed and high-quality MRI images ischial tuberosity might involve mostly other players so hamstring injury
Central Frequent direction High stress on soleus
risk the player and team are willing to are taken as soon as possible after tendon tissue in one player, and muscle rehabilitation may take longer for midfielders changes
take. Nevertheless, it is our experience muscle injuries occur. Knowing whether tissue in another. Careful examination of players in those positions. Similarly,
that when experienced practitioners any tendon or bony tissue is involved is each MRI image is therefore necessary. central midfielders frequently perform Strikers, High speed running, High stress hamstrings
attacking acceleration and and adductors
consider a range of important factors vital, as injuries involving these tissues rapid direction changes, which places midfielders deceleration and
together, it is possible to estimate RTP generally heal more slowly and might Variations between players’ connective high demands on their adductor direction changes
time surprisingly accurately. need referral to a surgeon. In addition, it tissue quality may also affect an injury’s muscles. Key positional demands and
is necessary to identify injuries to muscle recovery time. Although this may be their consequences for muscle injury
regions that are highly stressed during determined by genetic factors that we are rehabilitation are summarised in Table 1.
football, as these need to be managed currently unable to identify with certainty. FOOTBALL-SPECIFIC FACTORS Importantly, the RTP decision is also
THE FC BARCELONA more conservatively than injuries located A history of frequent muscle injury can Additionally, each player has a unique highly dependent on the level of re-
APPROACH in less-stressed regions. be a good indication of poor connective
tissue quality. More conservative RTP
playing style that may also affect his or
her RTP plan. For example, some players
Whenever a player returns to football
after a muscle injury, there is always a
injury risk that the player and others
(e.g. medical and performance team,
The foundation for any RTP estimate Although the patient history often provides plans should therefore be made for have an aggressive style, chasing every risk that the injury will recur. Generally, team manager) are willing to take.
is an accurate diagnosis. However, it vital information towards making an frequently injured players. ball and pressing opponents throughout the sooner the player returns, the Will they accept a re-injury higher risk
is also essential to consider player- accurate diagnosis, the initial amount of the whole game. Others are more higher the re-injury risk. However, it and return to play early, or reduce the
specific (intrinsic) factors, football- pain and functional impairment can be tactical and therefore more economical is impossible to know the exact risk risk by returning more slowly? This is
specific (extrinsic) factors and other misleading when estimating RTP time. with their energy expenditure. in each situation. Therefore, every RTP influenced by a wide range of contextual
risk tolerance modifiers. We highlight Knowing where the injury is located and decision is a “judgment call”, ideally factors called risk tolerance modifiers.7
that practitioners should continuously which tissues are affected provides much Finally, muscle injuries located in made by the player, the medical team, These include factors directly related
re-evaluate the initial RTP estimation more information. For example, hamstring players’ dominant and non-dominant and the coaching and performance team to football, such as the importance of
throughout the rehabilitation process, strains located in the middle third of the legs may have markedly different together.6 The decision is based on a the upcoming games, the importance
depending on how quickly the player muscle belly are often severely painful recovery time, and even different range of factors, such as: of the player, and the availability of
progresses along the milestones and cause a large haematoma, yet most management plans. For example, partial replacement players, as well as others
defined in the RTP continuum. Key players return to optimal performance ruptures of the proximal rectus femoris • Whether the injured tissues are such as financial factors (e.g. the player
indicators of whether the player is within one month – some as quickly as 3 direct tendon are possible to treat likely to have healed sufficiently to is currently negotiating a new contract)
on-target to meet the anticipated weeks. In contrast, partial ruptures of the conservatively if they are in the non- tolerate the loads of competitive or psychological factors (e.g. pressure
RTP date include regaining baseline proximal hamstrings tendons often initially dominant leg, but the same injury in the football from self, family, agents etc).
strength and flexibility measures, appear to be minor injuries; they are less dominant leg is a clear case for surgery.
completing high-intensity training painful and their onset is less dramatic. • Whether the milestones along the A number of risk tolerance modifiers, in
sessions comparable to (or even However, these injuries generally take far RTP continuum have been achieved particular those that are directly football-
greater than) their anticipated match longer to recover – often up to 10 weeks. related, can be identified as soon as
demands, and demonstrating an The expected return to play times for • If the player feels psychologically the injury occurs. These should be
appropriate level of football-specific specific injury locations in the hamstrings, ready to return considered when estimating RTP time.
cognitive skills and psychological adductors, quadriceps and calf muscles
readiness. can be found later in this guide.
CHAPTER 2 CHAPTER 2
2.2.1
MAKING AN ACCURATE
DIAGNOSIS
When an injury occurs during training or match play, the essential questions to
answer as clinician on-field are: where is the localisation of the muscle injury, what
type is the injury and, can the player continue to play? In most cases, the player
should be taken off the field for further assessments and acute injury management
according to the PRICE principle (protection, rest, ice, compression, elevation).
— With Thor Einar Andersen, Arnlaug Wangensteen, Justin Lee, Noel Pollock, Xavier Valle
72 The first step off-field is a 73

comprehensive clinical examination
including detailed patient injury
history taking and careful physical
assessments. In cases where the
clinical appearance and severity
is unclear and determining the
optimal treatment can be difficult,
supplementary radiological imaging
can provide important additional
information to confirm the radiological
severity of the injury and guide
further treatment. Making an accurate
diagnosis is essential to ensure that ^
injured players receive appropriate Figure 1
Schematic overview
treatment and correct information of the different types
regarding their prognosis.1 This chapter of muscle injuries.
Tendon and bone
will discuss the initial and subsequent injuries (avulsion
clinical and possible radiological fractures) are included
assessments to enable the clinician to as sub-classifications
of muscle strain
confirm an accurate diagnosis. injuries, as they
PLAYER 1 PLAYER 2 may appear to be
PUTTING IT ALL TOGETHER <
muscle injuries with
As illustrated in Table 2, making the RTP
Table 2
Example of how the ON-FIELD MANAGEMENT similar mechanisms
Injury location Biceps femoris tear Biceps femoris tear same injury can lead and often similar
estimate for a specific muscle injury and severity involving the intramuscular involving the intramuscular to markedly different Working on-field as a clinician, with Signs that the player may be able to clinical presentation.
tendon rupture, located tendon rupture, located (Reprinted with
involves adjusting the normally expected in the middle third of the in the middle third of the
RTP time estimates the pressure of limited time and the continue to play include for example muscle permission from
RTP time upwards or downwards, based thigh thigh requirement to act quickly when an cramps that resolve quickly with no residual Wangensteen 20182).
on player-specific factors, football-specific acute injury happens, the point of the symptoms, or mild contusion injuries with
“Normal” RTP 4 weeks 4 weeks
factors, and risk-tolerance modifiers. time for this
initial assessment is to answer some no loss of function and minimal pain.
injury important questions: Is there a muscle However, we encourage the practitioner to
This process requires medical knowledge, injury and where and what type is the err on the side of caution. If in doubt, take
Player-specific 1st injury in this location 3rd injury in this location
football knowledge and experience, factors (no change to initial RTP (Indicates poorer quality
injury? And can the player continue to them out.
and should be considered an art just as estimate) connective tissue: +1 week) play or not?
much as a science. We highlight that The acute management should be initiated
Football- Central midfielder, tactical Wing back, aggressive
throughout this section we have used the specific factors playing style (no change) playing style (High sprint
Typical signs of an acute muscle injury as soon as possible. Despite little evidence
term estimation, rather than prediction. demands: +1 week) to identify include an acute onset of basis for the early management of acute
None of us owns a crystal ball. However, pain where the player is able to recall muscle (strain) injuries3, the PRICE principle
Risk-tolerance Key player in the team. Player not normally in
using a guiding framework can help even modifiers Injury occurred in starting 11. Injury occurred the inciting event, pain or discomfort is traditionally considered the cornerstone
inexperienced practitioners make more February, 3 weeks before in October (Lower risk with isometric contraction, stretching, for treating acute soft tissue injuries.4,5
accurate and consistent RTP estimations. Champions League strategy: +1 week) and palpation of the injured muscle. In POLICE (protection, optimal loading, ice,
semi-final (Higher risk
acceptable: -1 week) many cases the range of motion (ROM) compression, elevation) is suggested as an
is restricted. In the section below, we alternative acronym, where optimal loading
Estimated RTP 3 weeks 7 weeks present a guide in how to establish a means replacing rest with a balanced and
time
tentative diagnosis. incremental RTP program where early ≥
CHAPTER 2 CHAPTER 2
<
74 activity encourages early recovery.6 It Later in this section, we describe PATIENT HISTORY Injury When did the injury occur? Table 1 75
is important to initially differentiate specific clinical examination tests situation General patient history
During game or training? (timing)
between the contact and non-contact for the most common muscle injury A thorough injury history forms the questions for muscle
First, middle or last part? (register minutes of the game) injuries
injuries. In contusion injuries, such locations in football – the hamstrings, foundation of diagnosis. In fact, in Season: beginning, middle, end, out of season
as quadriceps contusions, the injured adductor, quadriceps and calf muscles. many cases it is possible to accurately How did the injury occur? Injury mechanism
muscle is recommended to be stretched The initial clinical examination diagnose the injury based only on
Contact or non-contact? (i.e. contusion or strain?)
towards maximum during compression in should be performed as soon as the the injury history. The most important
Exact movement; high speed running – acceleration/deceleration (typically hamstring); kicking (typically adductor and
order to minimise hematoma formation player leaves the field and with daily questions regarding the injury situation rectus femoris), stretching; changing directions/cutting; jumps/take offs/landings; towards excessive outer ranges (NB total
(by increasing the counterpressure),7–9 follow-up examinations until the and mechanism, symptoms, previous ruptures!)
whereas muscle strain injuries should not correct diagnosis is established. In injury history and workload are shown Forced to stop immediately? Weightbearing impossible or restricted? (might indicate severity)
be elongated towards outer ranges during the following section, we outline a in Table 1. More detailed information Able to continue? Able to continue with restrictions?
the initial management to avoid additional systematic approach to the clinical specific to each muscle injury location ‘Popping’ feeling and/or sound at time of injury? (might indicate severity and suspicion of total rupture)
strain and damage. examination of muscle injuries. can be found later in this section.
Pain Location (where does the player report pain)
Onset: acute or gradual?
OFF-FIELD EXAMINATIONS Severity (a visual analogue scale or a numeric rating scale of 0-10 can be helpful):
• at the time of injury onset
• today (at time of examination)
Clinical examination, including patient • at rest
history taking and physical assessments, Time to pain free walking?
is the cornerstone in the diagnosis of Function:
any muscle injury and should be the first • pain with walking?
step before any further investigations • pain with ascending/descending stairs?
• specific activity provoking pain?
are performed.10–12 The primary aim of
Other aggravating factors?
the clinical examination is to determine
the type, location and extent of the injury Previous Is this a re-injury?
and whether imaging and/or other injury
Any feeling of tiredness/discomfort/pain last 7 days before injury onset?
history
investigations are needed. In addition, Previous injury of same type (location) and side?
clinical examinations form the basis for
Previous injury of same type (location), other side?
further RTP decisions, and are valuable
Other muscle injury? (specify)
as the foundation for re-testing and
Other injuries and/or complaints
comparison when considering information • low back pain
to be provided for the RTP decision- • fractures
making process. The clinical examination • other
may provide a rough estimate of the Workload Previous last training and games played (last week/month)
severity and time needed to RTP, although Intensity/workload last week/month
further evaluation and observation is likely
Other Initial treatment received
to increase the accuracy of this estimation. questions Factors that might influence general recovery – e.g. poor sleep, nutrition, recent long-haul flights
Clinical assessment, in conjunction with
imaging, can also identify the rare cases
when early surgery is required.
CHAPTER 2 CHAPTER 2
76
Gait and Walking:
PHYSICAL EXAMINATION IMAGING AND OTHER SUPPLEMENTAL ULTRASONOGRAPHY MUSCLE INJURY GRADING 77
INVESTIGATIONS
function - antalgic gait pattern?
- need for crutches?
The physical examination should Imaging investigations assist in AND CLASSIFICATION
Jogging:
start with careful inspection and an
assessment of function, followed by
Imaging investigations assist in
confirming the initial clinical diagnosis
confirming the initial clinical diagnosis
and may help guide the RTP estimation.
SYSTEMS
- able to jog?
Other functional movements (observe ability to and quality, register pain):
palpation, active and passive ROM and may help guide the RTP estimation. MRI and ultrasonography are normally
- two leg squat testing, isometric pain provocation MRI and ultrasonography are normally the best modalities to assess muscle Following the initial examinations,
- one-leg squat and muscle strength testing. the best modalities to assess muscle injury, although X-ray and CT are clinicians commonly assign a grade
- trunk flexion (hamstrings)
- calf raises (gastrocnemius) Finally, additional tests (such as injury, although X-ray and CT are occasionally indicated.15,16 or classify the muscle injury based on
- jumping, kicking and change of directions (minor injuries) neural sensitive structures, pulse occasionally indicated.15,16 the clinical and/or radiological signs
etc.) can be performed (Table 2). and symptoms. An injury ‘classification’
Inspection Visible ecchymosis (bleeding / hematoma) X-RAY AND CT
We recommend starting with the refers specifically to describing or
Swelling? MRI
uninjured side, as this provides the X-ray of the affected limb is indicated in categorising an injury (for example
Visible disruption? player with a reference as to what Magnetic Resonance Imaging (MRI) using two situations: by its location, injury mechanism
‘Bulk’ / ‘gap’? feels ‘normal’, before examining fluid-sensitive techniques (fat-suppressed or underlying pathology), whereas
the injured side. Normally, pain spin-echo T2 weighted) is ideally suited a ‘grade’ provides an indication for
Palpation Tenderness / pain provocation with palpation is useful for identifying the specific 1. When bony avulsion of the
region/muscle injured, as well as the presence or absence of a palpable defect in the experienced during the different tests since it allows the detection of oedema clinical and/or radiological severity
tendon attachment is suspected.
musculotendinous junction. Importantly, detection of any discontinuity or ‘gap’ at the is recorded, where pain indicates a and fibre disruption (tear) at the site of the of the injury.19 Using a grading
proximal or distal tendinous insertion should lead to suspicion of a total rupture and This is particularly relevant to the
should be further investigated and confirmed or disproved by MRI. positive test and no pain indicates damage in the first hours after the injury or classification may ease the
adolescent athlete where one
a negative test. Visual analogue and to provide an objective assessment communication between clinicians.
Location and length of pain might suspect an apophyseal
scales (VAS) or numeric pain rating of the intramuscular and extra-muscular Although there has been several
Palpable disruption/discontinuity of muscle/tendon avulsion injury.17,18 A cortical
scales (NRS)13,14 are commonly used tendon of the muscle. MRI provides clinical and radiological grading- and
Insertional pain avulsion may not be visible on
in order to quantify the player’s pain. a complete assessment of the whole classification systems purposed for
MRI as the fragment is often low
Active and ROM is assessed as the presence of pain, the intensity of pain (VAS or NRS) and/or Objective measurements, for example muscle-tendon-bone unit.15 muscle injuries, there are currently no
passive range objective in grades with goniometer/inclinometer (°). signal within a retracted low-
using goniometers and hand-held uniform approach or consensus to the
of motion signal tendon.
(ROM) testing
Active ROM: the player is asked to perform an active ROM exercises without assistant dynamometers, might be useful At FC Barcelona, MRI is initially used categorization and grading of muscle
and the restriction of ROM compared to unaffected side is registered. The tests depend
on the muscle suspected to be injured but are always instructed to be performed first
in order to quantify side-to-side to identify the location and extent of 2. Full-delineation of myositis injuries.19,20 An overview of the some
with a slow motion, thereby with increased speed if appropriate. differences or deficits, and to track tissue damage. In addition, MRI is used ossificans. CT scans may confirm of the most common grading- and
Passive ROM: is used to elicit muscle stiffness/ assess muscle length. By applying excessive progression during the RTP process. at specific time points during the RTP a diagnosis of myositis ossificans classification systems purposed are
stress/overpressure at the end range, the test might reproduce the player’s symptoms. In section 2, specific physical tests process to ensure there is no increased following direct muscle trauma.15 discussed below and summarized in
and objective measurements for each oedema or connective tissue gap (see The CT demonstrates classic Tables 3-7. Radiological systems have
Isometric The affected muscle or muscle group is tested isometrically at different ranges, commonly
pain by the clinician applying resistance that the player is asked to withstand. Often, a ‘brake’ of the specific muscle injury locations Section 3 – Return to Play from Specific “egg-shell” appearance of the historically categorized muscle injury
provocation test is performed at the end of the test (f.ex after 3 seconds) to assess the eccentric are elaborated and discussed. Muscle Injury) calcification. with simple grading systems based on
component. The amount of force required to provoke pain can be quantified using a HHD.
the severity/extent of the injury ranging
Muscle Muscle strength of the affected muscles or muscle group is tested either manually or from 0-3 representing minor, moderate
strength/ objectively by HHD to detect any weakness / deficit compared to the unaffected side. and complete injuries,19,21–23 and
muscle
capacity
these have been widely used among
clinicians and researchers.24 The four
Neural The mobility of pain-sensitive neuromeningeal structures might be assessed by relevant < grade modified Peetrons classification
tension tests neural tension tests related to the specific muscles or muscle groups tested. Straight Table 2
leg raises (SLR) and slump tests are for example used after hamstrings injuries, as Overview of general
is based on an ultrasound ordinal
involvement of the sciatic nerve is a potential source of pain in the posterior thigh. physical examination severity grading system,22 first described
tests for muscle for MRI findings after hamstring injuries
Other Clinical examination of the joints above and below the injury may provide injuries used to
information about contributing factors for the muscle injury. establish a diagnosis. among European professional football
for muscle players in a ≥
CHAPTER 2 CHAPTER 2
<
78 larger study from the UEFA Elite Club be expected by an understanding GRADE CLINICAL EXAMINATION ULTRASONOGRAPHY MRI Table 3
79
Injury Study.(12) It has also been of tendon healing and adaptation Overview of
applied for other muscle groups25 to load. The British Athletics Muscle O’Donoghue (1962)43 Järvinen (2005)10 Peetrons (2002)22 Modified Peetrons simple clinical and
Ekstrand et al. (2012)23 radiological grading
(see Table 3). Radiological grading Injury Classification has been assessed systems for muscle
using modified Peetrons have shown for reliability in two radiological 0 Lack of any ultrasonic lesion Negative MRI without any injuries
correlations with lay-off time after acute studies,37,38 and shown associations visible pathology
hamstring injuries23,26,27 and quadriceps with RTP in one retrospective I No appreciable tissue Mild (first-degree): strain/ Minimal elongations with Oedema but no architectural
injuries.26 However, this grading clinical review,33 but further work is tearing, no loss of function contusion represents a tear less than 5% of muscle distortion
system has been criticised for being required to investigate its prognostic or strength, only a low-grade of only a few muscle fibers involved. These lesions can
inflammatory response with minor swelling and be quite long in the muscle
too simplistic, without considering the significance and relevance among discomfort accompanied by axis being usually very
anatomical location and specific tissue football players. The Munich consensus no or only minimal loss of small on cross-sectional
strength and restriction of the diameter (from 2 mm to 1 cm
involvement.19,28 Thus, the diagnostic statement classification system39 was movements maximum)
accuracy and prognostic value of these developed for muscle injuries in 2012,
grading systems are questionable 19 differentiating between functional II Tissue damage, strength, Moderate (second-degree): Partial muscle uptures; Architectural disruption
only a low-grade strain/contusion with greater lesions involving from 5 to indicating partial muscle tear
and the prognostic value of MRI has muscle disorders and structural muscle inflammatory response damage of the muscle with a 50% of the muscle volume or
recently been reported as limited.29,30 injury (Table 4). It has shown a positive clear loss in function (ability cross-sectionaldiameter. The
prognostic validity among professional to contract) patient often experiences a
“snap” followed by a sudden
New MRI classification systems football players in a correlation study.40 onset of localized pain.
including both the extent (severity However, the differentiation between Hypo-and/or anechoic gap
grading) as well as the anatomical ‘functional’ and ‘structural’ has been within the muscle fibers
site/location of the injury has been criticized.28,41 III Complete tear of Severe (third-degree) Muscle tears with complete Total muscle or tendon
proposed.28,31 For example, Chan et al.31 musculotendinous unit, strain/contusion: tear retraction. rupture.
complete loss of function extending across the entire
described a comprehensive system to A strength with using more detailed cross section of the muscle,
classify acute muscle injuries based on classification systems including resulting in a virtually
the severity of imaging assessments grading and severity, is that they complete loss of muscle
function is termed.
using MRI or ultrasound and the force a more accurate description
exact anatomical site (including the of the injury with a more diagnostic
proximal or distal tendon, proximal precision and defined tissue
or distal musculo-tendinous junction involvement, which may aid clinicians
and muscular injuries). The British when communicating with other
Athletics Muscle Injury Classification28 professionals, athletes or coaches.
grades muscle injuries from 0-4, However, more comprehensive
based on MRI parameters of the classification systems may
extent of injury and classifies the compromise on the ability to provide
injuries according to their anatomical an accurate prognosis. One of the
site within the muscle (Table 5). In problems is that there are large
total, the classification constitutes individual variations in time RTP
11 grading categories combining the within each of the categories,42 and
severity grading and the anatomical the evidence here is scarce. The most
site classification. There is evidence important may be that clinicians specify
in hamstring and soleus muscle which classification or grading system
injuries that those injuries which they are using to avoid misinterpretation
involve the tendon are associated with and/or miscommunication in clinical
longer time to RTP32–36 which would practice and research.
CHAPTER 2 CHAPTER 2
80 MUNICH CONSENSUS STATEMENT: CLASSIFICATION OF ACUTE MUSCLE DISORDERS AND INJURIES BRITISH ATHLETICS MUSCLE INJURY CLASSIFICATION 81
< <
INDIRECT MUSCLE DISORDER/INJURY: DIRECT MUSCLE INJURY: Table 4 GRADING ANATOMICAL SITE COMBINED CLASSIFICATION Table 5
The Munich The British Athletics
FUNCTIONAL MUSCLE DISORDER consensus statement GRADE 0: a. Myofascial 0a: MRI normal Muscle Injury
classification of acute NEGATIVE MRI Classification28
b. Musculotendinous 0b: MRI normal or patchy HSC throughout one or more muscles.
Type 1 Overexertion-related muscle disorder Contusion muscle disorders and GRADE 1:
injuries39 c. Intratendinous 1a: HSC evident at the fascial border <10% extension into muscle belly. HSC of CC length <5 cm.
“SMALL
Type 1A: Fatigue-induced muscle disorder INJURIES 1b: HSC <10% of CSA of muscle the MTJ. HSC of CC length <5 cm (may note fibre disruption of <1
(TEARS) TO cm).
Type 1B: Fatigue-induced muscle disorder THE MUSCLE”
2a: HSC evident at fascial border with extension into the muscle. HSC CSA of between 10%-50% at
Type 2 Neuromuscular muscle disorder GRADE 2: maximal site. HSC of CC length >5 and <15 cm. Architectural fibre disruption usually noted <5 cm.
“MODERATE
2b: HSC evident at the MTJ. HSC CSA of between 10%-50% at maximal site. HSC of CC length >5
INJURIES
Type 2A: Spine-related neuromuscular Muscle disorder and <15 cm. Architectural fibre disruption usually noted <5 cm.
(TEAR)
TO THE 2c: HSC extends into the tendon with longitudinal length of tendon involvement <5 cm. CSA of
Type 2B: Muscle-related neuromuscular Muscle disorder MUSCLE” tendon involvement <50% of maximal tendon CSA. No loss of tension or discontinuity within the
tendon.
STRUCTURAL MUSCLE INJURY Laceration GRADE 3:
“EXTENSIVE 3a: HSC evident at fascial border with extension into the muscle. HSC CSA of >50% at maximal site.
Type 3 Partial muscle tear TEARS TO THE HSC of CC length of >15 cm. Architectural fibre disruption usually noted >5 cm
MUSCLE”
3b: HSC CSA >50% at maximal site. HSC of CC length >15 cm. Architectural fibre disruption usually
Type 3A: Minor partial muscle tear GRADE 4: noted >5 cm
“COMPLETE
3c: HSC extends into the tendon. Longitudinal length of tendon involvement >5 cm. CSA of
Type 3A: Minor partial muscle tear TEARS TO
tendon involvement >50% of maximal tendon CSA. May be loss of tendon tension, although no
EITHER THE
discontinuity is evident
Type 4 (Sub)total tear Subtotal or complete muscle tear MUSCLE OR
TENDON” 4: Complete discontinuity of the muscle with retraction
Tendinous avulsion 4c: Complete discontinuity of the tendon with retraction
CHAPTER 2 CHAPTER 2
THE FC BARCELONA MUSCLE INJURY CLASSIFICATION – A PROPOSAL

