MUSCLE INJURY GUIDE: Prevention of and Return to Play from Muscle Injuries - Lasse Lempainen

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MUSCLE INJURY GUIDE: Prevention of and Return to Play from Muscle Injuries - Lasse Lempainen
MUSCLE INJURY GUIDE:
PREVENTION OF AND RETURN TO
PLAY FROM MUSCLE INJURIES

  MUSCLE
  INJURY
  GUIDE:                                             1

  Prevention of
  and Return to
  Play from
  Muscle Injuries
  Editors:                    Senior Editorial
  Ricard Pruna                Assistant:
  Thor Einar Andersen         Steffan Griffin
  Ben Clarsen
  Alan McCall                 Editorial Assistant:
                              Johann Windt

CHAPTER 1
MUSCLE INJURY GUIDE: Prevention of and Return to Play from Muscle Injuries - Lasse Lempainen
MUSCLE INJURY GUIDE: Prevention of and Return to Play from Muscle Injuries - Lasse Lempainen
SECTION
LEADERS
                       FC BARCELONA
                       CONTRIBUTORS
                                              Muscle Injury
                                              Guide:
Clare Ardern           Juanjo Brau
Roald Bahr             Xavi Linde
Aaron Coutts           Antonia Lizárraga
Maurizio Fanchini      Sandra Mecho

                                              Prevention of
Phil Glasgow           Edu Pons
Tero Jarvinen          Jordi Puigdellivol
Lasse Lempainen        Xavi Valle
Andrea Mosler          Xavi Yanguas
James O’Brien

                                              and Return to
Tania Pizzari
Nicol van Dyk
Markus Waldén
Arnlaug Wangensteen    EXERCISE-BASED

                                              Play from
                       MUSCLE INJURY
                       PREVENTION (EBMIP)
                       GROUP (see section
                       1.4.4a)

                                              Muscle Injuries
INTERNATIONAL
CONTRIBUTORS           Andrea Azzalin
                       Andreas Beck
Abd-elbasset Abaidia   Andrea Belli
Khatija Badhur         Martin Buchheit
Natalia Bittencourt    Gregory Dupont
Mario Bizzini          Maurizio Fanchini
Ida Bo Steenhal        Duccio Ferrari Bravo
Martin Buchheit        Shad Forsythe
Phil Coles             Marcello Iaia
Aaron Coutts           Yann-Benjamin Kugel
Michael Davison        Imanol Martin
Gregory Dupont         Samuele Melotto
Caroline Finch         Jordan Milsom
Brady Green            Darcy Norman
Martin Hägglund        Edu Pons
Shona Halson           Stefano Rapetti
Joar Harøy             Bernardo Requena
Per Hölmich            Roberto Sassi
Franco Impellizzeri    Andreas Schlumberger
Gino Kerkhoffs         Tony Strudwick
Ozgur Kilic            Agostino Tibaudi
Justin Lee
Matilda Lundblad
Nicolas Mayer
Bob McCunn
Tim Meyer              DESIGNER AND
Haiko Pas              PUBLISHER
Noel Pollock
Janne Sarimo           FCB Marketing
Anthony Schache        Department
Andreas Serner
Karin Silbernagel
Adam Weir
Jonas Werner                                  Editors:              Senior Editorial
Nick van der Horst                            Ricard Pruna          Assistant:
Anne D van der Made                           Thor Einar Andersen   Steffan Griffin
                                              Ben Clarsen
                                              Alan McCall           Editorial Assistant:
                                                                    Johann Windt
MUSCLE INJURY GUIDE: Prevention of and Return to Play from Muscle Injuries - Lasse Lempainen
MUSCLE INJURY GUIDE:
              PREVENTION OF AND RETURN TO
              PLAY FROM MUSCLE INJURIES

6   Summary   E. Editor’s biographies
              P8
                                                                1.3.4 BARRIERS AND FACILITATORS TO DELIVERING
                                                                INJURY PREVENTION STRATEGIES
                                                                P 37
                                                                                                                    2.3.1 EXERCISE PRESCRIPTION FOR MUSCLE INJURY
                                                                                                                    P 96
                                                                                                                                                                    7