The FC Barcelona muscle injury classification proposal44 is an evidence-informed and expert consensus-
based classification system for muscle injuries developed by experts from three institutions (FC Barcelona
Medical Department, Aspetar, and Duke Sports Science Institute); it is based on a four-letter initialism system:
MLG-R, respectively referring to the mechanism of injury (M), location of injury (L), grading of severity (G),
and number of muscle re-injuries (R) (see Table 7).
<
MECHANISM OF INJURY (M) LOCATIONS OF INJURY (L) GRADING OF NO. OF MUSCLE Table 7
SEVERITY (G) RE-INJURIES (R) Summary of the
proposed FC
Hamstring direct injuries P Injury located in the proximal third of the muscle belly 0–3 0: 1st episode Barcelona muscle
T (direct) classification system44
M Injury located in the middle third of the muscle belly 1: 1st reinjury
D Injury located in the distal third of the muscle belly 2: 2nd reinjury...
Hamstring indirect injuries P Injury located in the proximal third of the muscle belly. 0–3 0: 1st episode
I (indirect) plus sub-index s The second letter is a sub-index p or d to describe the
1: 1st reinjury
for stretching type, or sub- injury relation with the proximal or distal MTJ, respectively
index p for sprinting type 2: 2nd reinjury...
M Injury located in the middle third of the muscle belly,
plus the corresponding sub-index
D Injury located in the distal third of the muscle belly, plus
the corresponding sub-index
< Negative MRI injuries (location N p Proximal third injury 0–3 0: 1st episode
82 GRADE ACTIVE KNEE GAIT TYPICAL Table 6 is pain related) N plus sub-
83
FLEXION (°) PATTERN PRESENTATION Classification of N m Middle third injury 1: 1st reinjury
index s for indirect injuries
Quadriceps contusion. stretching type, or sub-index p N d Distal third injury 2: 2nd reinjury…
MILD <90° Normal May or may not remember incident Adapted from Jackson for sprinting type
(Grade I) & Feagin (1973), in
Can usually continue activity
Kary et al. (2010)7
Sore after cooling down or next morning and Brukner & Kahn Grading of injury severity
Minimal pain w/resisted knee straightening (2017)12
0: When codifying indirect injuries with clinical suspicion but negative MRI, a grade 0 injury is codified. In these cases, the second letter
Might be tender with palpation describes the pain locations in the muscle belly
Full prone ROM 1: Hyperintense muscle fiber edema without intramuscular hemorrhage or architectural distortion (fiber architecture and pennation
angle preserved). Edema pattern: interstitial hyperintensity with feathery distribution on FSPD or T2 FSE? STIR images
+/- Effusion
2: Hyperintense muscle fiber and/or peritendon edema with minor muscle fiber architectural distortion (fiber blurring and/or pennation
+/- Increased thigh circumference
angle distortion) ± minor intermuscular hemorrhage, but no quantifiable gap between fibers. Edema pattern, same as for grade 1
Moderate 45-90° Antalgic Usually remembers incident, but can continue activity, although may stiffen up 3: Any quantifiable gap between fibers in craniocaudal or axial planes. Hyperintense focal defect with partial retraction of muscle fibers ±
(Grade II) (slight limp) with rest (half-time or full-time) intermuscular hemorrhage. The gap between fibers at the injury’s maximal area in an axial plane of the affected muscle belly should be
documented. The exact % CSA should be documented as a sub-index to the grade
Mild/moderate swelling
r: When codifying an intra-tendon injury or an injury affecting the MTJ or intramuscular tendon showing disruption/retraction or loss of
Pain w/palpation tension exist (gap), a superscript (r) should be added to the grade
Pain w/resisted knee straightening
Limited ROM
+/- Effusion
+/- Increased thigh circumference THE BARÇA WAY: CLASSIFYING MUSCLE INJURIES
Severe >45° Severe limp Usually remembers incident. Assisted ambulation, difficulty with full weight-bearing
(Grade III)
Severe pain
The FCB muscle injuries proposal has several key points; the starting point was to incorporate the
scientific evidence about muscle injuries at this time in the proposal, the classification was build
Immediate swelling/bleeding
up within this idea, together with the medical experience of the three sports medicine institutions
Pain with static contraction
involved in the project. It is also very important that the structure of the proposal is flexible; the
+/- Bulge in the muscle
proposal has the capability to adapt to future scientific evidences within the muscle injuries field
+/- Increased thigh circumference and grow with the future knowledge.
The role and function of connective tissue in force generation and transmission is in our opinion
a key factor in the signs, symptoms and prognosis of muscle injuries. Thus, it was one of our
purposes to create a grading item that could classify injuries based on a quantifiable parameter
(exact % CSA) based on the principle that the more connective tissue is damaged, the greater the
functional impairment and the worse the prognosis of the injury will be. The history of an injury
plays also an important role, it will not be the same to face a first injury episode than a re-injury or
a second reinjury, so the chronology of the injury is included in our proposal.
The fact to avoid confusing terminology will help to have and easy communication. The classifi-
cation is still a theoretical model that needs to be tested and see if it shows an adequate grouping
of injuries with similar functional impairment, and prognostic value. The goal of the classification
is to enhance communication between healthcare and sports-related professionals and facilitate
rehabilitation and RTP decision-making.
CHAPTER 2 CHAPTER 2
2.3.1
EXERCISE PRESCRIPTION
FOR MUSCLE INJURY
When a player sustains a muscle injury, the chances of it recurring are high. In
fact, epidemiological research consistently identifies previous injury as the most
powerful risk factor for muscle injuries.1 Fortunately, the risk of recurrence can
be reduced through careful management of the return to play process, including
appropriate prescription of therapeutic and football-specific exercises.
— With Phil Glasgow, Thor Einar Andersen and Ben Clarsen
84 A carefully planned exercise STRUCTURED, BUT throughout return to play process to ensure < 85
Figure 1
programme is not only essential to
optimise the quality of healing tissues,
FLEXIBLE the programme aligns with their functional
ability, psychological readiness and specific
What Are the Goals of
Loading? MUR = Motor
but also to maintain the player’s fitness, The RTP process is a dynamic continuum performance demands. Unit Recruitment,
RFD= Rate of Force
skills and football cognition so that during which the nature and difficulty of Development
when they do return to play, they are exercises are progressed in response to
ready to perform optimally. tissue healing and the functional abilities
of the player. Every player is unique, and TARGET SPECIFIC
This chapter outlines the general
principles of exercise prescription for
no two injuries are exactly the same.
As such, the RTP process should be
ADAPTATIONS
muscle injuries, including strategies individualised. The multi-dimensional When designing an exercise programme,
to optimise structural adaptations nature of return to play means that the practitioners should ask a number of
and maintain football-specific fitness, therapists, strength and conditioning simple questions (Figure 1):
skills and cognition. The chapter is not and technical staff must organize several
intended as a recipe; practitioners need concurrent phases with different goals • What is happening at a tissue level?
to consider each player individually and and milestones.
assess their progress throughout the • What outcomes are you trying
entire RTP process. to achieve with your exercise
FACTORS INFLUENCING LOADING
prescription?
PROGRESSION
The most common way of measuring • What is the specific adaptation
BEGIN WITH THE END progress in the RTP process is the player’s associated with different exercise or
IN MIND perception of pain.2 The amount of
discomfort tolerated during training should
football activity types?
TARGET SPECIFIC RESTORING MUSCLE STRUCTURE STRENGTH TRAINING
In top-level football, the medical
and performance team is under
be guided by the rationale for the specific
exercise. For example, when the primary
• Is the goal of the exercise to
reduce symptoms, stimulate tissue
ADAPTATIONS Muscle tissue is highly sensitive and Adequate strength is essential for safe
constant pressure to return the player goal of the exercise is tissue loading, some adaptation (tissue capacity) or The RTP process commences almost adaptable to mechanical loading. and effective return to football. During the
to competition safely, in the shortest discomfort may be acceptable. In contrast, enhance function (movement immediately following injury with Following injury, muscle undergoes a return to play process, strength training
possible time. To accomplish this, they when the focus is to restore movement capability)? attention given to graduated loading of number of changes in structure and should concentrate on the restoration of
need to manipulate a range of training quality, exercises should be pain-free. the injured tissue to facilitate healing. function both as a direct consequence injury-related deficits. Lieber8 has suggested
variables to ensure that the player is Once the desired outcome of an exercise While the main focus of management of tissue insult and as an indirect that during the first two weeks of strength
working at the limit of their capacity, Other tests of muscle function (e.g. Askling’s or football activity is clear, it is possible to during the early stages of the RTP process consequence of reduced loading training in uninjured, untrained individuals,
while simultaneously allowing sufficient H-test and Isokinetic testing) can also plan progressions to maximise adaptation. will be directed towards resolving the and recruitment. These changes only 20% of strength increases may be
time and restitution for tissue healing. To help inform RTP readiness. However, it For example, where the goal of loading is clinical signs and symptoms, targeted include, reduced fascicle length and attributed to structural changes. This implies
define the necessary tissue capacity and is important to recognise that no single increased fascicle length, the intervention loading of the tissue should also be physiological cross-sectional area (PSCA) that initial strength gains are primarily due
functional requirements, practitioners test can determine the player’s ability to may be eccentric loading and progression included. Early loading is an effective as well as alterations in neuromuscular to neuromuscular adaptations. Given that
need a detailed understanding of the progress. Instead, practitioners should will include addition of load, increased stimulus for regeneration and has been activation.4-7 The RTP process should following injury neuromuscular capacity can
football-specific activities and level to use a battery of tests assessing different speed and range of motion. In contrast, shown to result in better outcomes therefore focus on restoring muscle be significantly diminished, it is reasonable
which the player must return. We refer to aspects of function. Execution of sport where the desired outcome is to increase in terms of capillary ingrowth, less structure (especially fascicle length and to suggest that it may be more effective
this as beginning with the end in mind. specific skills with good technique also rate of force development, the exercise (or fat infiltration, fibre regeneration, cross-sectional area). during the early stages of return to play
At FC Barcelona, this involves a close helps guide progression. Clinical testing football activity) may be a jump squat and more parallel orientation of fibres, to carry out strengthening exercises ‘little
collaboration between the player and for specific muscle groups is discussed progressions involve a move from high less intramuscular connective tissue, and often’ in order to avoid neural system
medical, coaching and performance in the relevant sections. It is necessary load power (80% 1RM load) to low load improved biomechanical strength and fatigue and facilitate both structural and
analysis specialists. to communicate closely with the player power (30% 1RM load). less atrophy.3 neuromuscular adaptations.
CHAPTER 2 CHAPTER 2
86 EARLY IN THE RTP PROCESS: study reported adverse effects with the At the injury site, the injured muscle and football-specific performance benefits such range of purposeful movements during Introduction of unanticipated 87
MOVEMENT IS KEY early inclusion on eccentric training. its agonists will lose strength, power, and as increased muscular endurance, running a sporting event can have a significant movements is essential for effective
endurance capacity. The extent to which speed or jump height, as well as protection influence on football performance and the restoration of function. The ability to
Simple isotonic training may be necessary
Although protection of the injured muscle each of these attributes is affected should from recurrence. potential for (re)injury. It is also recognized respond to a dynamic and variable
to facilitate motor recruitment in the early
is paramount, low-level, controlled be identified using specific testing, for that that functional ranges of motion during environment is often a key driver in the
stages of the RTP process. The recruitment
eccentric exercises have the potential to example isokinetic and jumping tests. Muscle injuries also have consequences on activities such as kicking and long passes perpetuation of symptoms. Gradual
of muscles throughout range during
further reduce pain inhibition and facilitate Thereafter, exercise prescription should the player’s general conditioning, including exceed those normally measured during introduction of physical perturbations
functional movements often help to restore
tissue adaptation without causing any specifically address the identified deficits. their cardiovascular fitness and their clinical assessment.17 The role of flexibility facilitates reactive neuromuscular
pain free range of motion and normalise
further damage. Practitioners must take general load tolerance. A comprehensive in the site of muscle injury has been the adaptations as well as sudden responses
pain. While there is some evidence that
care to ensure that the player can tolerate Muscle injury results in both structural and RTP programme must therefore include source of debate for many years with to verbal or visual commands. At all
isometric contractions may reduce pain in
the resistance, complexity and range of neuromuscular deficits. During football general conditioning strategies that conflicting findings for all major muscle times the quality of the movement is
tendinopathy, more dynamic movements
motion. They should seek to identify ways sporting activities, muscle is constantly replicate the player’s normal football groups. monitored and where maladaptive
tend to be more effective in muscle injury
to stimulate the muscle under lengthening ‘tuned’ to enable an individual to maintain demands as much as possible, both in patterns are adopted, exercises and
management. Some principles for early
conditions while providing appropriate position, move voluntarily and react to terms of the metabolic pathways involved, Tests of multi-segmental whole body football activities should be regressed to
strengthening of muscle following injury
support and safety. Examples of early perturbations.13 Neuromuscular control and the stresses on musculoskeletal mobility18 and dynamic flexibility17 have ensure correct form.
are summarised below.
stage eccentric training are included in (NMC) is the product of the complex system. shown strong correlations with injury
the relevant muscle specific sections and integration of afferent proprioceptive input, presentation and may be more useful Reintroduction of sport-specific skills,
As soon as the player can effectively
football specific exercises below. central nervous system (CNS) processing An intelligently designed return to measures (and interventions) of flexibility competition and other environmental
recruit the muscle without significant
and neuromuscular activation. While great play programme that has the correct during the RTP process. It is suggested constraints should focus on widening the
pain or inhibition, it is important to
Eccentric training should be maintained attention has been given to the role of NMC combination of contraction type (concentric, that mobility training during the RTP movement repertoire of the athlete and
incorporate eccentric (lengthening)
throughout the entire RTP process in ligament rehabilitation, it has often been eccentric, isometric, plyometric), exercise process reflects the range and direction allow sufficient time for skill acquisition
contractions. Eccentric contractions have
and should target movement-specific overlooked in muscles. choice (e.g. free weights vs. machine of the movements carried out during the and consolidation through practice. It
consistently been shown to result in
adaptations for the affected muscle. For weights and football activities), load, football activities. Rather than a reductionist is important to incorporate cognitive
greater morphological and neuromuscular
example, for hamstring training should There is evidence that prolonged deficits number of sets, repetitions, speed of approach that views flexibility in isolation, challenges and decision making into the
adaptations than both isometric and
include both knee-flexion dominant and in NMC following muscle injury may have contraction and frequency of training clinicians should consider whether a rehabilitation programme.
concentric training.9,4,5
hip-extension dominant movements. a role to play in recurrence. Reduced can significantly enhance the benefits muscle group has adequate flexibility
Similarly, for quadriceps injury, eccentric activation of previously injured biceps of training. Principles for progression of combined with increased strength at longer At FC Barcelona, every effort is made
exercises should focus on both hip flexion femoris long head at longer muscle lengths strengthening during the mid to late stage lengths for safe and effective function. to return the injured player to modified
ECCENTRIC EXERCISE IN RTP PROCESS:
and knee extension. Examples are included may be related to shorter fascicles, eccentric of the RTP process include: Max Strength training participation on the pitch and
WHEN AND HOW?
in the muscle specific sections. weakness and reduced ability to protect the > Longer Muscle Lengths > Rate of Force with the team as early as possible to
Eccentric exercise has become the mainstay muscle at longer lengths.14,15 Reduction in Development Training > Move from preserve football technical and tactical
MAINTAINING FOOTBALL COGNITION
of the muscle injury return to play process. the ability of the muscle produce, transfer Moderate to High Speed with and without skills and cognition abilities. As much as
Traditionally, clinicians often delay the or modulate load will likely result in an ball and on and off field. Hence, the nature As the RTP process develops, the complexity possible should be done with a ball as
introduction of eccentric training until late RESTORING FOOTBALL- increased risk of reinjury. The RTP process of training used should minimise stress on of the task should be increased to involve soon as possible and drills should reflect
stage rehabilitation due to perceived risks
associated with increased muscle tension
SPECIFIC FITNESS, should therefore seek to improve the central
nervous system’s ability to fine tune muscle
the injured tissues while simultaneously
exercising muscle groups involved in
multiple segments through multiple planes
of movement. Early examples of this include
the demands of the player, such as team
tactics, position and role in the team.
and associated muscle soreness. This is SKILLS AND COGNITION coordination and improve the football skill football. This is essential towards the end football -specific tasks such as dribbling, Data derived from Global Positioning
also reflected in most RCTs, where eccentric execution; this is discussed below. of the RTP process to adapt to the high passing and receiving a ball, snake runs Satellite (GPS) systems during training
training is often not included until halfway Muscle injuries have a range of demands of match play. The footballer must and basic training drills. Particular attention drills and match play is used to tailor the
through the RTP process. However, two consequences on a player’s football It is important when designing strength have trained enough and specific to return should be given to facilitating effective on-field RTP process individually in close
protocols have included eccentric training performance that need to be addressed training programmes that the content to football and performance safely.16 loading of tissues through functional collaboration between medical staff,
from day 5 onwards, and both reported throughout the RTP process. Therefore, reflects how the muscle functions during patterns as well as release and attenuation performance analysts and coaching staff.
favorable outcomes in terms of RTP time you have to think wider than just the football. Careful manipulation of training It is widely accepted that the ability to move of force; for example, deceleration and Specific examples are discussed in the
and recurrence rates.10-12 Importantly, neither injured muscle. load, volume and frequency can achieve part or parts of the body through a wide change of direction. next section.
CHAPTER 2 CHAPTER 2
2.3.2
RESTORING PLAYERS’ SPECIFIC

FITNESS AND PERFORMANCE
CAPACITY IN RELATION TO MATCH
PHYSICAL AND TECHNICAL
DEMANDS.
Restoring the players’ specific fitness and performance capacity before joining the
team for collective training sessions and competitions is essential
— With Martin Buchheit and Nicolas Mayer
88 In the lead up to returning to variations in players’ physical profiles, 89

THE BARÇA WAY: unrestricted football training and play, style of play and match context,
the players generally train individually we have chosen to use the average
The above schematic (figure 2) provides an overview of the Return to with a physical/rehabilitation coach demands of those 2 playing positions
Play process in FC Barcelona in regards to managing and rehabilitating who ensures that the player’s as a starting point to illustrate our
the injured player. The various components are not step by step i.e. you locomotor and technical loads are methodology. In real-life scenarios,
do not need to complete one before moving to the next; this process is progressively built in relation to match we recommend the systematic use of
dynamic and components can overlap as the player progresses throu- demands (Figure 1), while respecting each player’s unique locomotor and
gh the RTP process. indices of load tolerance, well-being technical profile based on historical
(i.e. how the player is coping with club data (i.e. from match analysis
The key point is to get the player moving as soon as is safely possible. those loads) and psychological data) and personal observations (style
1. The acute stage following the injury can last anywhere from readiness. Importantly, since these of play and technical demands).
approximately 1 to 3 days. At this very early stage, the focus is on individual RTP sessions should prepare
ice and compression. the players to train/play with the
team within a few days, it is of utmost
2. Table treatment is the time to stimulate the muscle and promote importance for the ball to be integrated
healing and gain mobility – e.g. passive and active muscle stret- as much as possible, and that specific MATCH DEMANDS
ching, isometric and eccentric types of contractions. movement coordination and muscle
actions, decision-making, mental The physical activity performed during However, we use this to illustrate the
3. As soon as possible, it is time to get the player moving in the gym. fatigue and overall self-confidence are matches should be considered as target for importance of the distinction between
This component can be (and usually is) a combination of table considered continuously. the conditioning programming. Assuming HSR and HIA in relation to individualising
treatment and gym based exercises, from basic through to more that the building up of minutes of play the RTP program according to the muscle
advanced functional exercises (as the progression of the injured To illustrate our approach, we provide during matches may be progressive as injury location and player demands.
player allows). The key is to progress continuously from passive example of sequential RTP load well following an injury (i.e., playing 25-35
workouts to active workouts. progressions, i.e., designed for two min as a sub for the first match post injury),
common muscle injuries (hamstrings the demands of 1 full half (45 min) to 60
4. Basic field work – In this component of the RTP process, we start and rectus femoris) for two different minutes could be considered as the initial
to introduce field based sessions, with varying surfaces. It is playing positions in the field (wide pre-competition target. To assess those
important to maintain the gym work here, but to reduce the table defender, WD full back - FB and central specific physical demands, we recommend
treatment. Basic football skills are reintroduced and trained and midfielder (playing as a ‘6’), CM) assessing the injured player’s locomotor
position specific movements are included. (Figure 2). The re-conditioning of both load with respect two distinct types of
muscle groups requires the targeting demands; high-speed running (HSR, which
5. Complex field work – In this part of the RTP process, the basic of different locomotor patterns (with essentially put constrains on the hamstring
work in the field is phased out in favour of more advanced skills reference to the selective activation of muscles) and high-intensity actions (HIA)
and movements with decision-making tasks at higher intensities those muscles in relation to specific which encompasses all acceleration,
and more challenging. Gym work is still maintained here, in parti- running phases1); playing positions deceleration and changes of direction
cular as a pre field session activation. are also associated with distinct activities and put major constrains on
locomotor and technical demands the quadriceps, adductors and the gluts)
6. As the player has sufficiently progressed through this RTP process, (Figure 1), which all need to be taken (Figure 1). In the example given, we use
he/she is ready to return to training, starting partial training with into account when designing the RTP mechanical work (MW) as the metric
the team (maintaining additional work with the physical coaches). program. While we acknowledge to measure HIA. It is important to note
With appropriate management of loads, the players demands will that there exist large differences in that this metric currently has preliminary
be increased until he/she is ready to join 100% with the team. locomotor and technical demands validity and reliability only and needs to be
within the same positions due to tested further in scientific investigations.
CHAPTER 2 CHAPTER 2
90 91
paradigm, allowing the physiological quality targeted
a given day to recover the following day 6). This should
avoid creating excessive muscle soreness / residual
fatigue from one day to the other, and helps players
to train every day, which in turn may accelerate their
full return to train/competition. Figure 2 illustrates
how the locomotor contents of the sessions, in terms
of HSR and MW may be modulated in response to
1) the muscle injured and 2) the position-specific
locomotor demands. Table 1 and 2 provide the details
of the sessions both in terms of locomotor load and
technical orientations. For example, after a typical
introductory session (S1) the focus/building up of
HSR vs. MW differs in relation to muscle injury (with a
greater emphasis on progressively building HSR after
hamstring (HS) injury (S2HS) vs. building MW after
a quadriceps injury (S2Q)). After some progressions
^ in terms of HSR and MW, the locomotor targets are
Figure 1 further adapted based on the player’s playing position.
Summary of the worst case-scenarios for locomotor volume demands (± standard deviation, SD) during League 1 and Champions League matches (1st half) for a wide
defender (WD) and a midfielder (playing as a ‘6’, CM), in terms of volume (left panel) and intensity (right panel) of high-speed running (HSR) and HIA expressed as Following those final individual sessions (S1-S4),
mechanical work (MW). Volume refers to the greatest running distances covered during halves (± SD). Intensity is expressed, over exercise periods from 1 to 15 min, as 1) when it to transition with the team, we request players
peak distance ran > 19.8 km/h per min, which is used as a proxy of HSR intensity and 2) peak MW per min (adapted from2). For example, over block periods of 4 min, CM
can cover a maximum of 20 m of HSR / min. Similarly, WD can cover up to 55 m of HSR over 1 min-periods. For figure clarity, SD (̃ 25%) are not provided for peak intensities.
to participate in some (but not all) team training
Adapted from Lacome et al.3 The 4 coloured circles refer to 4 of the specific training drills within S4 sessions, as indicated in Table 1 (HSR) and 2 (WM). #2/4 refers to the sequences, and to perform some extra/individualized
types of high-intensity training sequences with both a high neuromuscular strain and a metabolic component (mainly oxidative energy, Types #2; oxidative and anaerobic conditioning work. When taking part to in some of
energy contribution, Type #4). #6 refers to Type #6 drills involving a high neuromuscular strain (but a low metabolic component), referring to quality high-speed and
mechanical work training (long rests in between reps). The HSR and mechanical work intensity of 4v4 game simulations (with goal keeper, GS) and 6v6, 8v8 and 10v10 the game situations, we have them playing as jokers
possession games (PO, without goal keeper) in which player participate at the end of the RTP process (S5, Table 1 and 2) is also shown. HSR intensity is not mentioned for (or floaters, being systematically with the team in
such GSs, since the size of the pitch prevents player to reach such high speeds. possession of the ball) for a few days, which has
been shown to decrease their locomotor demands by
30% compared with the other players.2 This offers a
MUSCLE INJURED, It is essential to build the cognitive and change of direction (i.e. measured MW relatively safe (less contacts, no defensive role and no
LOAD PROGRESSION technical aspects alongside the locomotor
demands. The sessions detailed in Figure
as a proxy of HIA), speed and strength
training which primarily relies on the
shots) and progressive loading for RTP players, while
allowing them to be exposed to the most specific
AND INTEGRATION 2 and Table 1 are designed to target, performance of the neuromuscular types of locomotor (especially decelerations and
OF POSITION-BASED alongside the integration of player-
and position-specific technical tasks
system. Metabolic conditioning refers
to the contribution and development
turns), technical and cognitive demands. This last
phase of the RTP process is crucial since it allows
PHYSICAL AND i) neuromuscular components in an of the aerobic and/or anaerobic energy players to regain their confidence and in turn, their
TECHNICAL MATCH isolated manner (“quality” sessions, such
as Type #6 4, see Table 1 legend) as well
systems.4 It is important to consider
that the progressions in load should be
full match-performance capacity. Finally, before
their participation with the team as jokers/floaters,
DEMANDS as ii) metabolic conditioning that often subtle to avoid excessive spikes.5 We RTP players need sometimes to be exposed to
also integrates important neuromuscular believe that the progressions should specific warm-up and. They should also perform
demands (such as Types #2 or #44 see also be aimed at building up locomotor some individual conditioning work post session (in
Table 1 legend). Neuromuscular training loads with alternations in session main relation to the injury and individual game demands)
refers to acceleration, deceleration, objectives (cf tactical periodization (Table 1 and 2).
CHAPTER 2 CHAPTER 2
92 < 93
Figure 2 <
S1: Introduction session
Example of four sequential RTP load Table 1
progressions in terms of volume and • Low-intensity running sensations (6-8’) Example of session
intensity of locomotor demands, details of the
• Hip mobility + Running drills
i.e., high-speed running (HSR) and hamstring injury
mechanical work (MW). The sessions • Agility closed-drills sequential RTP load
are designed for two very common progressions.
• Functional work (without the ball)
muscle injuries (i.e., hamstrings, see
details in Table 1 and rectus femoris, • Type #1: 2x 4-min set: 6x 20s (slalom run 45° 80m) /20s (jog) (TD > 14.4 km/h ≈ 1000m, MaxV < 16 km/h).
see details in Table 2) for two different • Cool down (3-5’)
playing positions in the field (wide
defender, WD and central midfielder, S2HS: S3HS:
MD). The size of the battery represents
the actual/absolute volume of • Monitoring (1): 4-min run at 12 km/h • Hip mobility + Running drills
match demands (one half), while the • HIP mobility + Running drills • Agility closed to open-skills + Technical work
coloured part within each battery
represents the relative portion of • Agility closed-skills (quality) • Monitoring (2): 4 straight-line high-speed runs(box-to-
one-half demands that is completed box), 70m in 13s, 30-s passive recovery (> 19.8 km/h ≈
• Functional work with the ball (preparation)
during the given session. Note that 200m)
the total number of sessions required • Technical Work with a Metabolic component
• Technical Work Metabolic component + Neuromuscular
within each phase is obviously injury • Type #1: 1 x 3-min set: 15s (slalom run 65m) /15s (jog) (> 19.8 constraints
and context-dependent. km/h ≈ 250m, MaxV < 22 km/h)
• Type #2: 1 x 6min 40s set: 10s (50 m) /20s (passive) + 5s
• Cool down (3-5’) (28 m) /15s (passive) (> 19.8 km/h ≈ 250m, MaxV < 24
km/h)
• Cool down (3-5’)
S4HS-WD: S4HS-CM:
• Mobility + Technical work (short pass/volley) • Mobility + Technical work (short pass/volley)
• Running drills + Technical work (control/pass) • Running drills + Technical work (control/pass)
• Agility (<10m) + decision (quality) • Agility (<10m) + decision (quality)
• Type #6: Speed progression: 1x 10m, 1x 15m, 1x 20m (MaxV • Type #6: Speed progression: 1x 10m, 1x 15m, 1x 20m (MaxV
> 25km/h, rest between reps: 45s) > 25km/h, rest between reps: 45s)
• Technical work: being orientated (3/4), dribbling and • Technical work: taking information, controlling and COD
crossing with the ball, passing (5 to 20m)
• I. Type #2: 1 x 4-min set: 10s (slalom 55 m) /20s (passive) • I. Type #2: 1x 4-min set: 10s (COD = 2x 25m)/ 20s (passive)
(>19.8km/h ≈ 400m) * + 5s (constraints)/25s (passive) (>19.8km/h ≈ 200m)
• II. Type #2: Specific WD: 1 x 4-min set: 10s (technical • II. Type #2: Specific CM: 1x 4-min set: 10s (with technical
demand: dribbling, passing, crossing) / 20s (passive) demand: turning, dribbling, passing) / 20s (passive)
(>19.8km/h ≈ 300m) (>19.8km/h ≈ 150m)
S5HS-WD and SHS-CM: in addition to taking part into possession games (without goal keeper) and game situations (with goal keepers)
with the team as jokers/floaters initially, we recommend players to do some extra Type #6 high-speed runs aiming at reaching close-
to-max velocities (with the volume adjusted with respect to distance of the following match).
CHAPTER 2 CHAPTER 2
94 < 95
S1: Introduction session
Table 2
• Low-intensity running sensations (6-8’) Example of session
details of the
• Hip mobility + Running drills
quadriceps injury
• Agility closed-drills sequential RTP load
progressions.
• Functional work (without the ball)
• Type #1: 2x 4-min set: 6x 20s (slalom run 45° 80m) /20s (jog) (TD > 14.4 km/h ≈ 1000m, MaxV < 16 km/h).
S2Q: S3Q:
• Monitoring (1): 4-min run at 12 km/h • Hip mobility + Running drills
• Hip mobility + Running drills • Agility closed to open-skills + Technical work
• Agility closed-drills (quality) • Type #6: Mechanical work (45-90°): 2x 5+5+5m
45° CODx1 / 2x5+5+5m 90° CODx2 (r: 45s between
• Type #6: Mechanical work (45-90°): 6x 5+5m 45° CODx1 / 6x
repetitions)
5+5m 90° CODx1 (r: 45s between reps)
• Technical work with Metabolic component
• Functional work with the ball (sensations)
• Type #6: Mechanical work (130-180°): 4x5+5m 130° CODx1
• Type #1: 1 x 4-min set: 10s (slalom 45m) /10s (passive) (>
/ 4x5+5m 180° CODx1 (r: 45s between reps)
19.8 km/h ≈ 250m, MaxV < 22 km/h)
• Technical work with Metabolic component
Distance to run are provided for player response but with a large anaerobic See Table 1 for
legends. Note: for the
with an average locomotor profiles glycolytic energy contribution and S2Q session, 10s/10s S4Q-WD: S4Q-CM:
(i.e., maximal aerobic speed 17.5 km/h, high neuromuscular strain; and Type is preferred to other • Mobility + Technical work (short pass/volley) • Mobility + Technical work (short pass/volley)
velocity reached at the end of the 30-15 #6 (not considered as HIIT) involving HIIT formats for the
fact that it requires • Running drills + Technical work (control/pass) • Running drills + Technical work (control/pass)
Intermittent Fitness test (VIFT 7) of 20 a high neuromuscular strain only, a greater number • Agility (<10m) + decision (quality) • Agility (<10m) + decision (quality)
km/h and maximal spring speed of 32 referring typically to quality high-speed of accelerations
km/h8). Note that the physiological and mechanical work training (long than with longer • Monitoring (2): 4 straight-line high-speed runs(box-to-box), • Monitoring (2): 4 straight-line high-speed runs(box-to-
intervals, which 70m in 13s, 30-s passive recovery (> 19.8 km/h ≈ 200m) box), 70m in 13s, 30-s passive recovery (> 19.8 km/h ≈
objectives of each locomotor sequence rests in between reps). Extended from may help building 200m)
• Technical work: spreading, being orientated, controlling +
(in terms of metabolism involved and figure 1 in Buchheit & Laursen.4 Red up this capacity in a passing backwards, inside, forwards • Technical work: COD with the ball, being orientated,
controlled and safe
neuromuscular load) is shown while font: emphasis on HSR running. Blue manner. • I. Type #6, Mechanical work: 5+10m CODx1 + Finishing on
repeating short passes, playing between 2 lines and
using one of the 6 high-intensity font: emphasis on MW. Green font: behind the defensive line
small-goal, 2x 45°, 90°, 130°, 180° (r: 45s between reps)
training Types as suggested by monitoring drills (see below). Text • I. Type #6, Mechanical work: 5+5+5m CODx2 + Finishing
• II. Type #2/4: Specific WD Mechanical work: 2x 3min 30s-
on small-goal, 2x 45°, 90°, 130°, 180° (r: 45s between reps)
Buchheit & Laursen.4 Type #1, aerobic highlighted in orange refers to the HSR set: 6 x ≈10s (specific) /≈25s (walk)
• II. Type #2/4: Specific CM Mechanical work: 2x 2min 55s
metabolic, with large demands placed drills shown in Figure 1 (right panel); set: 5 x ≈10s (specific) /≈25s (walk)
on the oxygen (O2) transport and Text highlighted in blue refers to the
utilization systems (cardiopulmonary MW drills shown in Figure 1 (right S5Q-WD and S5Q-CM: in addition to taking part into possession games (without goal keeper) and game situations (with goal keepers)
with the team as jokers/floaters initially, we recommend players to perform some additional acceleration/speed work with specific
system and oxidative muscle fibers); panel). Note: Slalom runs with 45° movement patterns of high quality (Type #6) including some kicking exercises (long balls and shoots).
Type #2, metabolic as type 1 but with angles are often used (e.g., S1, S2HS)
a greater degree of neuromuscular to decrease the actual neuromuscular
strain; Type #3, metabolic as type 1 with load: turning at 45° requires to
a large anaerobic glycolytic energy decrease running speed (less HSR) and
contribution but limited neuromuscular doesn’t requires to apply strong lateral
strain; Type #4, metabolic as type #3 forces (less MW), which in overall make
but a high neuromuscular strain; Type the neuromuscular demands of these
#5, a session with limited aerobic runs very low.1
CHAPTER 2 CHAPTER 2
Figure 3
Schematic illustration
of each of the Type #2
sequence described
in Table 1 for session
S4HS-WD, S4HS-CM,
S4Q-WD and S4Q-CM.
v
96 97
MONITORING THE RTP KEY MESSAGES IN RESTORING
PROCESS IN THE FIELD PLAYER’S SPECIFIC FITNESS
AND PERFORMANCE CAPACITY
The monitoring of the responses DURING RTP
to these types of RTP sessions is
1. Consider the muscle injury type
performed using both objective and
as a guide for RTP progression,
subjective measurements. More
e.g. Hamstring muscle requires
specifically, toward the end of the
more progressive loading of HSR,
sequence progression, as a part of one
whereas Quadriceps muscle
of the specific session, we conduct
likely requires greater focus on
a standardized running test9 (4-min
HIA progressions and loading
run at 12 km/h where HR response is
monitored in relation to historical data 2. Individualise further, the target
and used as a proxy of cardiovascular physical loads (in terms of both
fitness, followed by 4, 60-m straight- volume and intensity, Figure
line high-speed runs where both stride 1 right panel) and technical
balance and running efficiency are demands based on the players’
examined via accelerometer data10) position on the field (using
(See Table 1, e.g., green fonts, session individual data if possible and
S2HS and S3HS). Daily wellness knowledge of his playing style).
assessment and medical screening are
3. Facilitate players transition from
conducted daily to guide/adjust the
individual to team work while
loading of each session.
adjusting the initial team sessions
(individual warm-up, extra
conditioning post session, and
more importantly playing as joker
during game-based sequences).
4. Monitor internal load to
determine how the player is
coping with these demanding
final sessions before returning to
competitions
5. Consider the players’
psychological readiness to a) re-
join the team and b) return to full
match-play
CHAPTER 2 CHAPTER 2
2.4.1
REGENERATIVE AND BIOLOGICAL

TREATMENTS FOR MUSCLE
INJURY
Despite the substantial regenerative potential that skeletal muscle possesses in
the form of its own stem cells, injured skeletal muscle still heals, like most of our
tissues, by a repair process, not by complete regeneration. Thus, the healing will
result in the formation of non-functional scar tissue.1-4 The outcome of this repair
process is that the ruptured skeletal muscle fibers remain terminally separated
by the scar tissue that has formed at the site of the injury, i.e. inside the injured
skeletal muscle1-4.
— With Tero AH Järvinen, Haiko Pas and Jordi Puigdellivol
98 Few tissues, such as bone, can heal by to treat sport injuries, especially acute on ability of the injured muscle to contract.8,9 CORTICOSTEROIDS PRP LOSARTAN 99
a regenerative response, i.e. the healing skeletal muscle ruptures. In addition, Furthermore, NSAIDs do not delay myofibre
tissue produced is identical by structure Actovegin® has been claimed to have regeneration.10 BACKGROUND BACKGROUND BACKGROUND
and function to the tissue that existed at oxygen-enhancing capacity, i.e. to
Corticosteroids are a class of steroid Platelet-rich plasma (PRP) is a concentrate Losartan, an angiotensin II type I receptor
the site pre-injury. Therefore, intensive improve the athletic performance.
CLINICAL EVIDENCE hormones that are involved in a wide of platelet-rich plasma protein derived from blocker , is one of the most commonly
research efforts have been aimed at
range of physiological processes, among whole blood by centrifugation that removes used drugs for hypertension. Some RCTs
finding ways to stimulate skeletal Three placebo-controlled, randomized trials
CLINICAL EVIDENCE them the suppression of inflammation. red blood cells (and immune cells). PRP carried out in the cardiovascular medicine
muscle regeneration and converting the have assessed the effects of NSAIDs on
Corticosteroids (either orally or by local has an increased concentration of plasma- provided “hints” that losartan could also
skeletal muscle repair process to the In acute skeletal muscle injuries (or human skeletal muscle injury and a large
injection) have been administered in acute derived growth factors and platelets, which inhibit fibrosis and scar formation, in
regenerative one.1-4 any other injury), only anecdotal number of studies have assessed their
skeletal muscle injuries with the aim of in turn, contain a large number of growth addition to its blood pressure-lowering
evidence exists for Actovegin,5,6 and efficacy in mild “skeletal muscle injury”
alleviating the inflammatory response in the factors.16 In vitro- as well as experimental function. Furthermore, early experimental
Regenerative medicine is an exciting there is no experimental or clinical data i.e. in delayed-onset muscle soreness
early phase of healing. Experimental studies studies have indicated that PRP could studies suggested that Losartan could
field of translational research in tissue available to prove its efficacy. The only (DOMS).11 In less severe type of muscle
have reported delayed elimination of the enhance the recovery of different sports inhibit growth factor-β1 (TGF-β1)-driven
engineering and molecular biology that clinical trial in sports medicine has injury (DOMS), a short-term use of NSAIDs
hematoma and necrotic tissue, retardation injuries, among them, skeletal muscle scar formation. As TGF-β1 is the growth
deals with the “process of replacing, shown that Actovegin® is not ergogenic resulted in a transient improvement in the
of the muscle regeneration process and, ruptures.17 factor responsible for fibrosis and scar
engineering or regenerating human (performance-enhancing) and does not recovery from exercised-induced muscle
ultimately, reduced biomechanical strength formation in injured skeletal muscle, there
cells, tissues or organs to restore or influence the functional capacity injury.12,13 More recently, NSAIDs were shown
of the injured muscle with the use of has been interest to use it as inhibitor of
establish their normal function to pre- of skeletal muscle.7 to enhance skeletal muscle regeneration CLINICAL EVIDENCE
glucocorticoids in the treatment of muscle scar formation in injured skeletal muscle.
injury level”. Regenerative medicine and remodeling in young humans with
injuries.8-15 Two placebo-controlled, randomized Experimental research has indeed indicated
holds the great promise of engineering skeletal muscle injury.13 However, NSAIDs
RECOMMENDATION controlled trials (RCTs) on athletes with that losartan can stimulate skeletal muscle
damaged tissues and organs by using did not accelerate the recovery from severe
acute skeletal muscle injury have shown regeneration and inhibit scar formation
stem cells or stimulating the body’s own Not recommended hamstring injury.14 CLINICAL EVIDENCE
that PRP has no beneficial effect on any of after injury.19-21 Despite enthusiasm towards
repair mechanisms to functionally heal
No clinical studies addressing the effect the recovery parameters (return to play, rate losartan, one needs to note that more recent
(regenerate) injured tissues or organs,
RECOMMENDATION of corticosteroids on injured skeletal of re-injuries).18,19 Recent meta-analyses research has proven that losartan is not an
better and faster than the body´s own
healing response.1-4 NSAIDS - NON-STEROI-DAL Recommended in acute phase as well
muscle exist. have shown that PRP does not shorten
“return to play”-time nor reduce the
inhibitor of TGF-β1.
As some regenerative medicine products

ANTI-INFLAMMATORY as in DOMS. Care must be taken with
prolonged or frequent use of NSAIDs RECOMMENDATION
recurrence rate of the injury.20,21 Furthermore,
CLINICAL EVIDENCE
are in clinical use and are being offered DRUGS however, due to their potential gastric
Not recommended (based on vast
it was recently shown in experimental
skeletal muscle injury-model that both PRP Losartan has been recently studied on
to football players, we will review the (and other) side-effects.
BACKGROUND experimental data showing significant, and early rehabilitation accelerate skeletal injured human skeletal muscle in RCT.22 No
scientific evidence supporting their use
almost complete, retardation of the muscle regeneration, but they do not effect on regenerating skeletal muscle was
in injured athletes as well as provide Non-steroidal anti-inflammatory drugs
healing process). have any synergy when both treatments identified for Losartan after DOMS-type
evidence-based recommendations for (NSAIDs) are a class of drugs that provide
are prescribed together.18 This may be the of mild skeletal muscle injury in the RCT.22
their usage. analgesic (pain-killing), antipyretic (fever-
explanation why PRP has failed in the RCTs Furthermore, losartan has also been tested
reducing) and anti-inflammatory effects.
to stimulate skeletal muscle regeneration in in large RCTs as an anti-fibrotic molecule in
NSAIDs are widely used in athletes to
ACTOVEGIN provide pain-relief after injuries. NSAIDs
athletes with an injury.18 other human diseases where fibrosis and
scar formation take place. Losartan has
have been extensively studied on injured
BACKGROUND failed in all these RCTs to inhibit and fibrosis/
skeletal muscle. Short-term use of different RECOMMENDATION
scar formation.23-25
Actovegin® is a deproteinized NSAIDs in the early phase of healing leads
Not recommended
hemodialysate of ultra-filtered (<6 to a decrease in the inflammatory cell
kDa) calf serum from animals under 8 reaction, with no adverse effects on the RECOMMENDATION
months of age. It has been used widely healing process or on the tensile strength or
Not recommended
CHAPTER 2 CHAPTER 2
100 STEM CELLS EXTRACORPOREAL SHOC- HYPERBARIC OXYGEN THERAPEUTIC ULTRA- EARLY TAKE HOME MESSAGE 101
(MESENCHYMAL) KWAVE THERAPY (ESWT) THERAPY (HBOT) SOUND (TUS) REHABILITATION Despite the vast amount of scientific
interest and financial resources devoted
BACKGROUND BACKGROUND BACKGROUND BACKGROUND BACKGROUND
to the field of regenerative medicine,
Stem cells are cells with the ability to Extracorporeal shockwave therapy HBOT is the medical use of oxygen at TUS is widely used in the treatment of A series of experimental studies have most of the recent and the promising
differentiate into a multitude of cell types. (ESWT) is based on abrupt, high greater than atmospheric pressure to muscle injuries, although the scientific established that early, active mobilization innovations have failed to live up to their
Among the different populations of stem amplitude pulses of mechanical energy, increase the availability of oxygen to the evidence on its effectiveness is somewhat started after a short period immobilization/ billing in clinical trials. For some of the
cells, mesenchymal stem cells (MSCs) similar to soundwaves, generated by body. HBOT has been used to treat various vague. The micro-massage produced by rest (duration: inflammatory period of new, basic research-derived innovations
have received most interest in sports an electromagnetic coil or a spark in conditions such as gas gangrene, chronic high-frequency TUS waves are proposed healing) is ideal therapy for injured skeletal such as stem cells, the jury is still out
medicine. MSCs are stem cells that are water. “Extracorporeal” means that the wounds, carbon monoxide poisoning. to have analgesic properties, and it has muscle.38 the as they have not progressed from
able to differentiate into cells of one germ shockwaves are generated externally As the supply of oxygen is crucial for the been proposed that TUS could somehow pre-clinical studies to clinical studies,
line, mesenchyme, i.e. to osteoblasts to the body and transmitted from a pad repair of sports injuries, HBOT has been enhance the initial stage of muscle and as such fail to truly address their
CLINICAL EVIDENCE
(bone), chondrocytes (cartilage), tenocytes through the skin. ‘Shock wave’ therapies advocated for skeletal muscle rupture. regeneration. However, TUS does not potential clinical value in the care of
(tendon), myocytes (skeletal muscle) or are now extensively used in the treatment There is indeed preliminary, experimental seem to have a positive (muscle-healing A recently published randomized injured athletes.
adipocytes (fat).26 of musculoskeletal injuries and have been evidence supporting the use of HBOT to enhancing) effect on the final outcome of controlled trial showed that early
advocated also or skeletal muscle injuries. treat skeletal muscle injuries.27-30 muscle healing in experimental skeletal rehabilitation produces significantly We still rely on rehabilitation protocols
The mode of action of MSCs is considered muscle injury models.34-36 faster return to sports than delayed started early after the injury in the
two-fold: firstly, their differentiating potential rehabilitation protocol without any treatment of the ruptured skeletal
CLINICAL EVIDENCE CLINICAL EVIDENCE
would theoretically allow them to replace significant risk of re-injury.1 muscle. What is both encouraging
CLINICAL EVIDENCE
lost or injured tissue.22-24 Secondly, MSCs No clinical studies addressing the effect HBOT was shown to improve the as well as helpful, is that substantial
produce a vast number of growth factors of ESWT or “shock waves” on injured recovery from less severe skeletal Randomized controlled trial showed scientific progress has been made in
RECOMMENDATION
that could augment tissue regeneration. In skeletal muscle exist. muscle injury, i.e. delayed-onset that TUS reduced pain and improved terms of validating early rehabilitation
addition, MSCs have an immunoregulatory muscle soreness (DOMS), in one recovery after DOMS37. No clinical Recommended. Athletes should as the gold standard therapy for injured
effect (suppression of chronic, detrimental randomized controlled trial31, but study are available on TUS on severe be encouraged to start early, active skeletal muscle. Standardized, “battle-
RECOMMENDATION
inflammation) on their environment.25,26 another two randomized controlled skeletal muscle injuries. rehabilitation immediately after the tested” rehabilitation protocols have
Not recommended (based on total lack trials found no or very little beneficial inflammatory period (3 – 5 days). Safe been introduced to the field recently
of clinical evidence) effects.32,33 There are no clinical studies and effective treatment protocols have to provide a framework for safe and
CLINICAL EVIDENCE RECOMMENDATION
addressing the effects of HBOT on been developed and scientifically efficient rehabilitation.1-4 By adhering
To our knowledge, stem cells of any severe skeletal muscle injuries. Recommended for DOMS-type of tested (proven to work without to these protocols, the injured athletes
kind, have not yet been tested to treat injuries, no evidence available to increased risk of re-injury) for certain can recover from serious skeletal
muscle injuries in clinical trials. Some support the use in severe skeletal muscle groups such as hamstrings, calf muscle injuries as fast and effectively as
RECOMMENDATION
sports medicine organizations, such as muscle injuries. and quadriceps muscles.1-4 possible.1-4
The Australian College of Sports and May have a slight benefit in treating
Exercise Physicians, strongly advise DOMS, but no clinical studies on
against the use of stem cell-therapies, “severe”/”real” skeletal muscle injuries
and there is no definitive evidence have been published.
ruling out a potential increased cancer
risk with these cell therapies.
RECOMMENDATION
Not recommended (based on total lack
of clinical evidence)
CHAPTER 2 CHAPTER 2
2.4.2
SURGERY FOR MUSCLE

INJURIES
When dealing with muscle injuries, the main principles of non-operative treatment
should be used as a common guideline. There are, however, more severe muscle
injuries in which surgical treatment should be considered. Especially in athletes,
but also in other physically active people, if misdiagnosed and/ or improperly
treated, a complete or even a partial muscle rupture can cause considerable
morbidity and lead to decreased performance.1,2
— Lasse Lempainen and Janne Sarimo
102 The indications for surgery in muscle They could however also be considered 103
injuries are not always generally as tendinous injuries, as the site of the
acknowledged. However, there are rupture often involves both the muscle
certain clear indications in which surgical and tendon tissue itself, like in the cases
treatment is beneficial even though no of complete avulsions or central tendon
evidence-based treatment protocol exists.3 ruptures.4-6 Early and correct diagnosis, as
These indications include the athlete with well as accurate classification of muscle
a complete rupture of a muscle with few injuries, are the basic elements for proper
or no agonist muscles (e.g. hamstring, treatment and recovery from injury.7 The
pectoralis, adductor), or a large tear where tendon area involved in the muscle injury
more than half of the muscle is torn. has to be taken into account when making
Furthermore, surgical treatment should a decision of possible surgical intervention
be considered if an athlete complains of and also when deciding the surgical
permanent extension pain (e.g. rectus technique itself.6
femoris) in a previously injured muscle. In
such a case, formation of scar restricting In the later section on ‘Specific Muscle
the movement of the injured muscle has to Injuries’ section of this Guide, we and
be suspected and surgical deliberation of other experts will provide further
adhesions should be considered. information and guidelines related to the
surgical indications and management of
In literature, muscle injuries are often specific muscle injury types; hamstrings,
categorized as isolated muscle injuries. quadriceps, adductor and calf.
CHAPTER 2 CHAPTER 2
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Diclofenac sodium Romandini I, et al. Is rat skeletal muscle
(Voltaren) reduced exer- Platelet-Rich Plasma regeneration. PloS one
cise-induced injury in (PRP) Effective in the 2014;9(12):e115685.
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31. Staples JR, Clement 2.4.2. Surgery for muscle
Medicine and science Muscle Injuries? A Sys-
DB, Taunton JE, et al. injuries
in sports and exercise tematic Review and
Effects of hyperbaric
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[published Online First:
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onset muscle soreness. J, Heikkilä J, et al. Surgi-
2016;30(6):2266-81. ligament injuries? PM R
Medicine and science cal treatment of partial
2015;7(4 Suppl):S33-40.
14. Reynolds J, Noakes in sports and exercise tears of the proximal
doi: 10.1016/j.
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pmrj.2014.12.012
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teroids on healing of cells: regulation of
CHAPTER 2 CHAPTER 2
OF MUSCLE INJURIES
3.1
RETURN TO PLAY FOLLOWING