                                                                                                                    2.3.2 RESTORING PLAYERS’ SPECIFIC FITNESS AND
                                                                1.4.1 STRATEGIES TO PREVENT MUSCLE INJURY           PERFORMANCE CAPACITY IN RELATION TO MATCH

              0. Introduction to                                P 38
                                                                1.4.2 CONTROLLING TRAINING LOAD
                                                                                                                    PHYSICAL AND TECHNICAL DEMANDS
                                                                                                                    P 101

              the Guide                                         P 40                                                2.4.1 REGENERATIVE AND BIOLOGICAL TREATMENTS
                                                                                                                    FOR MUSCLE INJURY
              P 12
                                                                1.4.3 RECOVERY STRATEGIES
                                                                                                                    P 110
                                                                P 44
                                                                                                                    2.4.2 SURGERY FOR MUSCLE INJURIES
              0.1 PREVENTING AND TREATING MUSCLE INJURIES       1.4.4A EXERCISE-BASED STRATEGIES TO PREVENT
                                                                                                                    P 114
              IN FOOTBALL                                       MUSCLE INJURIES
              P 13                                              P 46
              0.2 PARTNERSHIP WITH OSLO SPORTS TRAUMA
              RESEARCH CENTRE
                                                                1.4.4B EXERCISE SELECTION FOR THE MUSCLE INJURY
                                                                PREVENTION PROGRAM                                  3. RTP from Specific
              P 14
              0.3 SCIENCE AND MEDICINE IN FOOTBALL JOURNAL’S
                                                                P 54
                                                                1.4.4C EXERCISE SELECTION: HAMSTRING INJURY
                                                                                                                    Muscle Injury
              SUPPORT
              P 15
                                                                PREVENTION
                                                                P 55
                                                                                                                    P 120
              0.4 A LETTER OF SUPPORT FROM                      1.4.4D EXERCISE SELECTION: QUADRICEPS INJURY        3.1 RETURN TO PLAY FOLLOWING HAMSTRING
              DR MICHEL D’HOOGE                                 PREVENTION                                          MUSCLE INJURY
              P 16                                              P 58                                                P 121
              0.5 INTERNATIONAL COLLABORATORS                   1.4.4E EXERCISE SELECTION: ADDUCTOR MUSCLE          3.2 RETURN TO PLAY FOLLOWING QUADRICEPS
              P 17                                              INJURY                                              MUSCLE INJURY
                                                                P 61                                                P 140
                                                                1.4.4F EXERCISE SELECTION:CALF INJURY               3.3 RETURN TO PLAY FOLLOWING GROIN MUSCLE
              1. General Principles of                          PREVENTION                                          INJURY
                                                                P 63                                                P 156
              Preventing Muscle Injury                          1.4.5 COMMUNICATION                                 3.4 RETURN TO PLAY FOLLOWING CALF MUSCLE
              P 18                                              P 66
                                                                1.5 CONTINUOUS (RE)EVALUATION AND MODIFICATION
                                                                                                                    INJURY
                                                                                                                    P 170
                                                                OF PREVENTION STRATEGIES
              1.1.1. AN INTRODUCTION TO PREVENTING MUSCLE
                                                                P 68
              INJURIES.DOCX
              P 19
              1.1.2 A NEW MODEL FOR INJURY PREVENTION IN TEAM
              SPORTS: THE TEAM-SPORT INJURY PREVENTION (TIP)    2. General Principles
              CYCLE
              P 20                                              of Return to Play from
              1.2.1 EVALUATING THE MUSCLE INJURY SITUATION
              P 22
                                                                Muscle Injury
              1.2.2 EVALUATING THE MUSCLE INJURY SITUATION IN   P 78
              YOUR OWN TEAM
              P 25                                              2.1.1 RETURN TO PLAY FROM MUSCLE INJURY: AN
                                                                INTRODUCTION
              1.3.1 RISK FACTORS AND MECHANISMS FOR MUSCLE
                                                                P 79
              INJURY IN FOOTBALL
              P 26                                              2.1.2 RETURN TO PLAY IN FOOTBALL: A DYNAMIC MODEL
                                                                P 80
              1.3.2 THE COMPLEX, MULTIFACTORIAL AND DYNAMIC
              NATURE OF MUSCLE INJURY                           2.1.3 ESTIMATING RETURN TO PLAY TIME
              P 31                                              P 82
              1.3.3 MUSCULOSKELETAL SCREENING IN FOOTBALL       2.2.1 MAKING AN ACCURATE DIAGNOSIS
              P 34                                              P 85