HAMSTRING MUSCLE INJURY
In this section, we build upon the general principles described earlier in the guide,
with specific reference to hamstring muscle injuries.
— With Thor Einar Andersen, Arnlaug Wangensteen, Nicol van Dyk and Ricard Pruna
108 RTP from MAKING AN ACCURATE affected. In football players, the majority PHYSICAL EXAMINATION 109
Specific
DIAGNOSIS of hamstring injuries occur during high-
speed running when the player is running
As with other muscle injuries, the physical
examination should include observation
Making an accurate diagnosis is at maximal or close to maximal speed,5–7
of gait pattern and function, inspection
the cornerstone of effective injury and the injury is thought to occur during
of the injured area, palpation of the
Muscle
management and return to play planning. eccentric muscle contractions when the
hamstring muscle complex, flexibility
An accurate diagnosis facilitates an hamstring muscles are lengthening while
and ROM testing of the hip and knee
estimation of prognosis, and in turn, producing forces.12,13 The biceps femoris
joints, isometric pain provocation tests
shared decision-making regarding injury long head is the most frequently injured
Injury
and muscle strength testing.1,3,14–16 Pain
management. Imaging may be used muscle 6,8–10 and commonly located to the
and deficits compared to the uninjured
judiciously at this step, but you must be musculotendinous junction.6,8 Other injury
leg with the different tests are usually
clear about what (if anything) imaging situations during movements leading to
registered,14 and a pain rating scale (NSR
will do to change the return to play plan. extensive lengthening of the hamstrings,
or VAS) can be used to quantify the
At FC Barcelona, we work backwards such as slow-speed stretching type,7
player’s subjective pain 14,17 during testing.
from the anticipated time to return to full kicking, high kicking, glide tackling,
Pain during palpation at the insertion(s) of
match-play. Understanding biology will twisting and cuttings,7,11 may typically
the proximal tendons around the ischial
help when estimating injury prognosis and involve the semimembranosus.6,7
tuberosity, as well as excessive pain
planning a strategy for appropriate loading Whether there was a sudden onset with
with provocation tests, large ecchymosis
through the return to play continuum. sharp/severe pain and whether the
(bruising) of the skin, severe loss of
player was forced to stop immediately,
function and ROM restrictions should
can aid in confirming the diagnosis
raise the suspicion of a more severe injury
and might give some indications
PATIENT HISTORY (total rupture).3,12 In addition, if palpating
about severity. Common acute injury
and applying pressure just distal to the
The patient history provides valuable situations with a mechanism of extreme
ischial tuberosity, while the player flex
information about the injury event and hip flexion with the knee extended
the knee, and the clinician is not able
a preliminary impression of the injury (e.g. sagittal split or falling forwards
to palpate the tendon having normal
severity. As with other muscle groups, with the upper body while the leg is
tension, is a strong indication of an
some of the most pertinent elements to fixated to the ground) combined with
avulsion injury.
focus on include the nature of pain, the an audible ‘pop’ indicate a possible total
mechanism of injury and the functional rupture of the proximal tendon (-s), and
Gait and function should be assessed
impact of the injury.1–3 further radiological investigations are
fully around the time of injury, by
warranted.12,13
observing whether the player has pain
Asking about the time to pain free walking
and/or display an antalgic movement
(when not seeing the player at the time Previous hamstring injury, low back
pattern. It is also useful to register pain
of injury), pain at the time of injury (using pain problems or other injuries, as
with progressive trunk flexion with
VAS or NRS) and self-predicted time to well as recent loading history may
knees extended towards the level of
RTP may give valuable information of the aid the diagnosis. More gradual onset
maximal flexion, as this will stress the
injury extent and has shown associations of posterior thigh pain where the
hamstrings. Hamstring function can also
with time to RTP in some studies.4 player reports characteristic deep,
be assessed with two-legs and single
localized pain in the region of the
leg squats, and two-leg and single leg
Although the evidence regarding the ischial tuberosity that often worsens
supine bridges, using different degrees of
actual hamstring injury mechanism during or after running, lunging and
knee flexion to assess different portions
is limited, the injury mechanism may sitting, suggest a proximal hamstring
of the muscles and tendons16,18. Palpation
provide an insight into the likely muscle tendinopathy.13
CHAPTER 3
Table 1
Estimated RTP times
for hamstring muscle
injuries based on FC
Barcelona data and
clinical experience.
Note that these are
initial estimations only,
that do not consider
* See figure 1 for player-specific factors,
illustration of football-specific
semimembranosus factors, or risk
sections A, B and C tolerance modifiers
v
110 may assist to identify the location of the the focus in the literature mainly has been without avulsion fractures) have a worse ESTIMATING RTP TIME INJURED TISSUES CONNECTIVE TISSUE INVOLVEMENT ESTIMATED RTP TIME 111
injury and whether there is a presence directed towards isokinetic and eccentric prognosis and in footballers, surgery Hamstrings free tendon avulsion Bone Surgery, 4 months
of palpable defects.3 The hamstring strength deficits at or (long time) after is often indicated 27,31 (see later in this LOCATION AND EXTENT OF TISSUE
muscles should be palpated along their RTP.26 chapter for more information on surgery DAMAGE Hamstrings free tendon Connective tissue gap, wavy tendon Surgery, 4-5 months
transverse tear
entire course, from origin to insertion for hamstring injuries).
and bruising, pain, swelling, and tissue Additionally, acute posterior thigh pain Estimating how long a player will take Hamstrings free tendon Connective tissue affected without 10 weeks
defects (discontinuity or ‘gap’) should may be hip-related or have other non- Ultrasonography and MRI are commonly to RTP following a hamstring injury longitudinal split gap, wavy tendon
be noted, using the ipsilateral leg as a musculoskeletal causes.3,27 Clinicians used in assisting the clinical diagnosis of is challenging. Recent research has Hamstrings free tendon tear + No connective tissue gap, wavy 7 weeks
reference point.3,16,19 In our experience, the should consider whether a potential pain acute hamstring injury. Ultrasonography highlighted a poor correlation between RTP biceps femoris proximal MTJ tendon
injury
muscles and tendons should be palpated source of the player’s presentation may be is described as an excellent modality times and a range of MRI measures.34–36 Connective tissue gap, wavy tendon 8-10 weeks
both in a relaxed and contracted state. lumbar spine related, or due to peripheral that is also useful in the evaluation Accordingly, a new study from the UEFA Hamstrings free tendon Peritenon halo ( tendon fiber 4 weeks
Palpation during contraction makes the neurogenic pain, and additional tests of hamstring injuries and has the UCL study 8 did not find any association stretching microdamage)
anatomical orientation easier and is more (for example slump tests) needed to advantage of increased accessibility between different edema measures and
Biceps femoris proximal MTJ Peritenon halo 4 weeks
likely to provide a specific location of the rule sensitive structures 3,13,28,29 must be and decreased cost.2 The drawback with time to RTP. Similarly, there is conflicting injury
Little connective tissue involvement 3-4 weeks
injury. To measure deficits in ROM and considered, especially if the player has an this imaging measurement, is that it is evidence on the predictive value MRI-
muscle strength, objective assessments atypical presentation. highly operator dependent 2 and has based injury classification systems.8–10,34–40 Connective tissue gap, wavy tendon 7 weeks
using goniometers or inclinometers and failed to show any association with RTP We therefore urge practitioners not to Biceps femoris – Deep zip Little connective tissue involvement 3-4 weeks
hand-held dynamometer are commonly The diagnostic accuracy of specific prospectively.32 MRI has recently been rely on MRI results alone, or muscle (distal myofascial)
used.14–16,18,20,21 Hamstring flexibility of the hamstring tests presented are poorly suggested as the preferred imaging injury classification systems only, when Biceps femoris superficial zip Connective tissue involvement 4-5 weeks
injured leg is usually reduced compared investigated 30 and the prognostic value of technique over ultrasonography, based estimating RTP after hamstring injury. (distal MTJ)
to the uninjured leg after injury,3,14–16,22 these assessments are also inconclusive on its greater sensitivity for minor Biceps femoris mixed zip 4-5 weeks
and commonly examined in conjunction and conflicting,4 thus more evidence is injuries.2 At FC Barcelona we always use At FC Barcelona, we use MRI results as a
with other assessments to establish a needed to identify which clinical tests MRI as the preferred mode of imaging. starting point for the RTP estimate, which Biceps femoris distal tendon Bone injury Surgery, 4 months
avulsion
diagnosis. The active and passive straight are most valuable to provide a prognosis Clinical examinations (i.e. hamstring may then be adjusted due to player-
leg raise tests and active and passive for RTP. Of interest, daily physical flexibility and strength) seems to be less specific factors, football-specific factors, Semitendinosus proximal MTJ Little connective tissue involvement 3 weeks
knee extension tests are most commonly measures have recently been shown to useful in discriminating the presence and risk tolerance modifiers (as described injury
referred to in the literature following be useful to inform the progression of of intramuscular tendon involvement,33 previously in this guide). Generally, injuries Semitendinosus raphe MTJ Little connective tissue involvement 3 weeks
hamstring injuries.14–16,18,20,23–25 These the rehabilitation;16,18 repeated physical and for this purpose MRI is the preferred located more proximally, and those that
flexibility tests show moderate to good examinations after the initial examination diagnostic tool. involve a large amount of tendon tissue, are Semitendinosus distal MTJ Little connective tissue involvement 2 weeks
reliability among healthy participants,24 and throughout the RTP continuum expected to take longer to RTP. Connective tissue gap, wavy tendon Surgery, 4 months
and the active and passive knee extension should be considered. Semimembranosus proximal Bone injury Surgery, 4 months
tests show good intertester reliability in Table 1 shows the expected RTP times tendon avulsion
athletes with acute hamstring injuries.25 for various hamstring muscle injury Semimembranosus proximal Partial rupture 5 weeks
Pain with isometric contraction and locations and severities, based on FC tendon rupture
Complete rupture 6 weeks
hamstring muscle strength deficits Barcelona clinical experience and injury
PATIENT HISTORY Semimembranosus proximal
at various angles of knee- and hip data collected over 10 seasons. These have Little connective tissue involvement 3 weeks
MTJ, section A*
flexion compared to the uninjured In cases where the clinical appearance not yet been validated in scientific studies
leg is commonly present initially after and severity is unclear, imaging is used and are based on our club only. Note Semimembranosus proximal Little connective tissue involvement 4 weeks
injury.3,14,16,26 Just recently, a meta-analysis to confirm the diagnosis and to provide also that these data are only intended as MTJ, section B*
Connective tissue gap, wavy tendon 6 weeks
reported that lower isometric strength information about the radiological a starting point; player-specific factors,
Semimembranosus proximal Little connective tissue involvement 5 weeks
was found post injury, but did not persist severity and the location of the injury, football-specific factors and risk tolerance MTJ, section C*
beyond 7 days.26 However, there are as well as to guide further treatment.31 modifiers should also be considered when
Semimembranosus DISTAL MTJ Little connective tissue involvement 3 weeks
few studies that have reported strength Complete ruptures of the tendon estimating RTP time.
Connective tissue gap, wavy tendon 6 weeks
deficits throughout the RTP process, as insertions at the ischial tuberosity (with or
CHAPTER 3 CHAPTER 3
112 113
PLAYER-SPECIFIC FACTORS HAMSTRING MUSCLE STRENGTH TESTING EXERCISE PRESCRIPTION (1SD±15, range 8–58 days), compared
Practitioners should consider some

TESTING Assessment of muscle strength is one
FOR HAMSTRING to the C-protocol with 51 days (1SD±21,
range 12–94 days). Irrespective of the
intrinsic factors. With young players the component of the clinical examination, INJURIES protocol used, stretching-type injury of the
ischial apophysis must be recognized Specific and functional testing plays an management, screening, and prevention hamstrings took significantly longer time
as a potential injury location in proximal important role throughout the entire of hamstring muscle injury. Isokinetic The high incidence of hamstring re-injuries to return than sprinting-type (L-protocol:
injuries.41 Each player’s specific RTP process. During the initial physical strength dynamometry measurement remains enigmatic and an insufficient RTP mean 43 vs 23 days and C-protocol: mean
hamstring anatomy may also be examination, testing provides immediate remains a common strength assessment process are mentioned as one of the main 74 vs 41 days, respectively). The L-protocol
important to consider. For example, the information on which activities the in elite sports teams.42 However, this reasons for this.46,47 MRI abnormalities are was significantly more effective than the
length of the free tendon of the biceps player can perform with and without is expensive, time consuming and not common at RTP,48–50 with many athletes C-protocol in both injury types. Only one
femoris may vary from individual to pain, which may help practitioners specific to movements in the field. that have met clinical clearance returning reinjury was registered in the C-protocol
individual, and an injury 5 cm from the develop a clinical impression of injury Strength can be effectively assessed to play demonstrating incomplete healing group. It therefore seems reasonable to
ischial tuberosity may affect mostly severity and prognosis. Later, the test using a hand-held dynamometer of the injured muscle, and therefore may include lengthening/eccentric exercises in
tendon tissue in one player, but mostly can act as important milestones and / or (HHD).43,44 Following injury, these tests still be in an injury-susceptible state. a rehabilitation program aimed to return
A
the muscle-tendinous tissue in another criteria as the player progresses along can be compared with the uninjured leg Re-injuries commonly occur early after football players effectively, but safely back
player. However, providing an accurate the RTP continuum and help to guide at specific time points throughout the RTP,9,11,51 but an increased susceptibility to play after an acute hamstring injury,
estimate for RTP based on the location of the final decision to clear the player for RTP process 16,18 and provide valuable seems to be present for several months although, the optimal volume and intensity
the injury seem to be challenging and the unrestricted match participation. information to the RTP decision making after the index injury.46,52 Thus, a good of eccentric training after acute hamstring
evidence here is conflicting.8,36,37,40,42 process. Traditional strength tests include and effective RTP process following a injuries and re-injuries is yet not clear.
B While at FC Barcelona we acknowledge but are not limited to; isokinetic strength, hamstring injury is important not only for
that hamstring muscle testing such as mid-range and outer-range strength and a quick RTP, but also for reducing the risk Conversely, Mendiguchia et al.55 showed
those mentioned below can be of useful, the Nordic hamstring strength. of re-injuries. However, there is still lack of that male football players who underwent
FOOTBALL-SPECIFIC FACTORS however, we do not actually perform any consensus about the management and the an individualized, multifactorial, criteria-
of the isolated/non-functional tests of optimal exercise prescriptions following based algorithm with a performance- and
As the hamstring muscles are highly muscle strength or flexibility as markers acute hamstring injuries.53–55 There are primary risk factor-oriented training
POSTERIOR THIGH FLEXIBILITY
stressed during long sprints more than throughout the RTP process for hamstring several randomised controlled trials program from the early stages of the
30 meters, wing midfielders, full backs muscle strain. In our experience, through There are numerous ways to measure (RCT) investigating the effect of different process, markedly decreased the risk of
and other players who commonly mobilisation of the injured area as soon as hamstring flexibility, commonly used both interventions and exercise protocols after re-injury compared to a general protocol
C have to undertake maximal sprints for possible following injury and exposure to for screening, diagnosis and throughout hamstring injuries.53 Of particular interest, where long length strength training
longer distances during match play, field-based activities from early on (pain the RTP process, as mentioned above. The two larger RCT’s have been published exercises were prioritized, although the
may need longer RTP times and specific permitting) e.g. on-field football specific most common are the straight leg raises on the effect of different rehabilitation time to RTP was longer.
drills following injury. In particular this exercises, that the strength and flexibility 14
and active and passive knee extension programs following acute hamstring
is related to the ability of performing does not suffer and therefore any initial tests,25 with various degrees of hip flexion, injuries in male football players.54,55 Independent of exercises applied, a
repeated sprints. losses are negligible and do not impact on and the Askling H-test.45 multifactorial approach including a
the RTP process. Askling et al.54 reported that a protocol comprehensive evaluation of health
emphasizing hamstring exercises status, participation risk as well as factors
performed at longer muscle length involved in the decision modification is
(L-protocol), was significantly more suggested to provide clinicians with an
effective than a conventional exercise evidence-based rationale for RTP decision
protocol with less emphasis on making.56,57 Importantly, these factors
lengthening exercises (C-protocol). Time should be considered along the course of
to RTP was significantly shorter for the the RTP continuum.58
< players in the L-protocol with 28 days
Figure 1
CHAPTER 3 CHAPTER 3
114 Still, specific data regarding hamstring EXERCISES TO OPTIMISE how to progress or adapt the treatment ACUTE STAGE TARGETED TREATMENT 115
strength recovery, self-reported pain/
insecurity during ballistic flexibility
TISSUE HEALING AND session of the player on a specific
day.16,18,55 Additionally, clinical reasoning At FCB a five-stage approach to the Targeted interventions at this initial stage
movements (Askling H-test 45), active RESTORE PERFORMANCE should be performed continuously by management of muscle injuries is used following injury (e.g. the day/s following
and passive ROM tests and relevant sports the clinician to optimise the loading (see RTP principles section). Stepwise muscle injury) that help to reduce pain
specific tests to use in the decision of RTP A carefully-planned, progressive loading and the progression for each session progression of loading will facilitate and enhance movement quality include
are sparse. There are yet no valid definitions program is essential to optimise the and the individual player. Monitoring effective tissue healing while restoring ‘physio-table’ based methods such as
or objective criteria for RTP,59 nor criteria quality healing of the tissues and to of the athlete’s response through daily functional capacity. Focus during the manual therapy and passive mobilisation
for progressing throughout the different prevent injury recurrences. The program measurements (reported pain, palpation, acute phase of management is to limit the of the affected area. Passive modalities
stages.60 Just recently, a Delphi procedure 61 should include fundamental therapeutic muscle strength, and flexibility) may extent of the initial injury and to provide should not be seen as standalone
with experts within the field of hamstring exercises (sometimes referred to as assist in determining the response to a strong foundation upon which to build interventions but rather as an auxiliary to
management selected by 28 FIFA Medical mechanotherapy 63) and strategies to the loading, and whether the athlete is the rehabilitation process. enhance the mechanotransducive effect
Centres of Excellence, concluded that restore football-specific function. As ready for progression or not. In addition of high quality tissue loading. Passive
the RTP decision should always be a previously discussed, maintaining football- to muscle strength measurements, Reduction of pain and inhibition are key interventions are used primarily to reduce
multidisciplinary decision, and for RTP specific cognitive skills is vital throughout isometric contractions at different muscle goals during this phase. Application of pain and enhance movement so that the
readiness assessment of the player after the entire RTP process. Importantly, these lengths may be performed as pain the principles of the POLICE 69, acronym active strategies more effectively target
a hamstring injury, emphasis should be three areas are non-hierarchical; there provocation tests throughout the RTP should be initiated as soon as possible the injured tissue.
placed on pain relief, flexibility assessment, should be gradual progression in all areas process to help guide exercise and load following injury. Key interventions
psychological readiness, and functional and milestones should be determined progression. In the clinical reasoning include compression and ice. This can be During the subacute phase, active
performance. Further, that MRI findings for each area as the player progresses process, the clinician will also consider achieved through the use of compressive mobilisation will facilitate both movement
should not be used alone for RTP-readiness through the RTP continuum.58 factors related to the presumed injury bandage (see quads section 3.2. figure capability and improve tissue healing.
assessments. However, this Delphi study mechanism, player-specific hamstring 1A); where the injury is at lower-third of Exercises performed during this phase
also revealed the different opinions and Regarding pain during exercises, it is demands, and presumed individual thigh, it is recommended to include the should be carried out with good form
discrepancies among the experts within generally recommended that all exercises risk factors such as trunk stability and knee joint in this compression. Modalities and compensatory strategies avoided.
the field. should be performed close to pain free lumbo-pelvic control.65,67,68 For players combining cooling and compression (see Examples of interventions during this
limit, since loading healing tissue beyond with an injury involving the proximal quads section 3.2. figure 1B) or use of phase include dynamic mobility, and
The management guidelines for hamstring its elastic limit might result in further tendon (-s) (free or intramuscular) or graduated segmental compression (e.g. gentle active tension stretching towards
injuries presented here are based exacerbations, signalled by the presence more longstanding problems (proximal Normatec, see quads section 3.2. figure outer pain-free ranges are recommended
predominantly on basic science, therapeutic of pain with this loading.64 If the exercise hamstring tendinopathy), our experience 1C) can further facilitate reduction of pain to be initiated, in addition to active
principles from previous studies on or movement elicits pain from the injured is that exercises towards outer ranges and swelling in the affected area. Players lengthening exercises54 (Figure 2).
hamstring injuries and clinical expertise. area, the exercise should therefore should be prescribed with caution, in are allowed to walk as able although
immediately be adjusted or terminated. particular exercises involving excessive hip it may be necessary to use crutches In addition, to maintain the muscle
The journey from early rehabilitation to Uncontrolled movements of the pelvis flexion. The RTP continuum can be divided following severe injuries. function of the lower limb, the player
team training will often be highly individual. could adversely affect load on the into several phases, but with an overlap of should also focus on exercises for the
To design a RTP program following a hamstrings during high stress events such exercises between the phases. hip, gluteus and calf.55 It is also advised
hamstring muscle injury based strictly on as sprinting, thus patients are continuously that general upper quadrant and aerobic
muscle injury healing phases 62 is likely instructed to perform the exercises with conditioning is maintained; this can be
not appropriate for all athletes. The athlete’s adequate control and stabilization of the achieved through the use of elliptical
signs and symptoms, the combination hip and trunk.65,66 trainers, stationary cycles, aqua jogging ^
of clinical expertise and evidence-based and AlterG Treadmill, before progressing Figure 2:
knowledge should guide decision-making Physical assessments and specific criteria walking on a treadmill is initiated when Active tension
stretching towards
process for exercise progression. Potential for progression throughout the RTP tolerated. extension
complications should be carefully monitored process is usually recommended in order
at all times. to assist with the clinical reasoning of
CHAPTER 3 CHAPTER 3
116 FOCUSED MUSCLE ACTIVATION PROGRESSING TO THE GYM hamstring exercise reduces the risk of 117
hamstring strain injury when compliance
Low level exercises that provide adequate Once able to effectively recruit the is adequate,78–80 and the benefits of this
loading during the early phase of healing muscle through range it is important type of training are likely to be at least
are recommended. Functional exercises to combine table based activation with partly mediated by increases in biceps
aimed at retaining and even improving more conventional gym based training. femoris long head fascicle length and
movement patterns are also utilized. In this phase, the main aim is to regain improvements in eccentric knee flexor
Typically, active movements in mid and full muscle function, which means strength.70 Selecting exercises with a
inner ranges (of knee- and hip flexion) regaining full voluntary control over the proven benefit on these variables should
could be performed without resistance injured muscle throughout a full range therefore be included in any effective
or external loading (such as for example of motion. This is achieved through pain- injury and reinjury prevention protocols.
prone or seated knee flexion). Focused free hamstring strengthening exercises In addition, the Nordic hamstring exercise
muscle activation can be useful in (with controlled progression to longer seems to improve sprint performance and
the early stages, as the use of manual hamstring lengths), appropriate control the in peak eccentric hamstring strength
resistance can help ensure mechanical of trunk and pelvis, and with progressive and capacity.81
stimulus is provided to the affected area, movement speed and increased load on
while the intensity can be modulated in the hamstrings. Typically, relatively higher levels
line with symptoms to ensure vulnerable of biceps femoris long head and
structures are not overloaded. Examples The exercises should be performed semimembranosus activity have been
of isometric to easy concentric exercises with controlled increase in the load observed during hip extension-oriented ^
with manual resistance are shown of the particular exercises to ensure movements, whereas preferential Figure 5A:
Two leg
in figures 3 and 4. Specific hamstring continuously increasing tissue capacity semitendinosus and biceps femoris
exercises, such as supine bridges with and monitored to ensure the exercises are short head activation have been
two legs or one leg if tolerated (Figure executed appropriately and adaptation is reported during knee flexion-oriented
5A-B), and more functional exercises such performed as required. movements.70 Preferably, both hip- and
as one leg squats with attention to pelvic knee dominant exercises should be
and leg posture may also be performed. Hamstrings specific strengthening included in the RTP program.55 Examples
exercises that are increasingly challenging of different bridge exercises commonly
During this phase, it is suggested that together with a gradual running used in FCB and other hamstring
exercises are carried out ‘little and often’ progression are introduced in this phase. strengthening exercises are shown in
and that movements are biased towards Typically, this includes progression to figures 6 to 8.
lengthening contractions as soon as higher loaded and/or single leg exercises,
possible. Movements during the early and exercises towards greater muscle
strengthening phase should be carried lengths, i.e. eccentric exercises. A variety
out in a slow and controlled manner. of exercises could be included, and the
It is recommended that 2-3 sets of 4-6 exercise selection may be influenced by
repetitions of sub-maximal contractions individual preferences and considerations,
(60-70% MVC) are carried out twice such as for example the location of the
daily. As rehabilitation progresses the ^ ^ injury. Several studies using surface
intensity of contraction should be Figure 3: Figure 4: EMG and / or fMRI suggest that the
increased and the frequency reduced to Isometric exercises Concentric exercises hamstring muscle activation patterns
against manual
align with conventional strength training resistance are heterogeneous and diverge between
^
parameters. different exercises.70–77 Eccentric knee Figure 5A:
flexor conditioning, such as the Nordic one-leg bridges
CHAPTER 3 CHAPTER 3
118 In addition, the player should 119

continue with active stretching
exercises (and active dynamic
mobility) (see figure 10) and
also include coordination- and
proprioception exercises.
^
Figure 8:
One leg bridge
(can be progressed
with plyometric
component)
^
Figure 10:
Various active
stretching and
dynamic mobility
exercises
Restoration of normal gym-based strength and architectural stimulus

training is important. Players should be included and maintained
routinely complete a range of lower beyond return to sport. These
limb strengthening exercises that might include general hamstrings,
combine eccentric, concentric and quadriceps and glute exercises, such
isometric muscle actions. Once as squats, deadlifts and hip thrusts
there is pain-free recruitment of (See figure 7 in quad specific section
the hamstrings through range, it is 3.2.).
important to normalise gym training
^ ^ ^ as soon as possible while maintaining
Figure 6: Figure 7: Figure 9:
Bridges and one-leg Bridges combined Seated leg curls with an additional eccentric stimulus
bridges with increased with knee extensions focus on the eccentric to facilitate adaptations in muscle
ranges and various (eccentric phase) (and phase architecture and prevent recurrence.
surfaces knee flexion curls
(concentric phase) Exercises that provide the necessary
CHAPTER 3 CHAPTER 3
120 RUNNING PROGRESSION < COMPLEX FIELD WORKOUT: RESTORING Exercises and activation routine before 121
Figure 12: FOOTBALL-SPECIFIC FITNESS, SKILLS training is advised to continue, in
Examples of early
As early as tolerated, the player should running in the field AND COGNITION addition to resumption of partial training
begin a running progression program, with the team. Program which exercises
addressing volume, intensity, and running As outlined in the general RTP section, to do with the team, and which to do
mechanics. An important aspect of on-field return to play requires the with medical and performance staff, as
the resumption of running is to ensure introduction of progressive complex well as analysing the locomotor loads
that the loading during running is football-specific tasks such as dribbling, (e.g. from GPS) and internal loads of
progressively and carefully increased. passing and receiving a ball, snake runs the player in addition to psychological
Asking the athlete to rate their perceived and training drills. The use of football readiness (refer back to section 2.3.2
effort during running may be a good Finally, sprints at various distances specific circuits and manipulation for specific guidelines for this final
way to ensure that similar loads are within specific football situations and of constraints such as the speed transition) when deciding on returning to
maintained within sessions, and to enable stimulations are added. Also a focus of movement, difficulty of the skill, full training and match-play.
careful increases in loading (running on running and sprinting technique, competition and decision-making
speed) when the athlete has safely as well as a controlled progression become increasingly important during
achieved a given speed.16 The running of total running load towards the the RTP process. Tasks that place greater
could preferably be performed outside on expected running and sprinting stress on the hamstrings should be
the field. In addition, specific drills and/ exposure in training and matches for identified and progressed as the player
or football-specific drills with low-speed the individual player is emphasised. is able i.e. coping with the demands.
tasks can be initiated. At FC Barcelona, Particular attention should be given to
running in the early stages is commenced Multi-directional running through managing the number of accelerations,
on dry sand (figure 11) and progressed the execution of simple football decelerations and changes of direction
to linear running on the field (e.g. figure skills can be included. Football as these activities are particularly
12). Manipulation of distance, velocity circuits and training drills can be important not only for re-injury risk but
and volume is then used to train specific BASIC ON-FIELD TRAINING: RESTORING introduced and progressed in terms also for performance.
subcomponents of running fitness and RUNNING, KICKING AND CHANGE OF of complexity and decision-making
muscle function. DIRECTION before returning to field sessions with At FC Barcelona, particular emphasis
the squad. Pain free running up to is placed upon incorporating the
The primary goal during the RTP maximal speed including change of ball during every session (or at least
process is to ensure the player directions, performed under fatigue, as many as is possible). Practical
can return safely to activities that is paramount. Similarly, passing and strategies to progress unanticipated
yield a high re-injury risk, such as kicking require controlled progression, movements include variation of the
sprinting and kicking. A strong focus as emphasized earlier (see quad speed and timing of signals for players.
on monitored progression of these section 3.2. for more information on Similarly, introduction of competition
activities during RTP is therefore passing/kicking progressions). and opponents can effectively progress
essential. unanticipated, open-skill aspects of the
The exercises are increased with game. Advanced skills and cognitive
The running is progressed by adding controlled load and strengthening challenges are introduced and the focus
changes in direction and velocity exercises may include more specific moves from being injury (hamstrings)
^
Figure 11:
through football-specific drills and modifications for the individual player specific in the early stages to activity
Running circuits in dry tests, including both linear, turns, and activation routine before training (football and position) specific as RTP
sand (starting easy) accelerations and decelerations. is introduced. progresses.
CHAPTER 3 CHAPTER 3
RETURN TO PLAY EXAMPLE FROM

FC BARCELONA
— With Xavi Yanguas, Juanjo Brau, Xavi Linde, Ricard Pruna
Figure 13:
An overview of RTP
from a hamstring
muscle injury at FC
Barcelona
v
122 123
THE BARÇA WAY:
Following an accurate diagnosis

of the hamstring muscle injury,
we work back from the estimated
RTP date. For example in the case
in figure 10, we estimate the RTP
at week 17. We subsequently work
backwards from this to determine
the key milestones and exercise
progressions to achieve this date.
Bearing in mind, that the RTP
framework is flexible in order to
either accelerate or slow down the
progression depending on how
the player responding to the RTP
program.
Compared to other muscle injury

cases that we will show you in this
specific muscle injury section (e.g.
quadriceps, adductor, calf), this in-
jury requires a greater integration
of multiple phases and focuses
simultaneously. i.e. several and
varied stimuli in the way of stren-
gth, accelerations, decelerations,
high-speeds.
CHAPTER 3 CHAPTER 3
SURGICAL TREATMENT OF
HAMSTRING INJURIES
Most hamstring injuries do not require surgery. However, in some cases surgery
should be performed immediately after the injury occurs. Surgery may also be
necessary if conservative treatment fails to achieve a satisfactory result – for
example if the player has chronic symptoms or recurrent injuries.
— With Lasse Lempainen, Sakari Orava and Janne Sarimo
124 INDICATIONS FOR EARLY SURGERY Apophyseal avulsions of the ischial A-B).90 Complete ruptures of the BF or < PROGNOSIS FOLLOWING EARLY 125
Figure 16 A-B:
tuberosity occur occasionally in ST with retraction should be repaired Distal rupture of the SURGICAL REPAIR
Early hamstring surgery is indicated adolescent players.89 Surgical repair is anatomically as soon as possible after long head of the BF
following avulsion of two or three of traditionally recommended if the avulsed injury. Sometimes, the proximal end of at the myotendinous Following surgical repair of proximal
junction. A coronal
the proximal tendons from the ischial fragment is displaced by more than 1.5 to the ST retracts so severely that it cannot image (B) shows the and distal hamstring tendon avulsions,
tuberosity (Figure 14 A-B, Figure 14 C).82-86 2 cm. However, these cases are unusual. be repaired anatomically and the ST retracted BF muscle players can normally begin running and
(axial and coronal
When only one of the tendons is avulsed, is sutured to the semimembranosus images).
performing controlled drills with a ball
conservative management may be an Although surgery is rarely necessary (SM) muscle. It is important to note that (i.e. “return to field”) after 10-12 weeks,
option. However, in the elite football for distal hamstring injuries, in some the consequence of an acute distal ST and most have returned to optimal
player, surgery is often recommended – cases it is necessary. Indications include avulsion is not similar to when the ST performance after 3 to 5 months.84,85,87,88,90
irrespective of which tendon is involved avulsion of the biceps femoris (BF) or tendon is harvested for graft purposes.90 However, in some cases rehabilitation
(Figure 15 A-B).87,88 For proximal tendon semitendinosus (ST) tendons from the may take up to 6-7 months. Persistent
avulsion repairs, suture anchors are bony insertion, as well as complete symptoms or performance reductions
typically used to reinsert the ruptured ruptures of the distal myotendinous following avulsion repair are rare. The
tendons back to the bone. junction (Figure 16 A-B, Figure 17 expected return-to-play timeline is similar
following surgical repair of complete
< ruptures at the myotendinous junction,
Figure 14C: and restoration of full function is also the
Perioperative photo of
two tendon proximal most likely outcome.
hamstring avulsion:
BF + ST.
INDICATIONS FOR DELAYED SURGERY

Some hamstring injuries become recurrent
or lead to chronic symptoms, despite
<
Figure 15 A-B: high-quality conservative treatment. In
Isolated complete these cases, surgery may be beneficial.
proximal SM tendon Although the research evidence is limited,
rupture with a clear
retraction from the potential causes of a poor conservative
ischial tuberosity on outcome include incomplete healing
the right side (axial
and coronal images).
of partial avulsions, injuries to the
^
Figure 17 A-B: central intramuscular tendon, increased
Distal rupture of the ST at the myotendinous compartmental pressure, excessive
junction. A sagittal image (B) shows loose and scarring, sciatic nerve entrapment, and
retracted ST muscle belly (axial and sagittal
images). heterotopic ossification.
^
Figure 14 A-B:
Complete 3-tendon proximal hamstring rupture
with a clear retraction on the right side (axial and
sagittal images).
CHAPTER 3 CHAPTER 3
126 INCOMPLETE HEALING OF CENTRAL TENDON The optimal treatment strategy HETEROTOPIC OSSIFICATIONS CONCLUSION 127
AVULSION SITE INVOLVEMENT of central tendon injuries is not
established. According to a recent Heterotopic ossifications can develop Even though surgery is rarely necessary
In proximal non-retracted partial avulsions It has also been suggested that paper, operative treatment of recurrent after proximal hamstring injuries, for hamstring muscle injuries, it remains
that remain symptomatic, the MRI may show hamstring injuries involving the central central tendon ruptures seems to lead resulting in significant chronic disability an important treatment option for the
fluid between the ischial tuberosity and tendon may have a greater tendency to a good overall outcome in high (Figure 20 A-D).94 These cases can be most severe cases. In fact, its role may
tendon head(s) (Figure 18 A-B). This is a sign to become chronic and recurrent, and level athletes, and return to optimal effectively treated by surgical excision even increase in the future.98,99 In our
of incomplete healing. Surgical treatment have a higher risk of poor healing with performance was achieved at 3-4 of the ossified masses and concomitant experience, hamstring injury severity is
involves debdridement of the ischial conservative treatment.91 When a partial months from the surgery with no debridement with suture fixation of often underestimated, and clear surgical
tuberosity and reinsertion of the detached and complete rupture of the central adverse events during follow-up921 the proximal hamstring tendons to the cases – such as when the proximal
tendon(s) to the bone. In these cases, tendon occurs, they are typically located However, future studies are required to ischium. Return to preinjury activities is tendon is retracted distally from the
surgery is often beneficial and the player can 5-20 cm from the proximal tendon find out whether these injuries should expected in the majority of these cases anatomical footprint – are often missed.
often return to optimal performance after origin (Figure 19 A-B, Figure 19 C).92 If be operated acutely if tendon heads approximately after 6 months from the This has serious consequences for the
approximately 4-5 months.88 a hamstring injury involving a central are clearly separated from each other operation. recovery time and functional outcomes,
tendon rupture remains symptomatic in MRI. The role of (repeated) MRI may which are of upmost importance to the
after conservative treatment or becomes be important for confirming the correct professional footballer.
Figure 18 A-B: recurrent, surgery should be considered. diagnosis and evaluating the extent of
Chronic incomplete
proximal hamstring
The continuity of the central tendon is the injury.92,93 OTHER CAUSES When choosing a treatment, practitioners
rupture at the left side. restored by suturing, and the attachment should remember that hamstring injuries
MRI shows fluid between of the muscle to the tendon is reinforced. Surgical treatment should also be can be career ending. Surgical treatment
the ischial tuberosity and
the tendon heads (axial Suture anchors may be used if the tear is considered in chronic and/ or recurrent should always be considered when athletes
and coronal images). located close to the ischial tuberosity. hamstring injuries with symptoms of sustain complete proximal or distal tendon
v pain and tightness of the posterior thigh. avulsions. Finally, it is important to note that
These symptoms can be a result of so surgery is technically easier if performed
called post traumatic hamstring syndrome soon after the injury has occurred.
or compartment syndrome.95-97 The
surgical procedure may include excision
<
Figure 19 A-B: of adhesions, fasciotomies, sciatic nerve
Recurrent central Figure 19 C: liberation and elongation of the scarred
tendon rupture of the Perioperative photo of tendons. After surgery, most of the athletes
SM at the right side the SM central tendon
(axial and coronal rupture. are able to return to the same level of
images). v sporting activity as before the onset of the
symptoms. This takes normally a mean of 5
months (range, 2-12 months). >
Figure 20 A-D:
Heterotopic
ossification next to the
right ischial tuberosity
causing sciatic nerve
impingement. A; x-ray
before operation. B
and C; mri axial view.
D; x-ray taken after
operation.
CHAPTER 3 CHAPTER 3
3.2

QUADRICEPS MUSCLE INJURY
In this section, we build upon the general principles described earlier in the guide,
with specific reference to quadriceps muscle injuries.
— With Phil Glasgow, Mario Bizzini and Andreas Serner
128
MAKING AN ACCURATE less than half the time to recover compared location of bruising, swelling, soreness and To measure rectus femoris flexibility IMAGING
ESTIMATING RTP TIME 129
DIAGNOSIS to indirect injuries.2 For proximal “indirect”
injuries, a distal iliopsoas injury may give
solid masses should also be identified.6 across both the hip and knee, the modified
Thomas test position is most commonly Clinical examination tests, including LOCATION AND EXTENT OF TISSUE
similar clinical findings as a proximal When testing the strength and range-of- used. Using goniometer to assess knee specific palpation of the rectus femoris, DAMAGE
Making an accurate diagnosis is rectus femoris injury.7 The mechanism of motion of the quadriceps, especially if flexion ROM with the hip in neutral, the test resistance and stretch tests with different
the cornerstone of effective injury injury may therefore in some cases be ‘indirect’ injury is suspected, it is important shows moderate reproducibility,13 whereas degrees of hip and knee flexion (e.g. the In regard to ‘direct’ muscle injuries, muscle
management and return to play helpful in differentiating between injury to remember that the rectus femoris is a a combined hip extension and knee flexion modified Thomas test) are often sufficient firmness rating and difference in knee
planning. An accurate diagnosis locations, as rectus femoris primarily occur bi-articular muscle, in contrast to the other measure using digital inclinometers has to diagnose injury location, However, in flexion ROM appears to have a high
facilitates an estimation of prognosis, during kicking and sprinting, and not quadriceps muscles. The position of the hip shown excellent reproducibility with athletes with pain in the proximal part of association with duration of return to sport6.
and in turn, shared decision-making change of direction, which is a common will therefore likely influence test focus. a standard measurement error of less the thigh, these test are generally poor at Active knee flexion range of motion at 12-24
regarding injury management. Imaging injury mechanism for acute iliacus and than 2% (Serner et al, unpublished). The accurately localizing injuries in the rectus hours after injury has also been used to
may be used judiciously at this step, psoas injuries.4 Practitioners should Strength can be measured subjectively modified Thomas test will also enable the femoris , as injuries in different hip flexor classify severity of contusions into mild,
but you must be clear about what (if however be cautious when interpreting by the clinician, or objectively using tools clinician to assess the neural sensitive muscles, such as the iliacus and psoas moderate and severe, as >90°, 45-90°, and
anything) imaging will do to change the injury mechanism information and such as handheld dynamometers, which structures of the anterior thigh, such as the major, may also cause positive tests in the <45° of knee flexion, respectively, with an
return to play plan. At FC Barcelona, we should never make a diagnosis based on can be useful in providing an indication femoral nerve. same areas.7 associated increase rehabilitation time.19
work backwards from the anticipated the mechanism alone. of strength at different ranges-of-motion.9
time to return to full match-play. Quadriceps strength is most commonly The clinician should consider that As such, imaging can play a prominent role In regard to ‘indirect’ muscle injuries,
Understanding biology will help when Practitioners should also consider a wide tested isometrically in a sitting position functional ranges of motion during in determining the precise diagnosis. MRI is the time frame for RTP varies greatly,
estimating injury prognosis and planning range of differential diagnoses in an (inner-mid range), but can also be measured activities, such as kicking and sprinting usually the imaging modality of choice, as and is considered to be related to initial
a strategy for appropriate loading athlete with anterior thigh pain, including in supine, which may be more relevant in the occur as part of the wider kinetic chain it enables the clinician to accurately localise injury extent. Imaging details show that
through the return to play continuum. herniae and neural pathology. assessment of rectus femoris strength. with the motion of the lower limb being the injury, and determine whether there is proximal injuries often include injury to
closely linked to the trunk and lumbo- any tendinous involvement. In adolescent the tendon itself, “Tp” injuries, and these
Range of motion of the quadriceps can also pelvic motion.14 Recently, a whole-body athletes, proximal rectus femoris injuries injuries will predominantly affect the
PATIENT HISTORY PHYSICAL EXAMINATION
be measured in different ways. To isolate test focusing on hip range of motion has may include an avulsion fracture of the AIIS, indirect tendon either as avulsion injuries or
A detailed patient history provides key Similar to other muscle injury locations, knee flexion range of motion as much been described for footballers with groin and plain radiographs should therefore tendon disruption along its intramuscular
information for the clinician, and can assist the clinical examination of quadriceps as possible, the hip should be in a flexed pain.15 The hip extension component of this be considered with presence of proximal course.4,22,23 This may explain why proximal
in differentiating between different muscle injuries comprises mainly of muscle position. This can be done in supine or a test may have relevance when considering insertion pain in this patient group.16,17 rectus femoris have been associated with
injury types. In particular, the history palpation, stretch and resistance tests, sitting position.10 This measure may however the demands on quadriceps flexibility a longer rehabilitation duration than distal
should provide a detailed insight into the and functional assessment.6-8 A detailed likely often be irrelevant as a measure of in the context of its relationship to other Imaging ‘direct’ injuries may be helpful in injuries.24
severity, location and nature of pain, the patient history should help guide the quadriceps flexibility, as the hamstring segments through a more sport specific determining both the location and extent
mechanism of injury, and the functional physical examination, allow differentiation and calf muscle bulk (or knee joint) can be range of motion. An additional knee flexion of the injury, as some injuries can have Whilst there is a current perception that
impact of the injury. between direct and indirect injury types, the limiting factor at end range. A similar may also be added to the test for a higher considerable muscle damage and fluid disruption of the intramuscular tendon is
and be followed by a tailored physical ceiling effect may also be present in a prone focus on rectus femoris flexibility. collection.18 Myositis ossificans develops associated with a longer RTP duration,25
The of injury may prove to be a diagnostic examination. position with the hip in neutral,11 however, in about 1 out of 10 injuries, and the risk the studies on which this perception is
aid, as it can provide insight into the likely this knee flexion test may still provide good appear to increase with higher extent of based upon, does not describe this factor
muscle affected, and the potential prognosis. Muscle palpation should be performed quantification of quadriceps flexibility e.g. injury.19 Therefore, imaging may assist in in detail.5,24 There is currently evidence
The more common ‘indirect ‘injury,1,2 globally across all compartments of following a quadriceps contusion, and can initial treatment decisions, such as potential that a higher extent of injury appears to
which usually occurs during sprinting and the thigh, and muscle firmness ratings be assessed using either a goniometer or aspiration of the fluid collection. Myositis be related to longer rehabilitation time,
kicking,3,4 is typically indicative of a muscle (examiner-rated score between -5 to +5) digital inclinometer to indicate progression of ossificans may be detected clinically a however, the large variations within
strain to the rectus femoris3,5, whilst ‘direct’ and thigh circumference (measured at flexibility and pain. The prone position may few weeks after the initial injury as a more the different classification categories,
injuries are typically associated with a supra-patellar border, as well as 10cm and also be used to get an impression of rectus firm mass at the initial injury site, and prevents clear RTP predictions.3,5,24 The
traumatic contusion injury, usually affecting 20cm proximally), noted in cases where femoris flexibility by assessing the point of plain radiographs can be used to confirm Munich muscle injury classification, using
the vastus lateralis muscle.6 It has been ‘direct’ injuries are suspected. During hip flexion movement during the knee flexion the suspicion, which may cause more MRI for categorisation, has been used to
shown that direct injuries on average take inspection and palpation, the presence and movement (Ely’s test).12 persistent pain.20,21 provide an overview of the duration of RTP
CHAPTER 3 CHAPTER 3
Table 1:
Estimated RTP times
for quadriceps muscle
injuries based on location
and tissues involved
v
130 timeline in elite football players. Functional

INJURED TISSUES CONNECTIVE TISSUE INVOLVEMENT/ ESTIMATED RTP TIME
PLAYER-SPECIFIC FACTORS FOOTBALL-SPECIFIC FACTORS QUADRICEPS MUSCLE 131
muscle-related neuromuscular disorders
and minor structural partial tears can be
IMAGING FINDINGS At FC Barcelona, over 10 seasons In our experience at FCB, players in playing TESTING
Direct tendon avulsion large connective tissue affected and gap and Surgery 4-5 months of consistent injury registration positions with high emphasis on shooting
expected to have similar duration of about
wavy tendon throughout the club, we have seen that and goalkeepers may require a longer RTP Functional testing plays an important
1-3 weeks, whereas moderate partial tears
younger players, in particular academy to ensure they are able to perform to at least role throughout the entire RTP process.
show longer duration of about 4-7 weeks, Direct tendon transversal Connective tissue Non-surgical?
tear players have a higher frequency of (or ideally) better level than at pre-injury. During the initial physical examination,
and subtotal/complete muscle injuries Findings: tendon gap, wavy tendon Surgery 4-5 months
rectus femoris injury and therefore this testing provides immediate information
taking around 8-12 weeks.26 Using the
Direct tendon longitudinal Connective tissue 8-12 weeks is a pertinent consideration for us when Additionally, the time of the season may be on which activities the player can
more detailed FCB classification, based on tear
Imaging findings: no tendon gap, wavy planning the RTP process and timeline appropriate to consider. Two studies have perform with and without pain. This
clinical experience and injury data over 10
tendon for players. reported an increased risk of quadriceps helps practitioners develop a clinical
seasons, we present our predictions on RTP
injury rates during pre-season compared impression of injury severity and
duration in table 1. These form the basis of Indirect tendon avulsion large connective tissue affected and gap Surgery 3-4 months
and wavy tendon Furthermore, unlike other lower to in-season incidence. In a study of 91 prognosis. Later, functional tests act
our rehabilitation strategy and planning,
extremity muscle lesions, leg English League football clubs,28 it is reported as important milestones as the player
however, it should be noted that variations Indirect tendon tear Connective tissue 6 weeks dominance appears to play a role in that quadriceps injuries were the most progresses along the RTP continuum,
between individuals can be expected. Findings: tendon gap, wavy tendon quadriceps injury with the dominant common pre-season muscle injury with and help guide the final decision to
Additionally, these have not yet been fully
(kicking) leg involved in approximately and incidence of 29% (Groin 12%; Hamstring clear the player for unrestricted match
validated in the scientific literature. Indirect tendon stretching Peritendon 2 weeks
2/3 of cases.1,27 This is an interesting 11%). The UEFA injury study27 also showed participation.
Findings: halo appearance
finding and suggests we may need a 40% increase in the rate of quadriceps
Conjoined tendon Connective tissue First try conservative to consider within the time to RTP injuries during pre-season. This is in contrast Assessment can begin by examining
transverse tear 10 weeks, if re-injury estimation if the injury is to the to other lower limb muscle injuries, which isolated muscle contractions, then
Findings: tendon gap, wavy tendon
surgery 4 months
dominant leg. tend to increase as the season progresses. progress to more dynamic lower limb
Conjoined tendon Connective tissue 8-10 weeks The reason for this pre-season increase is actions such as walking, running,
longitudinal tear Finally, whether or not the player not clear, but a number of authors have jumping, and kicking (Figure 1). Finally, if
Findings: no tendon gap, wavy tendon
has had a previous muscle injury in suggested that it may be due to an increase symptoms allow, high-demand actions
Direct tendon MTJ with Connective tissue 5- 7 weeks
tendon disruption.
the quadriceps (or any of the muscle in the volume of kicking during training. should be tested, such as maximal
groups) and how many, are key aspects Further studies are required to confirm sprinting, changing direction and
Anterior myofascial Little connective tissue affected 2- 3 weeks we account for when planning RTP. whether this is indeed the case. accelerating from stationary positions.2
Practitioners should not only assess
Indirect tendon Connective tissue 3 weeks
intramuscular MTJ the player’s pain, but also their ability
to perform high quality movements
Indirect tendon MTJ with Connective tissue 6 weeks repeatedly, as well as their ability to
intramuscular tendon
Findings: tendon gap, wavy tendon generate fast movement.
disruption.
Degloving 7- 8 weeks Strength and range of motion can be