              SUMMARY
MUSCLE INJURY GUIDE: Prevention of and Return to Play from Muscle Injuries - Lasse Lempainen
MUSCLE INJURY GUIDE:
                  PREVENTION OF AND RETURN TO
                  PLAY FROM 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                     PT, PhD                         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 Me-      postdoctoral research fellow    Assoc Prof Rob Duffield) at
                  additionally holds a PhD           dicine at the Norwegian School       at the Oslo Sports Trauma       Football Federation Australia.
                  in ‘Genetics and Injury in         of Sport Sciences, Norway. He        Research Center (OSTRC).        Alan’s background is as a fit-
                  Football’. Ricard has a rich and   has a master degree in health        He has a bachelor degree        ness coach and sport scientist
                  vast experience in top-level       administration from the Uni-         in physiotherapy from the       with over ten years experience
                  football having been the first     versity of Oslo. He is a trained     University of Sydney and        working in professional club
                  team doctor of FC Barcelona        physiotherapist, consultant phy-     a master degree in sports       teams competing in Ligue
                  for over 20 years. He is also      sician, and specialist in Physical   physiotherapy and PhD           1, English Premier League,
                  the Head of Medical Services       and Rehabilitation Medicine. His     from the Norwegian School       A-League, Scottish League
                  at FC Barcelona, overseeing        main research areas are football     of Sport Sciences. He is a      and European competitions.
                  the medical strategy and staff     injury epidemiology, injury me-      director of the IOC Diploma     He was Head of Sport Science
                  of all medical aspects in the      chanisms and causes, as well as      in Sports Physical Therapies    and fitness coach of the Aus-
                  club, including professional       injury prevention.                   and a lecturer on the sports    tralian Socceroos at the 2014
                  sports in addition to his first                                         physiotherapy master            FIFA World Cup and the U20
                  team football duties.              Thor Einar is the Chief medical      program at the Norwegian        Young Socceroos at the 2013
                                                     officer of the Medical Commit-       School of Sport Sciences. Ben   World Cup.
                  Ricard’s clinical interests lie    tee in The Football Association of   has been physiotherapist
                  in football medicine, muscle       Norway. He has served as team        for a number of professional    Alan’s research interests include
                  injuries, genetics, return to      physician for the senior male        road cycling teams, and the     injury prevention, recovery
                  play, anatomy and injury           national team from 2002-2014.        Norwegian and Australian        and performance in football.
                  diagnosis. He has many             He is medical director at the        national programmes. He         He holds a PhD in ‘Injury
                  scientific publications in         Norwegian FA Medical Centre          is a senior associate editor    Prevention in Elite Footballers’
                  the football medicine areas        and is a member of the board         of BJSM and was the senior      from Université de Lille 2 and a
                  and has received various           and director of elite sports in      editor of the 5th edition of    Msc in Strength & Conditioning
                  awards for his scientific work,    the football department at           Brukner and Khan’s Clinical     from Edith Cowan University,
                  including, the Award for           Nordstrand IF.                       Sports Medicine textbook.       Australia.
                  Medical Excellence from the
                  Medical College University         Thor Einar has a strong con-                                         Alan is a member of the
                  of Barcelona, a National and       nection with high-level football                                     Football Research Group, Senior
                  UEFA Award for research in         having played professionally                                         Associate Editor at British
                  sports medicine.                   winning two Norwegian cham-                                          Journal of Sports Medicine,
                                                     pionships with IK Start, and                                         Associate Editor at Science and
                                                     represented Norwegian interna-                                       Medicine in Football and on the
                                                     tional youth teams (U15-U23).                                        editorial board of Apunts which
                                                                                                                          is a joint publication by the
                                                                                                                          Conseil Catala de l’Esport and
                                                                                                                          Barca Innovation Hub.