Distal tendon MTJ Connective tissue 2 weeks measured using the test described above
under physical examination. Additionally,
Distal tendon MTJ with Large connective tissue affected, gap, wavy 7 weeks detailed strength information can be
tendon disruption tendon
provided using more advanced (and
expensive) isokinetic dynamometry,
which is frequently used to measure
open chain function of the quadriceps.
However, isokinetic dynamometry
is considered non-functional, time
CHAPTER 3 CHAPTER 3
132 consuming, expensive and specificity to QUADRICEPS MUSCLE protocol,32 should be initiated as soon as EXERCISE PRESCRIPTION EXERCISES TO OPTIMISE 133
TISSUE HEALING AND RESTORE
on-field tasks are questionable. As such
at FC Barcelona we do not use isokinetic
TESTING possible, e.g. meaning tight compression
around the thigh should applied as soon as
FOR QUADRICEPS MUSCLE PERFORMANCE
testing to guide the RTP process. Although this muscle injury guide possible, and include the knee joint if injury INJURIES
primarily deals with acute muscle strains, is at lower-third of thigh. Usually the athlete At FCB a five-stage approach to the
Other measures of quadriceps strength a brief mention on the management can fully weight bear, but following severe Rehabilitation of quadriceps injuries management of muscle injuries is used
and functional capacity include closed of quadriceps contusions is pertinent contusions crutches may be necessary requires both structure and flexibility (see RTP principles section). Stepwise
chain multi-segment actions, such considering these are not uncommon in initially. based upon both the best available progression of loading will facilitate
as squatting, leg press, and jump footballers. evidence and relevant individual effective tissue healing while restoring
performance. While not isolated to The use of ice, but foremost compression, factors (e.g. player history, physical functional capacity. Focus during the acute
the quadriceps, these exercises place should be maintained in the first 2 days in characteristics). While there are a phase of management (i.e. initial day/s) is
high demand on the anterior thigh and the case of severe contusions. Massage, number of studies investigating the to limit the extent of the initial injury and to
^
provide a good indication of the function INTRA- VERSUS INTERMUSCULAR electrotherapy and stretching should be management of other lower limb provide a strong foundation upon which to Figure 1A:
of the quadriceps during more functional HAEMATOMA avoided. Immobilising the knee in 120° muscle injuries, there is a distinct build the rehabilitation process. Compressive Bandage for Quadriceps Strain
activities. Various jump tests can be used, of knee flexion for the first 24 hours after lack of clinical studies related to
from more static jumps, such as the Any type of external impact can cause a trauma may also be beneficial,33 and ROM quadriceps injuries. There are no Reduction of pain and inhibition are key
counter-movement and drop jumps, to bleeding within a muscle, usually within should be increased gradually with only randomised studies on treatment goals during this phase. Application of
triple & six-meter timed hops. the muscle fascia, with a consequent minimal discomfort. of quadriceps muscle injuries. The the principles of the POLICE,32 acronym
increase in intramuscular pressure. Where management guidelines for quadriceps should be initiated as soon as possible
Several “functional tests” have been bleeding is contained within the fascial Continuously repeated examinations injuries presented here are based following injury just as they are for
described in the literature29. The T-test, sheath, localized swelling remains for can be helpful to distinguish between predominantly on basic science, contusions. Again, the key interventions
pro shuttle and long shuttle drills longer than 48 hours after trauma, and intermuscular and intramuscular bleeding, therapeutic principles extrapolated from include combining cooling and
can be used to evaluate the athlete’s is associated with pain, tenderness and with persistent/increased swelling and studies on other muscle groups and compression (e.g. Game Ready, Figure
performance in tasks requiring quick reduced knee ROM. Quadriceps muscle poor function suggesting an intramuscular clinical expertise. 1B) or use of graduated segmental
^
starts, dynamic direction changes, and activation is also usually significantly haematoma.34 compression (e.g. Normatec, Figure 1C) Figure 1B:
movement efficiency.29,30 Endurance reduced. An intramuscular haematoma, The journey from early rehabilitation can further facilitate reduction of pain and Game Ready
tests, such as the yo-yo intermittent depending on its severity, may take several to team training will often be highly swelling in the affected area. Players are
recovery tests, may also have a role days or weeks to fully recover/heal. individual. To design a Return to allowed to walk as able although it may
in determining functional capacity. play (RTP) programme following a be necessary to use crutches following
Additionally, sprint test over different Bleeding can also occur between muscles, quadriceps muscle injury based strictly severe injuries.
distances, as well as hard decelerations and in this case the blood spreads in the on muscle injury healing phases35 is
should be considered. surrounding structures, so that the local likely not appropriate for all athletes.
pressure does not raise. An intermuscular The athlete’s signs and symptoms,
Additional specific tests that are pertinent haematoma will usually result in bruising the combination of clinical expertise
to quadriceps function include speed and swelling distal from the trauma and evidence-based knowledge
dribbling, short-to-long passing, and location within 24-48 hours. Quadriceps should guide decision-making process
^
shooting, all of which have been muscle activation usually recovers within for exercise progression. Potential Figure 1C:
proposed in the literature,31 but have few days, and the overall healing is complications should be carefully Normatec
never been fully scientifically validated. significantly quicker than in cases with monitored at all times. It is also
intramuscular haematoma. important to differentiate between
contusions and strains of the quadriceps
The first 24 hours following a contusion (as outlined earlier in this section) in
are most important in the treatment of order to determine which RTP strategies
quadriceps contusions, where the POLICE to adopt.
CHAPTER 3 CHAPTER 3
134 It is important to commence controlled of interventions during this phase include Movements during the early strengthening RESTORING GYM-BASED TRAINING 135
active movements as early as possible. dynamic mobility, active tension stretching phase should be carried out in a slow and
A primary goal during this phase of (Figure 2). Focus should be placed on controlled manner. It is recommended that Once able to effectively recruit the
management is to facilitate quadriceps appropriate muscle activation throughout 2-3 sets of 4-6 repetitions of sub-maximal muscle through range it is important
activation. Several strategies may be range whilst maintaining good trunk and contractions (60-70% MVC) are carried out to combine table based activation with
used to enhance movement quality, whole body positioning. It is also advised twice daily. As rehabilitation progresses the more conventional gym based training.
reduce pain and facilitate healing of the that general upper quadrant and aerobic intensity of contraction should be increased Simple exercises such as a seated leg
injured tissue. Pain, muscle activation conditioning is maintained; this can be and the frequency reduced to align with extension (figure. 4) can be useful for a
and ability to walk pain free are useful achieved through the use of elliptical conventional strength training parameters. focus on the vastii muscles, whereas a
benchmarks for progression. It is trainers, stationary cycles, aqua jogging or It is also advised that pain during standing hip flexion and knee extension
important that the goals of the particular an AlterG Treadmill. strengthening is kept to a minimum and using a cable pulley (or elastic) would
rehab session and the individual that any symptoms improve within a given be an appropriate exercise for a focus
exercises used relate to the adaptation session. Where there is persistent inhibition on the rectus femoris (figure 5). These
required (see Figure 1. in section 2.3.1.). of the quadriceps, the use of electrical “isolated” exercises can be continued and
FOCUSED MUSCLE ACTIVATION
muscle stimulation may be beneficial (even progressed throughout the rehabilitation
in terms of strength gains), as it has been period to ensure ongoing improvements
Focused muscle activation can be useful
documented after ACL reconstruction.36 in tissue capacity.
in the early stages. While it is almost
TARGETED TREATMENT
impossible to completely isolate each
Interventions that help to reduce pain individual quadriceps muscle, knee
and enhance movement quality include extension exercises with the hip in a
table-based methods such as manual flexed position will tend to have a higher
therapy and passive mobilisation. Due to focus on the vastii muscles, whereas
the risks associated with the development knee extension exercises with the hip
of myositis ossificans in the quadriceps, it in extension will have a higher focus on
is advised that manual therapy (especially the rectus femoris. The use of manual
massage) is not applied directly to the resistance can help ensure mechanical
injured area during the early stages and that stimulus is provided to the affected area,
any treatments focus on enhancing mobility while the intensity can be modulated in ^
of the surrounding structures. Passive line with symptoms to ensure vulnerable Figure 5:
Cable kicking
modalities should not be seen as standalone structures are not overloaded. Isotonic
interventions but rather as an auxiliary. contractions through range at this stage are
Passive interventions are used primarily to useful to enhance recruitment and provide
^
reduce pain and enhance movement so a mechanical stimulus. It is suggested Figure 2:
that the active strategies more effectively that the quadriceps are challenged at a Dynamic mobility
target the injured tissue, thus enhancing the number of different hip and knee positions. and active tension
stretching
mechanotransductive effect. Multi-planar movements such as lower
limb PNF patterns can be particularly useful
^
During the subacute phase, active as they can reflect kicking positions (See Figure 4:
mobilisation will facilitate both movement Figure 3 for examples). During this phase, it Seated leg
capability and improve tissue healing. is suggested that exercises are carried out extension
Exercises performed during this phase ‘little and often’ and that movements are ^
should be carried out with good form and biased towards lengthening contractions as Figure 3:
Focused Muscle
compensatory strategies avoided. Examples soon as possible Activation
CHAPTER 3 CHAPTER 3
136 Reverse Nordics (figure 6) are a simple Restoration of normal gym-based training Abdominal and trunk strengthening will football circuits. Familiar training drills can will require specific focus on position- 137
and effective way of introducing is important. Players routinely complete a also be important, especially dynamic trunk be introduced and progressed in terms specific skill with greater attention given
eccentric training, these can be range of lower limb strengthening exercises rotation, to facilitate integration of dynamic of complexity and decision making (see to goal kicks and punt kicks. Other core
progressed by altering trunk position that combine eccentric, concentric and rotational movements, such as kicking below) before returning to field sessions skills, such as jumping, diving and shuffling
and increasing hip extension to increase isometric muscle actions. Once there is (e.g. Cable pulley woodchopper, Trunk with the squad. movement, will be of greater importance
the lever arm. Eccentrically biased pain free recruitment of the quadriceps rotation landmine. Strength training during for goalkeepers. Position-specific match
contractions that involved varying through range, it is important to normalise rehabilitation should consider sequential At FC Barcelona, particular emphasis is averages of kicking from a professional
degrees of hip extension and knee gym training as soon as possible, while progressions from slow speeds and higher placed upon incorporating the ball during football league have also been published
flexion are recommended. Bulgarian maintaining an additional eccentric loads through to low load and high speed rehabilitation. Given that quadriceps to help guide session construction.43 Key
split squats, Cable reverse lunges stimulus to facilitate adaptations in muscle and finally to plyometric activities that injuries are more common in the dominant considerations for the progression of
and Russian Belt exercises are useful architecture and prevent recurrence. reflect on-field demands. leg, it may be appropriate for quadriceps kicking are summarised in Table 2.
exercises that load different parts of the Exercises that provide the necessary injuries to delay introduction of the ball due
^
quadriceps and can be biased towards strength and architectural stimulus should to the potential risk associated with kicking. An important consideration, for kicking Figure 8:
eccentric action by adding assistance be included and maintained beyond return BASIC ON-FIELD TRAINING: The ball should be introduced to sessions in and sprinting, is that both iliopsoas and Hip flexion with
during the concentric phase. to sport. These might include general RESTORING RUNNING, KICKING AND a systematic and gradual manner. Different rectus femoris muscles generate hip resistance (cable pulley
or elastics)
quadriceps and glute exercises, such as CHANGE OF DIRECTION types of kick have been shown to involve flexion forces.44 Musculoskeletal modelling
squats, deadlifts and hip thrusts (Figure 7). different levels of quadriceps activation,40 studies have shown how a reduction in
Furthermore, the adductor longus is also
A primary goal during rehabilitation is to meaning that side-foot kicking will place the strength/activation of the iliopsoas
highly involved in hip flexion during
ensure the athlete can return safely to less stress on the quadriceps than an instep muscle may result in rectus femoris
kicking;47 a higher adductor strength may
high injury risk activities, such as sprinting or toe kick. Specific drills that introduce compensation to generate more hip flexion
therefore assist in reducing the load on
and kicking. A strong focus on monitored different types of kick and progress the force.45 This highlights the importance
the rectus femoris during kicking. This
progression of these activities during volume and intensity should be considered. of multi-segmental exercises, involving
can also be done with a simple cable/
rehabilitation is therefore essential. This both the lower limb and the trunk. Focus
elastic exercise,48 or without equipment
may include a focus on running and A number of authors have described on synergistic activation of these muscles,
using the Copenhagen Adductor exercise
sprinting technique, as well as a controlled “interval kicking programs” for football as well as other key muscles involved
(figure 9).49,50
progression of total running load towards players that outline appropriate in sprinting and kicking can be initiated
the expected running and sprinting progressions of kicking type, volume early and progressed independently of the
exposure in training and matches for and intensity following ACL injuries.41,42 progression of the isolated exercises for the
the player. In the early stages running is However, as muscle injuries, have a injured muscle.
commenced on dry sand and progressed to considerably shorter duration, the kicking
linear running on the field. Manipulation of progression will be much faster than Specific exercises for the iliopsoas muscle
^ distance, velocity and volume is then used these recommendations. The type of kick include standing hip flexion with a cable/
Figure 6: to train specific subcomponents of running (side-foot, instep), intensity of kick (passing, elastic46 (figure 8) or eccentric hip flexion
Reverse Nordics
fitness and muscle function. shooting) and the challenge associated using manual resistance.
with kicking (open play, free-kick, goal
Players should be progressively exposed kick) should be introduced gradually and
to acceleration, deceleration and change of relative volume and intensity progressed.
direction to enhance the force absorption Examples of kicking progressions include
capabilities of the quadriceps.37 Attention moving from two touch passing drills to
^
should be given to challenging players in one touch drills. Kicking a dead ball (corner Figure 9:
^ a wide range of positions and activities in kicks, goal kicks, free kicks and penalties) Copenhagen Adductor
Figure 7: order to build greater resilience.38,39 Multi- require greater accuracy and often involve exercise
Gym based
strengthening exercises directional running through the execution higher forces thereby placing greater stress
(squat and hip thrusts). of simple football skills can be included in on the quadriceps muscles. Goalkeepers
CHAPTER 3 CHAPTER 3
KICKING SKILL PROGRESSION COMPLEX FIELD WORKOUT:

RESTORING FOOTBALL-SPECIFIC
Passing Kick Type:
Side-foot FITNESS, SKILLS AND COGNITION
Instep kicking
Distance: As outlined in the general RTP section,
Short on-field Return to Play requires the
Long
introduction and progression of
Velocity:
Low
complex football-specific tasks such
High as dribbling, passing and receiving
Ball Control: a ball, snake runs and training drills.
Receive ball and pass, no constraints 2-touch The use of football specific circuits and
passing
1-touch passing
manipulation of constraints, such as
Passing to stationary target the speed of movement, difficulty of the
Passing to moving target (player) skill, competition and decision-making
Advanced passing drills: become increasingly important during
Running onto ball
Hurdles, cones
the rehabilitation process. Tasks that place
Vary how ball is fed to player: different directions, on greater stress on the quadriceps should be
ground, in the air. identified and progressed as able. Particular
Decision making
attention should be given to managing
Indirect tendon Kick Type: the number of accelerations, decelerations
stretching Side-foot and changes of direction as these activities
Instep kicking
138 place significant stress on the quadriceps.37 139
Distance:
Short
Long It is also important to prepare the player for
Velocity: return to contact situations. Block tackles
Low in particular have the potential to place
High
significant load through the quadriceps
Ball Delivery: and can be introduced during the final
Feed ball from different positions
Increase speed on ball stage of rehab in a controlled manner
Aerial balls – increase distance and provide target by kicking a partially deflated ball that is
Volley following execution of football skills: blocked by the therapist. These can be
Dribbling progressed through the use of harder balls,
Skills circuit
Opponent kicking pads or other objects (e.g. Swiss
Ball). Tackling technique and return to open
Shooting Kick Type: squad sessions should be progressively
Side-foot
Instep kicking introduced to include unpredictable
Knuckle ball challenges associated with the game.
Toe shot
Chipped ball
Movement characteristics (and
Distance:
Short associated quadriceps muscle activity)
Long differ significantly during anticipated
Velocity: and unanticipated movements, such
Low as landing and side-stepping.51,52
High
Importance should therefore be given to
Ball Position:
Moving ball incorporate unanticipated movements
Stationary Ball into rehabilitation. Practical strategies
Scenario: to progress unanticipated movements
Free-kick +/- wall include variation of the speed and timing
Corner
Penalty of signals for players. Similarly, introduction
Goal kicks (if applicable) of competition and opponents can
Challenge: effectively progress unanticipated, open-
Open goal skill aspects of the game. Advanced skills
Fixed target
Goalkeeper and cognitive challenges are introduced
and the focus moves from being injury
(quadriceps) specific in the early stages to
^
Table 2:
activity (football and position) specific as
Kicking rehabilitation progresses.
Progressions
CHAPTER 3 CHAPTER 3

FC BARCELONA
— With Xavi Yanguas, Juanjo Brau, Xavi Linde, Ricard Pruna
Figure 10:
Specific example from
FC Barcelona of the
Return to Play process
from quadriceps injury
v
140 141
THE BARÇA WAY:
The central tendon rectus femoris

injury above is, in our experience,
potentially one of the more serious
muscle injuries in a footballer.
This is especially so, if the injury is
located in the dominant leg.
The introduction of the ball is

brought in at the later stages of
rehabilitation for this injury due
to the potential re-injury risk with
kicking. It is not necessary to bring
it in earlier as this is a skill that the
player will not forget how to do in
a relatively short period of time.
Our approach to a graduated pro-

gram with the ball is to progress
from initial easy passes of the ball
with the inside part of the foot.
This is done by the player with the
physiotherapist or fitness coach
and later introduced with the team,
importantly, avoiding hard shots
at goal. This is progressed until
shots are allowed in a controlled
environment and eventually fully
with the team.
As with all of our RTP process for

muscle injury (and indeed injury in
general), the framework is flexible,
allowing for a faster or slower pro-
gression according to the coping
and adaptation of the player.
CHAPTER 3 CHAPTER 3
SURGERY FOR RECTUS FEMORIS

MUSCLE INJURIES
Rectus femoris muscle injuries are common in sports. Most of these injuries are
strains or direct contusions which are treated by conservative means with good
results.37 There are, however, also more severe rectus femoris injuries which can
result in impaired athletic performance and long rehabilitation times. In these
severe rectus femoris injuries the decision of optimal treatment method is not
always so evident.
— With Lasse Lempainen, Sakari Orava and Janne Sarimo
142 PROXIMAL RUPTURES avulsions in professional soccer 143

players if conservative treatment
Proximal rectus femoris (PRF) ruptures does not yield in good results within
are relatively rare injuries among a few months or if there is significant
top-level athletes. PRF injuries can be retraction of both tendon heads in a
complete avulsions or partial tears, proximal avulsion. The full return to
and some of partial injuries seem have play can be even achieved after 3 to 4
a tendency to progress to recurrent months from the operation.57
injuries.
In the literature the exact location

of the injury is often inadequately MID-SUBSTANCE RECTUS FEMORIS
presented which makes it difficult to RUPTURES
compare different studies. The tear
may be an avulsion of the tendon The clinical entity considering mid-
from bone or a rupture involving substance rectus femoris muscle
the proximal tendinous part. These ruptures is mainly lacking in the
different injuries may vary in their literature. Only few case reports of rectus
natural course. femoris mid-substance rupture repair
has been previously published.58-60 These
Overall it seems that most of the more serious mid-substance ruptures
^
injuries in the proximal insertional area may cause significant functional loss Figure 13
are primarily suitable for conservative in hip flexion and in knee extension Partial quadriceps
treatment and the outcome is mainly strength, poor coordination as well as tendon rupture
(sagittal image).
good even in complete avulsions with cramping pain and may require surgical
some retraction.22 However, sometimes intervention for proper healing. This has ^ ^ ^
the healing does not progress as previously been shown also in these Figure 11 A-B: Figure 11 C-D: Figure 12 A-B:
Specific example from Perioperative photos Recurrent central CONCLUSION
expected and return to play is delayed. earlier mentioned case reports. FC Barcelona of the of complete rectus tendon rupture of the
This can occur in both complete and Return to Play process femoris rupture with rectus femoris at the
from quadriceps injury clear gap between right side (coronal and There are many different types of tears
partial tears. Based on authors´ own experience,
ruptured ends. axial images). that can occur in the rectus femoris
operative treatment for complete mid-
muscle and the quadriceps muscle
Operative treatment of complete PRF substance rectus femoris rupture with
group. The indications for surgery are
rupture has typically a good prognosis clear cap between ruptured muscle
MID-SUBSTANCE RECTUS FEMORIS MID-SUBSTANCE RECTUS FEMORIS somewhat obscure but chronic pain
in professional soccer players. After ends is often beneficial for competitive
RUPTURES RUPTURES and disability that lasts for more than a
suture anchor fixation of PRF rupture athletes (Figure 11 A-D).61 Usually these
few months after a complete or partial
or resection of the proximal tendon athletes were able to return to their
Like in hamstring injuries rectus Complete and also severe partial tear is definitely one of them. Surgery
the athletes seem to return to the former level of sport after an average of 5
femoris injuries involving the central quadriceps tendon ruptures should be might also be considered in complete
same level of competition with high months from the surgery.
tendon seem to have a tendency to operated acutely after injury (Figure 13).62 proximal avulsions with significant
probability.53-57
become chronic injuries. If central retraction or complete tears in which
tendon is totally ruptured operative there is a significant gap between the
Given the mainly good functional
treatment may be the best option tendon ends in the muscular part.
outcome and low complication
in top level athletes especially in
rate, the authors advocate surgical
recurrent injuries (Figure 12 A-B).
treatment in proximal rectus femoris
CHAPTER 3 CHAPTER 3
3.3
IMAGING ESTIMATING RTP TIME than do other adductor muscle

tears based on FC Barcelona data
Ultrasound (US) and magnetic There is wide variation in RTP times and experience. Adductor longus
GROIN MUSCLE INJURY

resonance imaging (MRI) may assist following groin muscle injury.1 In some muscle injuries with a proximal bony
in the clinical diagnosis, both in cases, players may be able to RTP avulsion, or extensive connective
relation to injury location, and extent almost immediately, while other cases tissue damage and a large gap, result
In this section, we build upon the general principles described earlier in the guide, of injury. It should also be noted that can take months. To estimate the RTP in much longer time loss than do
with reference to acute groin muscle injuries, specifically, injuries to the adductor, hip approximately 20% of acute groin time for a specific injury, practitioners proximal MTJ injuries (Table 1). In rare
flexor and abdominal muscle groups. injuries will present with negative need to consider the exact location and cases these injuries may also require
— With Andrea Mosler, Andreas Serner, Joar Harøy, Jonas Werner and Adam Weir findings on imaging (i.e. grade 0).1,3 extent of the tissue damage as well as surgery.5,8
A lack of pain on muscle palpation is player-specific and football-specific
the best finding to predict a negative factors. As discussed earlier in this Other isolated adductor muscle
MRI.3 While MRI is still considered the guide, various risk tolerance modifiers tears are rare,5 and usually result in
gold standard for muscle injuries, and also influence the RTP estimate. a shorter absence from match-play
MRI assessment of acute groin injuries according to FC Barcelona data (often
has shown high intra- and inter-rater only a few days).
reproducibility,4 it appears that the
LOCATION AND EXTENT OF TISSUE
location of injuries may be determined Table 1 shows the expected RTP
DAMAGE
with a similar accuracy through US times for various adductor muscle
examination.1 As mentioned above, acute adductor injury locations and severities, based
injuries usually occur in a single on FC Barcelona clinical experience
144 MAKING AN ACCURATE injury risk, but this has not yet been pubic regions. Palpation should include: Most acute groin muscle injuries are muscle, most often the adductor and injury data collected over 10 145
DIAGNOSIS investigated. Change of direction is
also a frequent injury situation for
along the adductor muscles, along the
hip flexors, the inguinal region, as well
indirect, and direct injuries are rare.
Approximately two thirds of acute
longus muscle.5,7 These adductor
longus injuries can mostly be divided
seasons. These have not yet been
fully validated in scientific studies.
Making an accurate diagnosis is acute groin injuries, but the specific as the pubic symphysis. Substantial adductor muscle injuries involve into three characteristic locations: (a) Note also that these data are only
the cornerstone of effective injury contributing factors are currently bruising may also indicate a more a single muscle from the adductor The proximal insertion, (b) the MTJ intended as a starting point; player-
management and return to play unknown. Hip flexor injuries seem extensive muscle injury. The 0° Squeeze group, while multiple adductor of the proximal tendon, and (c) the specific factors, football-specific
planning. An accurate diagnosis to have a somewhat different injury test (long lever) has the highest muscles are injured simultaneously in MTJ of the distal tendon.5 Generally, factors and risk tolerance modifiers
facilitates an estimation of prognosis, situation pattern. Rectus femoris specificity and positive predictive value the remaining injuries. The adductor adductor longus injuries are more should also be considered when
and in turn, shared decision-making injuries occur primarily during kicking for diagnosing an adductor injury, and longus is the most frequently injured serious5 and lead to longer time-loss estimating RTP time.
regarding injury management. Imaging and sprinting, while the iliopsoas palpation has the highest sensitivity muscle, both in isolation, and in
may be used judiciously at this step, muscles are mostly injured during and negative predictive value.3 combination with other adductor
but you must be clear about what (if change of direction.1 Little is known muscle injuries.5 The adductor
INJURED TISSUES CONNECTIVE TISSUE INVOLVEMENT ESTIMATED RTP TIME
anything) imaging will do to change the about the common mechanisms On initial examination, groin injuries longus is injured in about 9 out of
return to play plan. At FC Barcelona, we of injury for abdominal muscles in that fall under the ‘hip flexor’ category 10 athletes with an adductor muscle Proximal avulsion Bone 8- 10 weeks
work backwards from the anticipated football players. may be difficult to differentiate, injury.1,5 Isolated injuries of the other
Proximal MTJ Large connective tissue affected, gap, wavy 6 weeks
time to return to full match-play. providing a considerable risk of adductor muscles are far less frequent tendon
Understanding biology will help when misdiagnosis.1 The clinical examination (about 10% of adductor injuries).
estimating injury prognosis and planning tests for the hip flexors muscles are Such injuries will usually be located Proximal MTJ Little connective tissue affected 3 weeks
PHYSICAL EXAMINATION
a strategy for appropriate loading generally poor, and cannot accurately in the pectineus, adductor brevis, or
through the return to play continuum. The clinical examination of athletes determine the specific muscle injury obturator externus muscles.5 Due to Proximal MTJ Peritendon Halo 2 weeks
with sudden onset groin pain should location.3 the deeper location of these muscles,
primarily aim to determine if it is the diagnosis of the specific muscle ^
a muscle injury, and distinguish About 10% of patients with acute groin involved in the injury may be difficult Table 1
PROXIMAL RUPTURES Estimated RTP times
specifically which muscles are injured. injuries will complain of some form of using only clinical examination, and
for adductor muscle
As with other muscle injuries, the Since the groin region encompasses abdominal-related groin pain, though imaging may be needed to provide injuries based on
patient’s history, with insight into pain, a large number of different muscles, not necessarily abdominal muscle greater certainty. Although these location and tissues
involved
mechanism of action, and functional a thorough clinical examination is injury.1 Palpation of the distal rectus injuries are often considered to have
impact will provide a great insight essential. As with other muscle injuries, abdominis, the inguinal ring, and a shorter rehabilitation time, good
into the likely pathology. A complete the clinical examination is based inguinal canal is useful to differentiate quality evidence on prognosis is
history should fully investigate the on muscle palpation, stretch, and abdominal muscle injury from other lacking.
onset, location, and severity of pain, resistance tests. These elements can sources of acute abdominal-related
and aim to differentiate between help differentiate between the various groin pain. Additionally, stretch and Imaging is rarely able to locate
chronic, and acute groin injuries. muscle groups in the groin region. resistance testing may cause pain in the abdominal muscle injuries, but when
With adductor injuries in particular, abdominal muscle region.3 found, the injury will likely be seen in
kicking is the most frequent groin Studies have shown that clinical the rectus abdominis in connection
injury situation in football, and the examination on its own can distinguish Consideration should also be given to with a complete proximal adductor
adductor longus the most commonly adductor muscle injury from other other differential diagnoses, including longus avulsion.5,6 There is currently no
injured muscle with this mechanism groin muscle injuries such as hip flexor, sacroiliac joint pathology, spinal/ evidence regarding the involvement of
of injury.1 The adductor longus reaches and abdominal injuries.1,3 Appropriate neural pathology, herniae, and hip-joint the oblique abdominal musculature,
its highest muscle activity and consent should be obtained, and the pathology, and examinations tailored or transversus abdominis, in relation
maximal rate of stretch in the swing patient potentially offered a chaperone accordingly if any of these pathologies to acute groin injuries.
phase of kicking, potentially exposing for medicolegal reasons prior to are suspected.
the muscle to injury risk.2 Ball impact clinical examination due to the need
may also influence muscle load and to palpate the sensitive inguinal and
CHAPTER 3 CHAPTER 3
<
TEST DESCRIPTION Figure 1A-E
Groin muscle tests
SQUEEZE 0° 15 Player lies supine with 0˚ hip flexion and legs using hand-held
abducted to the length of the tester’s forearm. dynamometry
The HHD is placed 5 cm superior to the medial
malleoli.
Other strength tests that may also
Player squeezes their ankles together, against the be considered in the physical
HHD and examiner’s hand, with maximal force,
without lifting the legs or pelvis. examination and RTP planning
The presence of pain in the hip/groin is recorded process include outer-range eccentric
using an 11-point numeric rating scale (NRS) (0-10), hip adduction, oblique sit-up, and
and location recorded. isometric hip flexion at 0°.
SQUEEZE 45°13 Player lies supine with 45˚ hip flexion and feet flat
These strength tests may provide an
on the table insight into isolated muscle function,
Examiner places hand with HHD between the but should then be progressed to
knees. more functional, dynamic and sports-
Player presses knees together, against the HHD and specific tasks including (but not
examiner’s hand, with maximal force, without lifting limited to) hopping, jogging, kicking,
the legs or pelvis.
and multi-directional high-speed
The presence of pain in the hip/groin is recorded
using an 11-point numeric rating scale (NRS) (0-10), running.
and location recorded.
146 PLAYER-SPECIFIC FACTORS GROIN MUSCLE TESTING good to excellent.13,15,17,18 The reported ECCENTRIC HIP Player lies on the side of the tested leg, knee straight 147
error of measurement with these ADDUCTION13 and foot beyond the end of bed. Hip and knee of the
Practitioners should consider a As with other muscle groups, muscle non-tested leg is in 90° flexion with knee resting on
tests means that the interpretation a firm surface to maintain neutral pelvic rotation.
range of intrinsic factors when testing provides a key role in determining
of small changes in strength using Player holds on to the side of the bed with one hand
estimating RTP following adductor injury severity, and also progress along for stabilisation.
a HHD dynamometer should be
muscle injury. Recurrence and/or the RTP continuum. During the initial Examiner lifts the tested leg into full adduction
done with caution.13,15,17 The various
progression to long-standing groin physical examination, testing provides with the HHD placed 5cm proximal to the most
testing positions using HHDs are prominent part of the medial malleolus. The
pain are problematic with groin immediate information on which
demonstrated in Figure 1. player exerts a 3 s isometric maximum voluntary
muscle injuries.9,10 Therefore, players activities the player can perform with contraction against the HHD and a 2 sec break is
who have sustained re-injuries need and without pain. This helps practitioners then performed by the examiner pushing the leg
slowly towards the bed, ensuring not to touch the
longer to recover from the same develop a clinical impression of injury bed.
initial tissue damage.11 Hance, the RTP severity and prognosis. Later, functional Standardised instruction is: “go ahead-push-push-
process should always be conducted tests act as important milestones as push-push-push”, a total of 5secs. Player instructed
thoroughly and carefully before the player progresses along the RTP to push as hard as possible within their comfort
zone and maintain the effort while the break is
returning to match-play following continuum, and help to guide the performed.
groin muscle injury.12 final decision to clear the player for Any pain experienced by the player during testing is
unrestricted match participation. recorded using an 11-point NRS (0-10), with location
also recorded.
FOOTBALL-SPECIFIC FACTORS ECCENTRIC HIP Player lies on the side of the non-tested leg, hip and
ABDUCTION13 knee in 90° flexion and holds on to the side of the
STRENGTH
As the groin muscles are loaded examination bed with one hand for stabilisation.
during rapid direction change, long Assessment of muscle strength is an Examiner lifts tested leg into abduction until level
with body, knee straight and the HHD placed 7cm
inside passing, shooting, and in essential component of the physical proximal of the most prominent part of the lateral
sliding tackles, midfielders and any examination and planning RTP malleolus. The player exerts a 3sec isometric
player who commonly perform these following groin muscle injury. Strength maximum voluntary contraction against the HHD
and a 2sec break is then performed by the examiner
actions, may require longer RTP can be measured subjectively, but pushing the leg slowly towards the bed, ensuring
times.8 Specifically, football players preferably objectively using a hand- not to touch the bed.
who perform with particularly rapid held dynamometer (HHD). Testing Standardised instruction is: “go ahead-push-
movements, repeated high intensity can be performed either unilaterally, push-push-push-push”, a total of 5secs. Player is
instructed to push as hard as possible within their
change of direction runs, and long- or bilaterally as a squeeze test.13,14,15 comfort zone and maintain the effort while the
distance shooting during matches Eccentric adduction strength is break is performed.
may be more prone to adductor usually assessed in side lying using Any pain experienced by the player during testing is
injuries, and these actions should be a hand held dynamometer.13,14 recorded using an 11-point NRS (0-10), with location
also recorded.
considered in planning RTP. Abduction strength testing is also
relevant to assess, and enables ISOMETRIC HIP Player is in the sitting position, with the hip in 90°
the calculation of the adduction/ FLEXION AT 90°17 flexion, and holds onto the sides of the examination
bed with both hands for stabilisation.
abduction strength ratio.13,14 The
The HHD is placed 5 cm proximal to the proximal
measurement of hip flexion strength edge of the patella.
has been described using a HHD and
The examiner applies resistance directly
an isokinetic dynamometer.16,17 The downwards while the player exerts a maximal effort
intra-tester and inter-tester reliability against the HHD and the examiner.
for the assessment of hip adduction, Standardised instruction is ‘‘go ahead-push, push-
abduction and flexion strength push-push and relax’’ (lasting 5secs).
using a HHD have been reported as
CHAPTER 3 CHAPTER 3
148 PLAYER-SPECIFIC FACTORS FUNCTIONAL TESTS 149

TEST DESCRIPTION EXERCISE PRESCRIPTION acute phase of the RTP process. In
contrast, exercises where load can be
SIDE PLANK19 Players are instructed to lift their hips off the bed (or
floor) by supporting their weight through their feet
Muscle endurance is a key consideration
when it comes to returning players to
The validity of functional tests of specific
relevance to groin muscle injuries has
FOR GROIN MUSCLE isolated as much as possible to the
and forearm sport after groin muscle injury and the not yet been established. However, the INJURIES injured muscle may provide optimal
structural adaptation. Additionally,
The head, trunk and legs to be placed in line with following tests could be relevant to following tests have shown reliability
each other isolated exercises can provide an
consider (Figure 2). and could be relevant to include in the Most groin muscle injuries make a
Players are then instructed to hold this position for impression of the load capacity of the
examination and management of acute complete and rapid recovery, yet some
as long as possible. injured muscle, and subsequently
groin injury: can progress to develop long-standing
Standardized encouragement is given at 30-second determine progression of exercises.
intervals throughout the test. PLAYER-SPECIFIC FACTORS symptoms. Therefore, the focus of acute
The time is recorded from the start of the test until • Single leg squat evaluated with the groin muscle injury RTP is to ensure
Deficits in the range of motion of
the player’s hips touches the bed (or floor), at which front plane projection angle (FPPA); complete recovery, prevent recurrence,
point the test ends. certain movements have been found
and avoid long-standing groin pain.
in athletes with current groin pain.22,23 TARGETED TREATMENT
LONG LEVER Lie face-down with fists on the floor, feet shoulder • Star Excursion Balance Test;
The reliability and measurement error
POSTERIOR TILT width apart, and spine and pelvis in a neutral An effective way to prevent inappropriate Isometric activation of the adductor,
PLANK20 position. of assessing hip range of motion
• Single leg hop for distance: loading during the RTP process is to use hip flexor or abdominal muscle may
(ROM) requires consideration when
Elbows are spaced 6 inches apart at nose level. anterior/medial/lateral; clinical milestones to guide progression be commenced very early in the RTP
determining which measurement
The gluteal muscles are contracted as strongly as of specific adductor loading exercises, process with the exercise progressed
possible while attempting to draw the pubic bone method to use.24 Therefore, when ROM
• Triple hop; fitness training, and graded return to in range, resistance and/or speed as
toward the belly button and the tailbone toward the measures are used for the monitoring of
feet (posterior pelvic tilt). football participation. the muscle recovers. This exercise
injury, it is recommended to use as few
Lift the body up on the forearms and toes, keeping • Change of direction tests (t-test, minimises the stability requirements
testers as possible, use a goniometer or
the body as straight as possible. Illinois). of the body, thereby better isolating
inclinometer, take the average of two
Time that the player is able to maintain this position muscle action, and provides easily
tests, and apply consistent methods,
is recorded. As with muscle injuries to the EXERCISES TO OPTIMISE monitored load progression throughout
particularly specifying the criteria for the
COPENHAGEN Players are in the side-lying position with their quadriceps, and especially pertinent TISSUE HEALING AND RESTORE rehabilitation.
end of range. Measurements relevant for
ADDUCTION21 lower forearm supporting their body on the ground, to RTP for the football player, kicking PERFORMANCE
and other arm placed along the body. groin muscle assessment include: bent
capacity should be assessed and Stretching, both active and passive,
knee fall out,13 passive adductor test, and
The upper leg is held higher than the head, either considered during the RTP continuum. As with all muscle injuries, reduction may be appropriate if the player has
on a bed, or at the height of the hip of a partner passive hip extension in the modified
Passing and drills progression25 and of pain, swelling and inhibition are considerable hip range of motion
The player lifts their lower leg and body in a 3-sec Thomas test position, with and without
“interval kicking programs”26 for football key goals for the acute phase of groin deficits or asymmetries. In particular,
concentric hip adduction movement until the body knee flexion.3
reaches a straight line, and the feet touch each players have been described in detail, muscle injury. Application of the restricted hip extension may have
other. and position-specific match averages principles of the POLICE28 acronym importance in groin muscle injury
This is followed by a 3-s eccentric adduction where of kicking from a professional football should be initiated as soon as possible management. However, practitioners
the body is lowered halfway to the ground and the
foot of the lower leg lowered until it just touches the
league have also been published, following injury. During the acute should consider that passive stretching
ground, without pushing on the ground enabling functional parameters to be phase, it is also important to activate of the injured groin muscle is often not
Repeat until fatigue, or loss of ability to maintain a set.27 the affected muscle early to optimise beneficial, and may even aggravate
straight body position the stimulus for regeneration through pain.
Number of repetitions recorded for the test. the process of mechanotransduction.29
Initially, this primarily involves active Prior to initiating resistance exercises,
^ or manual assisted ROM and light simple dynamic flexibility exercises are
Figure 2A-C
Groin muscle tests
resistance exercises performed on the recommended. Leg swings can include
using hand-held treatment table. Passive treatment hip adduction and abduction in the
dynamometry modalities provide little value and are frontal plane, hip flexion and extension
not normally needed beyond the initial in the sagittal plane, and combined
CHAPTER 3 CHAPTER 3
A B
C D
150 diagonal swings. These movements < RESTORING GYM-BASED ACTIVITIES 151
Figure 3 E F
will safely improve range of motion Supine eccentric hip During the transition to more advanced
from an early stage in the RTP process adduction against
gym-based exercises, the strategies
and increase the player’s confidence in manual resistance
discussed above can still be relevant.
movement. Speed and range of motion
However, ideally there should be a gradual
should be progressed according to the
phasing out of the low intensity exercises,
player’s symptoms and confidence.
in favour of more intense strength and
functional exercises, eventually progressing
Increasing the capacity of the groin
to field-based activities.
muscles to tolerate rapid loading at a
lengthened state is a key element to G H
In addition to specifically strengthening
include in the RTP process. Ensuring < the injured muscle, a strong focus is
that loading occurs through full range Figure 4
Concentric and recommended on optimising the function
is therefore important. Improving the eccentric adduction of the synergist muscles involved in the
ability of the muscle-tendon-unit to against the resistance
injury movement(s). Groin muscle injuries
tolerate load at a lengthened state may of an elastic band or
cable pulley are reported to occur mainly during kicking
be achieved with eccentric training,
and change of direction actions,1 which
which can often be incorporated early
are categorised as open and closed chain
in the RTP process, depending on player
movements respectively. Therefore, when
symptoms. There are many exercises
progressing through the RTP process, and in
for the groin muscles that incorporate
particular when transitioning into the gym
an eccentric contraction, however, few
and advancing resistance exercises, a focus
are able to induce an eccentric overload, I J K
< on both posterior and anterior kinetic chain
which is likely to increase the required Figure 5 muscle groups should be included in the
adaptation. Manual resistance exercises Hip extension with
isometric adduction rehabilitation of groin muscle injuries.
(e.g. figure 3) are therefore a good option
using a fit ball
for table treatment before progressing
Some examples of more advanced exercises
to more gym based exercises (figures 4
that may be used to optimise synergistic
and 5). Other options for early eccentric
muscle function, and restore function of the
training are also pictured below, and
injured muscle are shown below (figures
these exercises can be gradually
6A to 6).
progressed by increasing range, speed
and adding resistance. Should the player
have a fear of early movement, simple L M N
ball squeezes between the knees may
be used to activate the adductors very >
Figure 6A. Hip abduction at 90º flexion, and figure
early in the RTP plan, and will provide 6B “doggie” exercises. Figure 6C. Hip extension
a foundation for further progression. in 4-point kneeling and figure 6D “superman”
However, it is recommended to progress exercise. Figure 6E. Straight and 6F oblique sit-ups
with high concentric and eccentric load. Figure
these exercises to train with the muscle 6G. Front and 6H side plank exercises. Figure 6I.
at length as early as possible. Hip flexion and figure 6J bridge exercises. Figure
6K. Abduction side-step with an elastic band
and figure 6L abduction on a bosu. Figure 6M.
Reverse Nordic exercise. Figure 6N. Copenhagen
adduction exercise
CHAPTER 3 CHAPTER 3
Figure 8A.
Straight running
(run out, walk back).
Figure 8B.
Progression of straight
line to advancing
zig-zag / change of
direction runs.
Figure 8C.
Agility drills with
potential for reactive
situations.
v
152 General body strengthening, coordination and neuromuscular retraining are important progressions to BASIC ON-FIELD TRAINING: COMPLEX FIELD WORKOUT: 153
include as the player progresses through the gym based return to play phase before entering back into RESTORING RUNNING, KICKING AND RESTORING FOOTBALL-SPECIFIC A
basic field based workouts. Some examples of exercises that could be used to achieve these aims are CHANGE OF DIRECTION FITNESS, SKILLS AND COGNITION
shown below (Figure 7).
For returning to full kicking capacity, A football can be incorporated with
a general focus should be aimed at the various exercises outlined above
<
Figure 7 the adductor, hip flexor, trunk, and at almost all levels. In this phase it
Functional gym knee extensor muscles. This can be is essential that these exercises are
exercises achieved using cable exercises with a progressed further to prepare the player
focus on each of these muscle groups. to return to the team and eventually
Additionally, the tension arc exercise match-play. A controlled kicking
will focus on the anterior chain, with progression program is advised, with a
B
considerable stability requirements focus on increasing both velocity and
depending on the resistance and volume of kicks, to ensure the player
speed of movement. Other exercises of is ready for the kicking demands of
relevance to include in the gym program training and match play. In general,
are: squats/leg press, hip thrusts, seated short passes and technical ball
and standing calf raises, and unilateral skills can be introduced relatively
push-off exercises. Exercises focusing early in the RTP process, followed
on the posterior chain muscles can often by the introduction, and controlled
be performed with high load and very progression, of longer passes and
early following injury, whereas exercises shots. These can occur when the player
C
focusing on anterior chain muscles will can demonstrate adequate control,
often be affected by pain from the injured and their pain has resolved. Close
groin muscle, and load should therefore monitoring from the medical and
be progressed as symptoms dictate. performance team is therefore required.
A progressive running program should The aim of the final phase of the RTP
be commenced as soon as symptoms process is to train the player to return to
permit. Slow linear running can often their required level of play with a minimal
be performed very early following acute risk of re-injury. Therefore, it is important
groin injury, and can be progressed in to focus on training and testing all unanticipated actions, in addition to
intensity and volume relatively quickly. potentially injurious actions, in addition pre-planned actions, are essential in
Similarly, side-stepping with small steps to training the player to cope with his/ the RTP process, not only from the
is often possible early after injury. This her usual and worst-case scenario loads perspective of minimising re-injury
can be progressed to larger steps and of playing football. Many groin muscle risk but also for ensuring optimal
zig-zag running with increasing speeds, injury movements are influenced by performance (see section 2.3.2 for more
and be followed by faster change of the close presence of an opponent detailed information). For timed change
direction drills and reactive agility causing a rapid decision-making process of direction and agility drills, tests such as
exercises. See figures 8A to 8C for an influencing player movements, resulting the T-test and the Illinois Agility Test have
example of some of these types of drills. in injury risk. Therefore, training reactive/ shown good reliability.
CHAPTER 3 CHAPTER 3

FC BARCELONA
— Xavi Yanguas, Juanjo Brau, Xavi Linde, Ricard Pruna
Figure 9:
An overview of
RTP from an acute
adductor muscle
injury at FC Barcelona
v
154 155
THE BARÇA WAY:
Adductor injuries located

proximally in the miotendinosous
junction as detailed above in
figure X, are more disabling than
those located distally,.
In our experience, with this type

of injury, straight-line running is
usually possible a few days after
the injury and only sideways
movements should be restricted.
We believe that it is important
to stretch the structure (pain-
permitting) in order to minimise
the possible formation of scar
tissue. We have seen that
adductor injuries where this has
not been achieved could increase
the risk of ongoing groin pain.
As with all of our specific

examples, we estimate the time
to RTP and work backwards from
the anticipated return date to
plan the program, however, it
is important to remember that
this is flexible and can and will
be adjusted according to the
progression of each player.
CHAPTER 3 CHAPTER 3
3.4
A similar approach can be used for

gastrocnemius lateralis, noting that the
orientation of fibres are different to that
CALF MUSCLE INJURY