                  EDITOR’S BIOGRAPHIES
MUSCLE INJURY GUIDE: Prevention of and Return to Play from Muscle Injuries - Lasse Lempainen
MUSCLE INJURY GUIDE:                                                MUSCLE INJURY GUIDE:
     PREVENTION OF AND RETURN TO                                         PREVENTION OF AND RETURN TO
     PLAY FROM MUSCLE INJURIES                                           PLAY FROM 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, and 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-ups.   activities are structured into 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
MUSCLE INJURY GUIDE: Prevention of and Return to Play from Muscle Injuries - Lasse Lempainen
MUSCLE INJURY GUIDE:
                    PREVENTION OF AND RETURN TO
                    PLAY FROM 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 that we see in
                    elite football.
                     — With Ricard Pruna

12   Introduction   Due to the negative effects that we know injuries have on performance, club finances and
                                                                                                                  13

     to the Guide
                    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: ‘Prevention of and Return to Play from Muscle Injuries’. 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
MUSCLE INJURY GUIDE: Prevention of and Return to Play from Muscle Injuries - Lasse Lempainen
MUSCLE INJURY GUIDE:                                                                                                          MUSCLE INJURY GUIDE:
     PREVENTION OF AND RETURN TO                                                                                                   PREVENTION OF AND RETURN TO
     PLAY FROM MUSCLE INJURIES                                                                                                     PLAY FROM MUSCLE INJURIES

     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 Tim Meyer and Franco Impellizzeri
      — With Thor Einar Andersen and Roald Bahr

14   The main objective of the 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.
                                                                                                    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 corresponds to our vision of bringing research and
                                                                                                    2. Soligard T, Myklebust
                                                                                                    G, Steffen K, Holme I,         practice together. In this resource, FC Barcelona have brought together over 60 of some
     In football, one focus has been on the preventive effect of eccentric hamstring training       Silvers H, Bizzini M et al.    of the world’s leading applied researchers and practitioners to share and perhaps most
                                                                                                    (2008) Comprehensive
     using the Nordic Hamstring exercise.1 We have, in partnership with FIFA, also developed        warm-up programme to
                                                                                                                                   importantly, work together to combine their knowledge and experience into one voice.
     “The 11+”, a warm-up program with exercises focusing on core stability, neuromuscular          prevent injuries in young
     control, strength, balance, hip control and knee alignment in football.2 In 2011, we           female footballers: cluster    Not only will this Guide provide a great practical recommendations’ resource for football
                                                                                                    randomised controlled
     conducted an intervention study in the Norwegian male professional league involving            trial. BMJ;337:a2469           science and medicine practitioners worldwide, but should also help to drive forward
     sanctioning of two-footed tackles as well as tackles with excessive force and intentional      3. Bjørneboe J, Bahr R,
                                                                                                                                   meaningful applied research to further improve our field.
     high elbow with an automatic red card to enforce the Rules of the Game.3                       Dvorak J, Andersen TE.
                                                                                                    (2013) Lower incidence         It is with great pleasure that we support this initiative by FC Barcelona. One aspect that
                                                                                                    of arm-to-head contact
     We have through several conferences, workshops, visits and meetings with FC Barcelona          incidents with stricter        we are particularly excited about is that various contributors involved in the Guide will
     (FCB) and its medical staff, been inspired by the clubs’ constant strive to implement best     interpretation of the          progress on some of the chapters written within, by preparing scientific articles and
     medical practice and scientific knowledge into their daily practice. In particular, we have    Laws of the Game in            submitting these to enter the Science and Medicine in Football peer review process. So,
                                                                                                    Norwegian male profes-
     been impressed by the FCB philosophy on training principles, diagnostic procedures and         sional football. Br J Sports   watch this space…
     management of return to play after injury.                                                     Med;47(8):508-14

     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: Prevention of and Return to Play from 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
MUSCLE INJURY GUIDE: Prevention of and Return to Play from Muscle Injuries - Lasse Lempainen
MUSCLE INJURY GUIDE:                                                                         MUSCLE INJURY GUIDE:
     PREVENTION OF AND RETURN TO                                                                  PREVENTION OF AND RETURN TO
     PLAY FROM MUSCLE INJURIES                                                                    PLAY FROM MUSCLE INJURIES

     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 injury in the world of football remains a muscle injury.
      — With Michel Baron D’Hooghe, Chairman Medical Commission FIFA and UEFA

16   A lot remains to be studied, in the sphere of prevention, diagnosis and treatment                                                      17
     of these injuries. 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 injuries
     did not decrease over the last years.