of the medialis as they course to the
triceps surae MTJ.3 Soleus palpation
commences approximately one-third
In this section, we build upon the general principles described earlier in the guide, the distance down the tibia, however
with specific reference to calf muscle injuries. palpation of the proximal aspects of
— With Tania Pizzari, Brady Green, Karin Silbernagel, and Anthony Schache the soleus is often difficult and cannot
reliably differentiate between muscles
injured. As palpation continues down
the leg, the soleus becomes more
accessible in the middle third of the
lower leg, particularly from the medial
side. It continues further inferiorly than
gastrocnemius prior to terminating into
the central, medial and lateral aspects
of the Achilles tendon.1
156 MAKING AN ACCURATE positions, along with positions involving assessment, noting the consistency of IMAGING INJURED TISSUES CONNECTIVE TISSUE INVOLVEMENT ESTIMATED RTP TIME 157
DIAGNOSIS knee flexion and ankle dorsiflexion.
Therefore, practitioners should be
pain location or the manner in which
it changes.1 Clinical tests (palpation, Magnetic resonance imaging (MRI) is Soleus myofascial Little connective tissue involvement 2-3 weeks
Making an accurate diagnosis is cautious when interpreting injury strength, stretch) should be performed the most useful modality to identify Soleus injury with central Large connective tissue involvement 6 weeks
the cornerstone of effective injury mechanism information and should systematically in both knee extension the exact injury location, potential intramuscular tendon
management and return to play never make a diagnosis based on the and knee flexion.1 Pain reproduction prognostic indicators, and individual involvement
planning. An accurate diagnosis mechanism alone. on resisted calf contraction and anatomical factors.4-6-10 Ultrasound can Soleus injury with Large connective tissue involvement 4 weeks
facilitates an estimation of prognosis, applied stretch can change with the be useful for medial gastrocnemius lateral intramuscular
and in turn, shared decision-making Players with gradual-onset calf pain (i.e. test position.1 If there is a greater level ruptures at the distal muscle-tendon aponeurosis involvement
regarding injury management is planned. calf injuries without a clear mechanism of pain and loss of strength with the junction. However, ultrasound lacks Soleus injury with Large connective tissue involvement 5 weeks
Imaging may be used judiciously at this or inciting event) typically report a knee extended compared to with sensitivity for detecting soleus muscle medial intramuscular
step, but you must be clear about what sense of tightening and subsequent the knee flexed, it typically indicates injury.10 This may explain why research aponeurosis involvement
(if anything) imaging will do to change loss of function that progresses over the gastrocnemius involvement.1-3 studies conducted prior to widespread Gastrocnemius Little connective tissue involvement 2 weeks
the return to play plan. At FC Barcelona, course of a match or training session. In When findings are similar in both use of musculoskeletal MRI report myofascial injury
we work backwards from the anticipated some cases, these symptoms may not positions, or worse with the knee lower rates of soleus injuries.
Medial gastrocnemius Large connective tissue involvement 7 weeks
time to return to full match-play. be apparent for several hours, or even flexed, it typically indicates soleus injury including partial
Understanding biology will help when days, and subsequent investigations involvement.1 Note that calf muscle rupture of the distal MTJ
estimating injury prognosis and planning confirm the presence of an acute muscle injuries can involve more than one (tennis leg)
a strategy for appropriate loading injury. In our experience, gradual-onset muscle, which often confuses the
through the return to play continuum presentations most often involve soleus.
The diagnosis may be aided by other
clinical picture during the physical
examination.1
ESTIMATING RTP TIME ^
Table 1:
factors including recent loading history, There is a wide variation in RTP times aponeurotic portions of the soleus.4-7-8 Estimated RTP times
calf muscle and other injury history and During inspection and palpation, the following calf muscle injury.11 In some Central intramuscular tendon tears for calf muscle injuries
based on FC Barcelona
PATIENT HISTORY player age.1-4 Practitioners should also presence and location of bruising, cases, players may be able to return are generally considered to be the data and clinical
consider differential diagnoses when swelling, soreness and solid masses almost immediately. However, it can most serious.4-6 However, as discussed experience. Note
that these are initial
The patient history provides valuable assessing gradual-onset calf pain, such should be identified.1 In severe also take months. To estimate the RTP below, lateral aponeurosis tears can estimations only,
information towards making an accurate as neurological or medical causes of pain injuries, there may be a palpable time for a specific injury, practitioners be similarly serious in certain players. that do not consider
diagnosis.1-3 Descriptions of symptoms, (e.g. thrombophlebitis).1-3-5 tissue defect.1-3 Substantial bruising need to consider the exact location and player-specific factors,
football-specific
such as the pain intensity the extent of may indicate a larger muscle injury. extent of the tissue damage as well as Table 1 shows the expected RTP times factors, or risk
loss of function, provide an immediate However, bruising is naturally more player-specific and football-specific for various calf muscle injury locations tolerance modifiers
impression of the injury severity and pronounced in gastrocnemius factors. As discussed earlier in this and severities, based on FC Barcelona
prognosis.1 The injury mechanism has PATIENT HISTORY injuries than it is in soleus injuries, as guide, various risk tolerance modifiers clinical experience and injury data
previously been used as an indication gastrocnemius is more superficial.1-3 also influence the RTP estimate. collected over 10 seasons. They
of which muscle is affected, with Physical examination of calf muscle have not yet been fully validated in
gastrocnemius traditionally thought injures involves palpation, strength Palpation begins superficially and scientific studies. Note also that these
to be strained during high force or testing, applied stretch and a proximally with the gastrocnemius. data are only intended as a starting
high velocity actions.3 This is because functional testing battery (Figure Gastrocnemius medialis can be LOCATION AND EXTENT OF TISSUE point; player-specific factors, football-
gastrocnemius injuries are thought to 1).1-3 The practitioner should develop palpated from the posteromedial DAMAGE specific factors and risk tolerance
typically occur in positions combining an immediate impression of injury aspect of the knee and the course of modifiers should also be considered
knee extension and ankle dorsiflexion, severity.3 Early information from the fibres can be followed inferiorly, Generally, soleus injuries result when estimating RTP time.
resulting in eccentric overload or the physical assessment should eventually combining with the in greater time loss than do
attempted reversal of the stretch- also direct attention during further superficial central aponeurosis and gastrocnemius injuries, especially
shortening cycle.1-3 However, soleus testing.1-5 The location of pain should termination into the triceps surae when there is disruption of the central,
injuries can also occur in the same be established at rest and during the musculotendinous junction (MTJ).1 medial or lateral intramuscular tendo-
CHAPTER 3 CHAPTER 3
158 PLAYER-SPECIFIC FACTORS CALF MUSCLE TESTING A carefully-planned, progressive loading 159
programme is essential to optimise the
Practitioners should consider a range Functional testing plays an important role quality of healing tissues and to prevent
of intrinsic factors when estimating RTP throughout the entire RTP process. During injury recurrences.1-2 The programme
following calf muscle injury. In particular, the initial physical examination, testing should include fundamental therapeutic
players who have sustained re-injuries, provides immediate information on which exercises (sometimes referred to as
as well as older players (i.e. those over activities the player can perform with mechanotherapy)15 and strategies to
30 years) need longer to recover from the and without pain. This helps practitioners restore football-specific function. As
same initial damage. develop a clinical impression of injury previously discussed, maintaining
severity and prognosis.1 Later, functional football-specific cognitive skills is vital
Players with a genu varum (bow- tests act as important milestones as throughout the entire RTP process.
legged) anatomy, which is common the player progresses along the RTP Importantly, these three areas are non-
among footballers,12-14 often have more continuum, and help to guide the hierarchical; there should be gradual
developed lateral soleus muscles final decision to clear the player for progression in all areas and milestones
and a thicker lateral intramuscular unrestricted match participation. should be determined for each area as
aponeurosis. This can often been seen the player progresses through the RTP
on careful inspection of MRI images. The functional capacity of the calf muscles continuum.16
In these players, injuries involving the should be testing using a battery of
lateral aponeurosis are comparable to functional tests with increasing difficulty,
those involving the central intramuscular until the player’s symptoms prevent
tendon in players with a normal further testing (Figure 1). Assessment
anatomical alignment (Table 1). should begin by examining isolated,
stationary activities in weight-bearing
positions, such as calf raises,3 then
progress to more dynamic lower limb
FOOTBALL-SPECIFIC FACTORS actions such as walking, running,
jumping and hopping (Figure 1). Finally, if
As the calf muscles are highly stressed symptoms allow, high-demand actions
during rapid direction changes, central should be tested, such as maximal
midfielders and other players who sprinting, changing direction and
commonly change directions need accelerating from stationary positions.5
longer RTP times following injury. This Practitioners should not only assess
includes goalkeepers, who also expose the player’s pain, but also their ability
their calf muscles to particularly high to perform high quality movements
loads during multi-directional explosive repeatedly, as well as their ability to
movements. generate fast movement.1-5
CHAPTER 3 CHAPTER 3
160 EXERCISE PRESCRIPTION Early exercises can be progressed by and soleus.20 It is important to note Once the player has regained maximal to carry-out the specialised stretch- 161
FOR HAMSTRING adding weight-bearing plantarflexion,
such as standing calf raises, and light
that the seated calf machine still brings
about significant positive adaptations in
calf strength (e.g. compared to pre-
injury tests and/or the non-injured
shortening cycle actions in dynamic
functions.33-35 Stretching prescriptions
INJURIES resistance training.3 Training position the gastrocnemius, despite traditionally side), the player should gradually should include active lengthening of the
during calf raises will alter the degree being considered to be preferential begin performing exercises involving local tissues while in knee extension and
Traditionally, practitioners have of activity in synergistic muscles.19 For to soleus.21 Regardless, isolated calf explosive stretch-shortening cycle knee flexion, along with global drills that
prescribed calf muscle loading exercises example, flexor digitorum longus (FDL) strengthening is important because actions. This induces adaptations to apply a tensile force to the tissues in-
in positions of knee extension to target shows more activity during heel raises it stimulates structural adaptations in tissue length (fascicle length), type II series with the calf muscles, such as the
the gastrocnemius, and knee flexion in adducted foot positions compared the calf muscles that may be protective muscle fibre hypertrophy, maximal hamstrings and plantar fascia.3
to target the soleus. However, this is a to ‘normal’ and abducted positions, against re-injury and that underpin strength and contractile velocity more
misconception; both the gastrocnemius while tibialis posterior shows consistent high-level calf function: local muscle effectively than conventional resistance The rehabilitation programme should
and the soleus muscles contribute contractile activity in all three foot activation, hypertrophy, muscle-tendon training alone.24-26-27 Adaptations from include running as early as possible.3 In
to plantar flexion force generation, positions.19 Early muscle activation junction integrity and musculotendinous strengthening exercises prepare the the early phases, strategies to minimise
irrespective of the knee angle.17-18 exercises are progressed to begin unit stiffness.21-23-25 Progression of load entire triceps surae for advanced, ground reaction force may be necessary,
Therefore, practitioners should vary the regaining strength endurance and during general calf muscle rehabilitation power-based plyometric exercises such as running on an Alter-G treadmill
loading positions based on football- hypertrophy of the calf muscles.3 This is also needed to begin gradually and running-based stresses that are (figure 3) or in water. Alternatively, elliptical
specific functional demands. involves progressing the time under exposing the tissue to greater stresses encountered during ongoing field-based fitness machines can be a low-impact
tension, relative intensity, and overall throughout the stretch-shortening cycle, rehabilitation.24-27-28 In addition, retraining alternative to running in the early phases
volume of loading. In practice, exercises including the eccentric phase, which is of multi-joint, compound movements of rehabilitation. Once the player has
targeting gastrocnemius may involve implicated in muscle injury.5 should always occur in conjunction with achieved pain-free walking and is
a lower number of repetitions, or time training of local calf muscle function.3 tolerating eccentric loading, over ground
EXERCISES TO OPTIMISE
under tension, due to the fatigability of Compound exercises are useful to retrain running may be trialled.
TISSUE HEALING AND RESTORE
this predominantly fast-twitch muscle.18 the abilities of force application and
PERFORMANCE
load absorption in positions that mimic
During the early rehabilitation phase, High load resistance training is function, in order to achieve successful
players should perform low-load, introduced following achievement of transfer of gym-based rehabilitation
non-weight-bearing muscle activation an acceptable baseline of calf muscle to the pitch.22 Throughout general calf
exercises.1-3 This involves training with activation and strength-endurance (e.g.. strengthening the isometric capacity
no external resistance, or against light 25 high quality, single leg calf raises).1 (‘position-dependent strength’) of the
resistance (e.g. an elastic band). In this During this stage, resistance exercises are musculotendinous unit should also be
phase, gentle isometric and isotonic prescribed with a higher relative intensity developed in conjunction with isotonic
contractions can be performed in supine and a lower number of repetitions and dynamic calf training.23-25 Retraining
and seated positions.1 The position of than earlier exercises.3 Isolated calf isometric capacity in various positions1
the athlete, the degree of knee flexion, strengthening exercises utilise machine- is one method to ensure the force-
and the position of the foot should be based resistance to apply external load generating capacity has been developed
varied.1 Also, attention should be paid to the musculotendinous unit,20-21 and are across the spectrum of contractile modes
to intrinsic foot musculature and ankle performed in knee extension and knee and joint positions,25 including the joint
plantarflexors that are functionally flexion.1-2 Standing calf raises and seated positions considered to be injurious.1-2
interdependent of the calf muscles calf raise machines are commonly used ^
(flexor digitorum longus, flexor hallucis (figures 2A and 2B).20-22 These are effective Figure 1: General calf rehabilitation also includes
Standing calf raise
longus, tibialis posterior, and peroneus for developing the maximal force stretching and mobility practices.3 These
Figure 2: ^
longus).19 generating capacity of gastrocnemius Seated calf raise interventions are one method of ensuring Figure 3:
the injured triceps surae regains the Alter-G treadmill
compliance29-30 and length31-32 required
CHAPTER 3 CHAPTER 3
162 Once running ability has begun to consider the characteristics of the calf considered in the context of running- RESTORING FOOTBALL-SPECIFIC 163
progress, slow jogging prescriptions injury, including clinical indicators based training that is being completed FITNESS, SKILLS AND COGNITION
that are of an excessive volume should of injury severity and structures concurrently. The stresses encountered
be avoided.36-38 The calf muscles involved.4-6-8 Running prescriptions during the stretch-shortening cycle of Progressive reintroduction to skill-
have a high degree of muscle work should also take into account the recent plyometric muscle actions acutely affect based training is fundamental to player
throughout stance for stability and and long-term training history of the the capacity of the triceps surae and outcomes following calf muscle strain
propulsion even during slow running, athlete to ensure the prescribed volumes therefore have the potential to re-injure injury. A planned sequence of skill
and receive less contribution to work and intensities of running do not or exacerbate if not diligently planned. training should be outlined with the
from elastic recoil than occurs during compromise subsequent injury risk, or flexibility to be altered according to the
faster running, particularly in the case risk of re-injury.32-52-53 Bilateral plyometric exercises are ongoing clinical presentation. Early in
of soleus.39-42 Furthermore, despite generally commenced first (Figure 4) rehabilitation players can safely perform
the velocity remaining relatively slow, Retraining plyometric capacity is before moving onto unilateral exercises stationary passing drills and then
slower running results in longer ground a foundation of calf rehabilitation (Figure 5). Initial plyometric drills are progress to straight line running drills
contact times and peak forefoot loading following injury.5-35 Plyometric exercises also more concentrically-biased, and with dribbling and passing of the ball.
remains high, which creates large work develop athletic attributes underpinned are usually performed over a more
demands and time under tension for the by calf function; including starting limited range of motion to shield the Later in rehabilitation, ball drills that
triceps surae.37-38 Therefore once running acceleration, running velocity, change recovering muscles from attempting include change of direction and a
capacity begins to progress it is not of direction ability and jumping to store and release strain energy response to an opponent or external
necessary to overload the calf muscles performance. These attributes are beyond its current capacity.3 The relative cue can be incorporated. Following this,
with slow running prescriptions,36 correlated positively with a number intensity of plyometric exercises should the player can commence controlled,
particularly in cases of calf muscle of attributes of the triceps surae, such always be planned for, monitored lower level, skill drills with teammates
injuries that are hypothesized to be as both general and high-velocity intra-session and later progressed before participating in small-sided
related to the overall running workload strength, activation, musculotendinous appropriately. When prescribing games (e.g. 4 against 4 on a small pitch),
performed prior to injury.1 unit stiffness and neuromuscular plyometric exercises clinicians should and other uncontrolled training drills.
coordination.35-54-57 One key to successful take into account the requirement of At end-stage rehabilitation, the player
Progressive exposure to high-speed rehabilitation is to restore the capacity forces to be absorbed (eccentric phase), should be participating in full training
running and sprinting is necessary for of the triceps surae to tolerate repeated, summated (amortization phase) and and have satisfactorily restored complete
rehabilitation to progress. Progression rapid ground contacts and the force then utilized to generate positive work skill-based and running workloads that
of speed (or ‘running intensity’) should profiles, in both application and (concentric phase); along with the are comparative not only to the main
also occur during exercise and football- absorption,39-58-59 exposed to the lower relative movement velocity. In practice, training group60 but most importantly,
specific drills retraining change of leg during function. variables are not always progressed at to what that player is used to doing and
direction, multi-directional running, the same time due to the high stresses his/her worst case scenario. Internal load
accelerations, decelerations and reactive Plyometric exercises require sensible encountered by the triceps surae. should be monitored alongside external
agility.33-43-45 Running at greater speeds progression and integration into There should also be time afforded for (e.g. GPS) loads along with psychological
and in different conditions is required the rehabilitation plan. Plyometrics restoring plyometric endurance, as the readiness to return i.e. information from
to match the load requirements of are typically integrated later in the triceps surae will be required to function multiple but useful markers61 (refer back
the sport, and to best prepare for the rehabilitation once the athlete has in this way for extended durations once ^ to section 2.3.2.). Remembering also that
demands of competition.36-46 Sprint developed satisfactory activation, returning to play; and the calf muscles Figure 4: the local response of the triceps surae
Bilateral jumping
training is also useful for developing strength-endurance and maximal have been shown to be significantly should be monitored in conjunction
Figure 5:
calf force and power attributes, calf muscle strength. The frequency, more likely to be injured in the final Unilateral hopping/ with general quantification of training
musculotendinous unit stiffness and volume and difficulty of plyometric drills minutes of soccer match play.11 jumping workloads, utilizing tests of functional
fascicle lengths.47-51 The timeline for are each respective areas to consider capacity (Figure 1).
progressing parameters of both running when prescribing these exercises.24-54
speed and volume should however Plyometric prescriptions should also be
CHAPTER 3 CHAPTER 3

FC BARCELONA
— Xavi Yanguas, Juanjo Brau, Xavi Linde, Ricard Pruna
Figure 6:
An overview of RTP
from a calf muscle
injury at FC Barcelona
v
164 165
THE BARÇA WAY:
Following an accurate diagnosis

of the calf muscle injury, we work
back from the estimated RTP
date. For example in the case in
figure 11, we estimate the RTP at
17 days. We subsequently work
backwards from this to determine
the key milestones and exercise
progressions to achieve this date.
You will notice that, the order of

progression is not to finish one
step in order to start the next, we
gradually overlap the progressions
i.e. as one phase is coming to
an end, we introduce the next.
For example, in the above case,
running in dry sand can occur
simultaneously to introducing
running in the field which in turn
can be overlapped with integration
of football specific running circuits.
As with all of our case examples

(e.g. hamstring, quadriceps and
adductor muscles), the framework
is flexible, meaning that if a
player is progressing faster than
estimated, we can advance the
exercises also. Likewise, if his/
her progression is slow, then we
prolong if needed.
CHAPTER 3 CHAPTER 3
SURGERY FOR CALF MUSCLE of treatment alone. In the elite athlete,

these results make a compelling case
or an injury involving more than
half of the muscle belly is torn, and
Surgical treatment options of recalcitrant
Achilles tendinopathy generally aim
INJURIES
in favor of surgical intervention. In a the aforementioned compartment to remove pathological tissue and
11-year follow-up UEFA Champions syndrome.93-94-97-98 However, stimulate a healing response.100-103-105
League injury study, all total Achilles for calf muscle injuries, if no or Augmentation or reconstruction may be
The vast majority of calf muscle injuries can be successfully managed tendon ruptures were treated insufficient progress is made despite performed when a large portion of the
conservatively. In some cases, however, surgical intervention is warranted. Given surgically.89 prolonged treatment (duration>4-6 Achilles tendon is resected.103
the high pressure on players and medical and performance staff to return to the months), surgical treatment may
pre-injury level as fast as possible, it is paramount to recognize these cases as There are several surgical options. be considered.94-99 There are a With regard to prognosis, in the series
early as possible. Failure to do so could potentially result in suboptimal outcome, Repair can be performed open or few studies outlining the surgical by Paavola et al. 67% returned to full
persistence or worsening of dysfunction and complaints, or recurrent injury. percutaneous, by means of end-to-end treatment of injuries within the calf physical activity after 7 months, and
In this section, we review the specific injuries for which surgical intervention suturing techniques or an augmented muscle complex. Järvinen et al. have 83% were either asymptomatic or had
should be considered, surgical technique, and prognosis. repair. An open procedure allows advocated the following general mild pain during strenuous activities.105
— Özgür Kilic, Anne van der Made and Gino Kerkhoffs for the best control of tendon length principles: removal of hematoma Similar to Achilles tendon rupture, the
and has the has the advantage that it and necrotic tissue, deliberation of post-operative rehabilitation program is
allows for early tension on the repaired adhesions and reattachment if the likely to be an important determinant for
tendon. However, this approach injury is near the musculotendinous clinical outcome.100
is more prone to complications junction (MTJ).94 A recent case report
such as (minor) wound problems.85 showed good clinical results after
Percutaneous repair was found to surgical treatment of injuries near
effectively reduce the number of the MTJ.99 The surgery included
wound complications.85 However, this reattachment of the muscle fibers
166 COMPARTMENT SYNDROME ACS have been reported.64-67-72 ACHILLES TENDON RUPTURE 167
may be at the cost of inferior repair using sutures with the foot positioned
strength, and thereby higher risk of in plantar flexion.99 They also mention
The lower leg is divided into several Another syndrome that could cause CECS While Achilles tendon rupture is
rerupture, when compared to open that any scar tissue (especially in
compartments: anterior, lateral, deep is popliteal artery entrapment syndrome commonly known as an injury that
surgery.85 chronic injuries) should be excised
posterior and superficial posterior. A (PAES), which can also be treated plagues middle-aged individuals,
first.99 Post-operative treatment
compartment syndrome is caused by surgically.73 Approximately 80% of the young football players may also
In case of chronic Achilles tendon included immobilization of the patient
increased interstitial pressure within such patients were able to resume sport at pre- be affected.85 Since early reports of
ruptures, surgical repair involves for 3 weeks in a long leg cast with the
a compartment and consequently results injury level after PAES surgery.73 surgical intervention in the 1920s that
debridement until viable tendon knee flexed 60° and the ankle plantar
in compromised tissue perfusion and made surgical repair increasingly
tissue remains, often followed by flexed 20°-30° and an additional 3
compression of neurovascular structures.61-62 Finally, a rare cause of compartment popular, several techniques for surgical
a lengthening procedure (e.g. V-Y, weeks in a below knee cast, with
Compartment syndrome can be acute or syndrome is the presence of accessory repair have been developed. Fifty years
rotational flaps, tendon augmentation, the ankle plantar flexed, followed
chronic. muscles, such as an accessory soleus later, it became clear that conservative
tendon transfer) to achieve adequate by range of motion and progressive
muscle.74-79 Fasciotomy, tendon release, management by means of casting
length for reapproximation.90 Post- weight bearing exercises after removal
Acute compartment syndrome (ACS) accessory muscle debulking and excision techniques could also yield acceptable
operatively, early mobilization is of the cast.99
is a surgical emergency which can have been successful treatments for the results. However, there is no consensus
advised as it results in quicker
be devastating for the lower leg (e.g. symptomatic accessory soleus muscle.77-79 on which treatment is superior and
return to sports/work and improved
amputation in a worst case scenario) and it preferable.85-86 In this guide, we will
functional outcome, without increasing
is therefore of extreme importance that it is Treatment for ACS (and CECS if conservative mainly focus on acute ruptures.
the risk of a rerupture.85-87-88-91 Although ACHILLES TENDINOPATHY
recognized timely.63 treatment fails) is a surgical fasciotomy
there is a lot of variation between
to decrease intra-compartmental The primary treatment goal is to
studies, the average return to play rate The initial treatment for Achilles
The characteristic presentation of ACS is pressure.61-63-67-80 Conservative treatment for restore function, yet the possibility
is approximately 80%, at a mean 6 tendinopathy is a conservative and
commonly summarized using ‘the 6 P’s’: CECS (e.g. non-steroidal anti-inflammatory of a re-rupture is often mentioned as
months.92 multifactorial approach that includes
pain, pulselessness, pallor, paresthesia, drugs, physiotherapy, podiatry or massage) a rationale to opt for surgery. While
exercise (e.g. eccentric or heavy slow
paralysis and poikilothermia. Most often, has shown to be ineffective in most earlier research noted differences
resistance training, identification and
it occurs secondary to a trauma such as studies, despite reports of success in some in re-rupture rate between surgical
correction of etiological factors, and
tibial fracture.63 ACS following a direct blow studies.62-65-67-81-82 and conservative treatment in favor
MUSCULOTENDINOUS AND symptomatic therapies.100-101 While these
or fracture is usually suspected and thus of surgical intervention, more recent
INTRAMUSCULAR TENDON INJURY strategies are effective in the majority
timely recognized. Although rare, muscle Surgical techniques for fasciotomy vary. A systematic reviews found lower
of cases, a subset of patients will fail
rupture, exercise and chronic exertional long single incision made from the head of overall re-injury rates that were not
Primary treatment for to achieve a satisfactory result with
compartment syndrome (CECS) have been the fibula to the lateral malleolus is referred significantly different between both
musculotendinous and intramuscular conservative treatment.100-102 If no or
reported to induce ACS. It is paramount to as the single incision technique.83 The groups.86-87 This is undoubtedly the
tendon injuries in the calf muscle insufficient progress is made despite
to recognize these atypical and rare most commonly performed fasciotomy result of continuous development of
complex is conservative involving adequate and prolonged conservative
presentations of ACS, as these are easily is the double-incision, four-compartment both treatment modalities, for example
criteria-based rehabilitation programs. treatment, surgical consultation is
missed and can have grave consequences. technique incorporating a longitudinal by the use of newer techniques and/
This results in good outcome in a warranted. The 11-year follow-up
anterolateral and posteromedial incision.83-84 or functional braces that allow for
majority of cases.93-96 Järvinen et al. study UEFA Champions League injury
Chronic exertional compartment syndrome earlier mobilization, which is known to
suggested that the phrase “muscle study showed that 38% of the severe (
is well-described in athletes.64-65 In contrary If timely intervened, surgical treatment positively affect tendon healing.86-88
injuries do heal conservatively” could absence >28 days) tendinopathies were
to ACS, CECS-induced pain, muscle tightness of ACS and CECS can be expected to lead
be used as a guiding principle in treated surgically.89 Alfredson and Cook
and cramps are completely eliminated to complete recovery with a full return There is some evidence that surgical
the treatment of muscle traumas.94 recently proposed a treatment algorithm
within minutes after ceasing activity in the to sports at pre-injury level within three intervention leads to a quicker return
However, they also stated that in some including recommended timeframes,
majority of the cases.64 However, CECS can months.65-67-68-70 Failure to diagnose ACS to sports/work and better recovery
cases surgical intervention may be with surgical intervention as a last
lead to ACS.66 Next to CECS, exercise-induced timely can lead to long-term disability.68 of function.85-86 Again, this may also
indicated. These indications include resort.100
ACS and non-contact muscle strain/tear be attributable to a quicker start of
a large hematoma, a grade 3 injury
injuries in the lower leg in athletes causing rehabilitation rather than the choice
CHAPTER 3 CHAPTER 3
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CHAPTER 3 CHAPTER 3
Combining both current best practice with scientific
evidence is considered the gold standard in the
creation, implementation and delivery of the football
medicine and science program. In the true spirit
of FC Barcelona, we are ‘mes que un club’ (more
than a club) and in the creation of this Muscle
Injury Guide: ‘Prevention of and Return to Play from
Muscle Injuries’ we have welcomed into our football
family, over 60 sports medicine and performance
practitioners and applied researchers operating at
the highest levels of team-sports and research.
Our aim with this practical recommendations Guide

was to bridge the gap between what is done in
practice with what the highest quality evidence
from scientific research is telling us. We do not
intend this Guide to be a ‘must follow recipe’ but
rather to provide some key ingredients that you can
adapt and integrate appropriately into your own
practice and in your specific circumstances.
By identifying key gaps between current practice
and scientific evidence we aim to also provide some
key directions for future research for those readers
in applied research roles.
We hope you enjoy reading the combined

knowledge and experiences of FC Barcelona,
Oslo Sports Trauma Research Centre and the many
internationally renowned contributors included
throughout the Guide.
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Regenerative and biological treatments for muscle injury

Chapter · May 2018

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10 JOHANN WINDT DR. STEFFAN GRIFFIN WHAT WE DO? OUR FOCUS 11

EDITOR’S BIOGRAPHIES EDITOR’S BIOGRAPHIES

PREVENTING AND TREATING

1. Protect our players’ health

PARTNERSHIP WITH OSLO SPORTS SCIENCE AND MEDICINE IN

A LETTER OF SUPPORT FROM INTERNATIONAL

16 A lot remains to be studied, as well in the sphere of prevention, diagnosis and 17

I remain convinced that, in different aspects, our approach of muscular lesions

Countries represented Countires with

While in an ideal world, we would be able

THE TEAM-SPORT INJURY

PREVENTION (TIP) CYCLE

MECHANISMS? risk factors and implementation barriers/

NE members’ perceptions towards injury

EVALUATING THE MUSCLE 35

22 MUSCLE INJURY HAMSTRING MUSCLE INJURIES ADDUCTOR-RELATED MUSCLE INJURIES 23

EVALUATING THE MUSCLE

INJURY BURDEN (DAYS LOST PER 1000 HOURS)

muscle groups.2 About 10-15% of all 40,0

Higher grade hamstring injuries, as Calf 16.5 per 1000 hours

RISK FACTORS AND FACTORS players, recent data from FC Barcelona

THE COMPLEX, MULTIFACTORIAL

second halves, and more calf muscle Factors

32 MODIFIABLE RISK For football players, the main factors 33

A complex patterns model considers 2) fatigue and 3) strength qualities. The

TAKE HOME MESSAGE

2 COMPETITIONS PER WEEK

Load monitoring systems can also be HIGH RISK SCENARIOS <

speed demands of match play. Underload / Under

Day after the match:

52 FLEXIBILITY KEY PROGRAM PREVENTATIVE STRATEGY EFFECTIVENESS RATING <

There is no clear evidence for lower

MULTI-DIMENSIONAL et al. (2015)28 implemented a multi-

PROGRAMS ON MUSCLE eccentric, general strengthening

CONTINUOUS (RE) EVALUATION

• Injury severity corresponds to the

SEVERITY (# OF DAYS LOST)

* It is important to ask individuals from all the

REFERENCES exercise programmes

RETURN TO PLAY FROM MUSCLE

66 General As such we need to be optimally 67

The purpose of this chapter on ‘General

The concept of return to play as a

RETURN TO PLAY IN FOOTBALL:

72 The first step off-field is a 73

THE FC BARCELONA MUSCLE INJURY CLASSIFICATION – A PROPOSAL

RESTORING PLAYERS’ SPECIFIC

88 In the lead up to returning to variations in players’ physical profiles, 89

REGENERATIVE AND BIOLOGICAL

As some regenerative medicine products

SURGERY FOR MUSCLE