     I remain convinced that, in different aspects, our approach of muscular injuries
     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 of the injured player.

                                                                                                         Countries represented
                                                                                                         in the guide

                                                                                                         Australia       Norway
                                                                                                         Brazil          Northern Ireland
                                                                                                         Canada          Qatar
                                                                                                         Denmark         South Africa
                                                                                                         Finland         Spain
                                                                                                         France          Sweden
                                                                                                         Germany         Switzerland
                                                                                                         Holland         UK
                                                                                                         Italy           USA

     CHAPTER 0                                                                                    CHAPTER 0
MUSCLE INJURY GUIDE: Prevention of and Return to Play from Muscle Injuries - Lasse Lempainen
MUSCLE INJURY GUIDE:
                     PREVENTION OF AND RETURN TO
                     PLAY FROM MUSCLE INJURIES

                     1.1.1

                     AN INTRODUCTION TO
                     PREVENTING MUSCLE INJURIES
                     The objective of football is to win games and there are many factors (i.e. tactical,
                     technical, physical and mental) interacting to achieve this objective. However,
                     one key, contributing factor that the medical and performance team can influence is
                     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 would        benefits of preventative strategies to key     19

     Principles of
                     logically agree that having the best          stakeholders (players, coaches, board
                     players available to play, enhances the       level administrators etc) is essential if we
                     likelihood of winning. A higher player        are to succeed in at least reducing the risk
                     availability means that the coach will        and minimising the occurrence of injuries,

     Muscle Injury
                     have more players available to train          and in particular muscle injuries which
                     and in turn more opportunity and time         are one of the most common types of
                     to work on tactics, technical aspects         injuries that we are faced with.
                     and team dynamics. There is also

     Prevention
                     strongs cientific evidence to support         The purpose of this opening chapter of
                     this notion; less injuries have been          the FC Barcelona Muscle Injury Guide:
                     associated with increased success in          ‘General Principles of Muscle Injury
                     domestic league competition1, 2 and           Prevention in Football’ is to highlight,

     in Football
                     UEFA Champions / Europa League.3 In           explain and delve into some of the key
                     addition to performance and success,          general principles to consider when
                     injuries also carry with them a significant   the goal is to prevent muscle injury in
                     financial cost. It has been estimated that    footballers. Specifically, we will provide
                     the financial cost of one player missing      a new injury prevention model specific
                     one month due to injury equates to an         to team sports, followed by taking
                     average of ~€500,000.4 Remember that          you through a journey of this model,
                     this is an average, imagine the costif        providing practical guidelines along
                     this was a star player. A third important     the way.
                     potential consequence of injury is an
                     adverse effect on 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, impossible
                     and 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 must also be complex,
                     multifactorial and dynamic. We should
                     aim to identify and minimise known risk
                     factors for injury while simultaneously
                     identifying and maximising protective
                     factors. Communicating the risks and the

                     CHAPTER 1
MUSCLE INJURY GUIDE:                                                                                                                              MUSCLE INJURY GUIDE:
     PREVENTION OF AND RETURN TO                                                                                                                       PREVENTION OF AND RETURN TO
     PLAY FROM MUSCLE INJURIES                                                                                                                         PLAY FROM MUSCLE INJURIES

     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
                                                                    AND DELIVERY 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
MUSCLE INJURY GUIDE:                                                                                                                            MUSCLE INJURY GUIDE:
     PREVENTION OF AND RETURN TO                                                                                                                     PREVENTION OF AND RETURN TO
     PLAY FROM MUSCLE INJURIES                                                                                                                       PLAY FROM MUSCLE INJURIES

     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 is higher, 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 shown that 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 expect
     Most of the muscle injuries (92%) are
                                                         football.2 In that study, 37% of all muscle injuries were in the                            four to five muscle injuries to the hip
     located within the four big muscle
                                                         hamstrings (figure 1). The injury rate during match play is                                 and groin.2 The 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 other muscles such
     typically consisting of a squad of around
                                                         Studies incorporating imaging modalities have shown that a                                  as the abdominal, sartorius and tensor
     25 players eligible for first team match
                                                         clear majority of these injuries involve the long head of the                               fascia latae muscles are less frequent,or
     play, can expect about 16 muscle injuries
                                                         biceps femoris, i.e. the typical ‘sprinting injury’.4 5                                     even rare.11-12 Adductor-related injuries
     leading to time-loss each season (table 1).
                                                                                                                                                     are the second most common muscle
                                                         Other studies on high-level male players have reported                                      injury among men’s professional
     MUSCLE GROUP                   N. OF INJURIES
                                                         similar findings as those outlined above.6 7 However, two                                   players representing 23% of all muscle
     Hamstring                      6                    studies on US collegiate players found a lower rate of                                      injuries (figure 1) and 7% of all time-loss
                                                         hamstring injuries in female players,8 9 whereas one study on                               injuries.2 A typical 25-player squad in
     Quadriceps                     3
                                                         Swedish elite players observed no sex-related difference in                                 men’s professional football can therefore
     Adductors                      3                    the rate of hamstring injuries.3                                                            expect about three adductor-related
                                                                                                                                                     muscle injuries each season (table 1).
     Calf                           1-2                                                                                                                                                                      CALF MUSCLE INJURIES
                                                         MUSCLE GROUP         INJURY INCIDENCE      MATCH INJURY INCIDENCE   <                       The injury rate during match play is
                                                                                                                             Table 2
     Other Locations                2-3                                                                                      Muscle injury rate in
                                                                                                                                                     more than six times higher than during                  There is a lack of studies on lower leg
                                                         Hamstring            0.4 per 1000 hours    3.7 per 1000 hours
                                                                                                                             men’s professional      training (table 2). Studies involving                   muscle injuries in football, especially
     ^                                                   Quadriceps           0.3 per 1000 hours    1.2 per 1000 hours       football players        imaging modalities have documented                      in females and in males from non-
     Table 1      Average number of muscle injuries in                                                                       (adapted from
                                                                                                                             Ekstrand et al.2)
                                                                                                                                                     that most of the adductor-related                       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)                                                                                                    injuries involve the adductor longus.12 13              or two of all muscle injuries incurred
                                                         Calf                 0.2 per 1000 hours    1.0 per 1000 hours                               Although less detailed, publications on                 by a typical 25-player squad in men’s
     Muscle injuries also occur at a high rate                                                                                                       male sub-elite or amateur players have                  professional football will be located
     among, for example, female elite players                                                                                                        reported similar findings on the location               to the calf (table 1). In this sample, calf
     and male youth academy players.1 3 The                                                                                                          and rate of muscle injuries to the hip                  muscle injuries represented 13% of all
     muscle injury spectrum in those cohorts                                                                                                         and groin.14 15                                         muscle injuries (figure 1),and 4% of
     is essentially similar to high-level male                                                                                                                                                               all time-loss injuries.2 The calf muscle
     players, whilst quadriceps injuries may be                                                                                                      Finally, substantially less is known about              injury rate during match play is almost
     more frequent in early adolescence than                                                                                                         hip and groin muscle injuries in youths                 six times higher than during training
     in adulthood.1                                                                                                                                  and in female players, but a recent                     (table 2). The classical injury involves the
                                                                                                                                                     review on 34 epidemiological studies                    medial gastrocnemius, but less is known
                                                                                                                                                     on football players concluded that hip                  about soleus injuries even though these
                                                                                                                                                     and groin injury in general was twice as                injuries probably are more frequent than
                                                                                                                                                     common in males as in females..16                       once thought.17

     CHAPTER 1                                                                                                                                       CHAPTER 1
MUSCLE INJURY GUIDE:                                                                                                                               MUSCLE INJURY GUIDE:
     PREVENTION OF AND RETURN TO                                                                                                                        PREVENTION OF AND RETURN TO
     PLAY FROM MUSCLE INJURIES                                                                                                                          PLAY FROM MUSCLE INJURIES

                                                                                                                                                           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
                                                                                                                                                                                                                                                                                     HAMSTRING BURDEN   <                        25
                                                                                                                                                                                                                                                                                                        Figure 1
     AND SEVERITY
                                                                                                                       Table 3                                                                                                                                                       QUADRICEPS
                                                                                                                                                                                                                                                                                     QUAD BURDEN
                                                                                                                       Muscle injury severity                                                                                                                                                           Muscle injury burden
                                                 Hamstring      13         25            51            11                                                                                  90,0
                                                                                                                                                                                                                                                                                     ADDUCTOR
                                                                                                                                                                                                                                                                                     ADDUCTER BURDEN    in FC Barcelona during
                                                                                                                       according to lay-off
     Injury severity is commonly based on        Quadriceps     12         25            48            15              in men’s professional                                               80,0                                                                                      CALFBURDEN
                                                                                                                                                                                                                                                                                     CALF               nine seasons: (2008/09
                                                                                                                       football players                                                                                                                                                                 to 2016/17).

                                                                                                                                                INJURY BURDEN (DAYS LOST PER 1000 HOURS)
     the number of days that the player is
                                                                                                                       (adapted from Ekstrand
     unable to train and compete due to          Adductors      18         31            41            10              et al.2)
                                                                                                                                                                                           70,0

     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                   INJURY BURDEN (days lost per 1000 h)   <
     are severe with a lay-off time longer                                                                             Table 4                                                             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                     10.3 per 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                           6.5 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
MUSCLE INJURY GUIDE:                                                                                                                      MUSCLE INJURY GUIDE:
     PREVENTION OF AND RETURN TO                                                                                                               PREVENTION OF AND RETURN TO
     PLAY FROM MUSCLE INJURIES                                                                                                                 PLAY FROM MUSCLE INJURIES

     1.3.1
                                                                                                                                               NON-MODIFIABLE RISK                          In addition to the literature on senior         LEG DOMINANCE

     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                                                            injury rates are higher in the kicking
     INJURY IN FOOTBALL
                                                                                                                                                                                            players, whereas the reverse is seen for
                                                                                                                                               a significantly higher rate of muscle                                                        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                                                            studies on female players showed no
                                                                                                                     modifiable and non-       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               modifiable risk factors   injuries.18 Similar findings were found                                                      general is several-fold higher in matches
     on suggested risk factors are often                                                                             for muscle injury                                                      and future muscle injury; for thigh
                                                                                                                                               in male elite players where older                                                            than during training regardless of the
     identical or similar between studies                             Previous injury      Fitness level                                                                                    muscle injuries in youth players,26 and
                                                                                                                                               age (>23 years) was associated with                                                          setting and playing level. Muscle injury
     but could occasionally be muscle-                                                                                                                                                      for hamstring injuries in elite players.27
                                                                      Leg dominance        Psychological factors                               a significantly higher percentage of                                                         rates are also higher, of approximately the
     specific or even contradictory. Muscle                                                                                                                                                 In summary, a majority of studies have
                                                                                                                                               calf muscle injuries, but again no                                                           same 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
MUSCLE INJURY GUIDE:                                                                                                                                         MUSCLE INJURY GUIDE:
     PREVENTION OF AND RETURN TO                                                                                                                                  PREVENTION OF AND RETURN TO
     PLAY FROM MUSCLE INJURIES                                                                                                                                    PLAY FROM MUSCLE INJURIES

                                                                                                                     <
                                                                                                                     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
                                                                          STRENGTH                                   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 is seen quadriceps muscle                                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
     injuries with a higher injury rate during                            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
     the pre-season period (figure 1).18 Another                          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
     study on male elite players showed that                              consisting of high-level male football                                                  study where hamstring-injured male                                                         professional players occurred in non-
                                                                                                                     study, previous long-standing groin
     there was an accumulation of hamstring                               players, with previous hamstring injury                                                 professional players had significantly                                                     contact situations with few match-related
                                                                                                                     pain (>6 weeks) during the preceding                                                     PSYCHOLOGICAL FACTORS
     injuries in the spring season after the                              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
     winter break.36 Similarly, most thigh muscle                         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
     injuries in male youth players occurred in                           were common and that a rehabilitation                                                   Moreover, two studies on male               compared with studies on physical              re-enforcements of the existing rules will
     September (after the summer break) and                               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
     in January (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                        EQUIPMENT
                                                                          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
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