Muscle Guide: General Principles Of Return To Play From Muscle Injury
MUSCLE INJURY GUIDE:PREVENTION OF AND RETURN TOPLAY FROM MUSCLE INJURIESMUSCLEINJURYGUIDE:Prevention ofand Return toPlay fromMuscle InjuriesEditors:Ricard PrunaThor Einar AndersenBen ClarsenAlan McCallCHAPTER 1Senior EditorialAssistant:Steffan GriffinEditorial Assistant:Johann Windt1
SECTIONLEADERSFC BARCELONACONTRIBUTORSClare ArdernRoald BahrAaron CouttsMaurizio FanchiniPhil GlasgowTero JarvinenLasse LempainenAndrea MoslerJames O’BrienTania PizzariNicol van DykMarkus WaldénArnlaug WangensteenJuanjo BrauXavi LindeAntonia LizárragaSandra MechoEdu PonsJordi PuigdellivolXavi ValleXavi YanguasINTERNATIONALCONTRIBUTORSAbd-elbasset AbaidiaKhatija BadhurNatalia BittencourtMario BizziniIda Bo SteenhalMartin BuchheitPhil ColesAaron CouttsMichael DavisonGregory DupontCaroline FinchBrady GreenMartin HägglundShona HalsonJoar HarøyPer HölmichFranco ImpellizzeriGino KerkhoffsOzgur KilicJustin LeeMatilda LundbladNicolas MayerRobert McCunnTim MeyerHaiko PasNoel PollockJanne SarimoAnthony SchacheAndreas SernerKarin SilbernagelAdam WeirJonas WernerNick van der HorstAnne D van der MadeEXERCISE-BASEDMUSCLE INJURYPREVENTION (EBMIP)GROUP (see section1.4.4a)Andrea AzzalinAndreas BeckAndrea BelliMartin BuchheitGregory DupontMaurizio FanchiniDuccio Ferrari BravoShad ForsytheMarcello IaiaYann-Benjamin KugelImanol MartinSamuele MelottoJordan MilsomDarcy NormanEdu PonsStefano RapettiBernardo RequenaRoberto SassiAndreas SchlumbergerTony StrudwickAgostino TibaudiDESIGNER ANDPUBLISHERFCB MarketingDepartmentMuscle Injury Guide:Prevention of andReturn to Play fromMuscle Injuries FC BARCELONA, 2018.BARÇA INNOVATION HUB
Muscle InjuryGuide:Prevention ofand Return toPlay fromMuscle InjuriesEditors:Ricard PrunaThor Einar AndersenBen ClarsenAlan McCallSenior EditorialAssistant:Steffan GriffinEditorial Assistant:Johann Windt
Summary
MUSCLE INJURY GUIDE:PREVENTION OF AND RETURN TOPLAY FROM MUSCLE INJURIESE. Editor’s biographies1.3.3 MUSCULOSKELETAL SCREENING IN FOOTBALL0. Introduction tothe Guide1.3.4 BARRIERS AND FACILITATORS TO DELIVERINGINJURY PREVENTION STRATEGIES1.4.1 STRATEGIES TO PREVENT MUSCLE INJURY0.1 PREVENTING AND TREATING MUSCLEINJURIES IN FOOTBALL1.4.2 CONTROLLING TRAINING LOAD0.2 PARTNERSHIP WITH OSLO SPORTSTRAUMA RESEARCH CENTRE1.4.3 RECOVERY STRATEGIES0.3 SCIENCE AND MEDICINE IN FOOTBALLJOURNAL’S SUPPORT0.4 A LETTER OF SUPPORT FROM DR MICHELD’HOOGE0.5 INTERNATIONAL COLLABORATORS1. General Principles ofPreventing Muscle Injury1.4.4A EXERCISE-BASED STRATEGIES TOPREVENT MUSCLE INJURIES1.4.4B EXERCISE SELECTION FOR THE MUSCLEINJURY PREVENTION PROGRAM1.4.4C EXERCISE SELECTION: HAMSTRINGINJURY PREVENTION1.4.4D EXERCISE SELECTION: QUADRICEPS INJURYPREVENTION1.4.4E EXERCISE SELECTION: ADDUCTOR MUSCLEINJURY1.4.4F EXERCISE SELECTION:CALF INJURYPREVENTION1.1.1. AN INTRODUCTION TO PREVENTING MUSCLEINJURIES.DOCX1.1.2 A NEW MODEL FOR INJURY PREVENTION INTEAM SPORTS: THE TEAM-SPORT INJURYPREVENTION (TIP) CYCLE2. General Principlesof Return to Play fromMuscle Injury1.4.5 COMMUNICATION1.5 CONTINUOUS (RE)EVALUATION ANDMODIFICATION OF PREVENTION STRATEGIES2.1.1 RETURN TO PLAY FROM MUSCLE INJURY:AN INTRODUCTIONP72.1.2 RETURN TO PLAY IN FOOTBALL: A DYNAMICMODELP82.1.3 ESTIMATING RETURN TO PLAY TIMEP 102.2.1 MAKING AN ACCURATE DIAGNOSISP 132.3.1 EXERCISE PRESCRIPTION FOR MUSCLE INJURYP 242.3.2 RESTORING PLAYERS’ SPECIFIC FITNESS ANDPERFORMANCE CAPACITY IN RELATION TOMATCH PHYSICAL AND TECHNICAL DEMANDSP 292.4.1 REGENERATIVE AND BIOLOGICALTREATMENTS FOR MUSCLE INJURYP 382.4.2 SURGERY FOR MUSCLE INJURIESP 423. RTP from SpecificMuscle Injury3.1 RETURN TO PLAY FOLLOWING HAMSTRINGMUSCLE INJURY1.2.1 EVALUATING THE MUSCLE INJURY SITUATION3.2 RETURN TO PLAY FOLLOWING QUADRICEPSMUSCLE INJURY1.2.2 EVALUATING THE MUSCLE INJURY SITUATIONIN YOUR OWN TEAM3.3 RETURN TO PLAY FOLLOWING GROIN MUSCLEINJURY1.3.1 RISK FACTORS AND MECHANISMS FORMUSCLE INJURY IN FOOTBALL3.4 RETURN TO PLAY FOLLOWING CALF MUSCLEINJURY1.3.2 THE COMPLEX, MULTIFACTORIAL ANDDYNAMIC NATURE OF MUSCLE INJURYSUMMARY
Generalprinciples ofReturn to Playfrom MuscleInjury
MUSCLE INJURY GUIDE:PREVENTION OF AND RETURN TOPLAY FROM MUSCLE INJURIES2.1.1RETURN TO PLAY FROM MUSCLEINJURY: AN INTRODUCTIONThe previous section on preventing muscle injury in football has outlined variousstrategies and tools that can be adopted to minimise the risk of players incurringa muscle injury. While in an ideal world we would be able to prevent all muscleinjuries from occurring this is unfortunately, impossible. As outlined in our ‘InjuryLandscape’ article (1.2.1.) a professional football team can expect around 16 muscleinjuries in a season.— With Ricard Pruna, Alan McCall and Thor Einar AndersenAs such we need to be optimallyprepared to deal with muscle injurieswhen they come. Following a muscleinjury (or any injury for that matter)there are 2 main objectives (and atthe same time challenges); 1) to returnthe player to match-play as soon aspossible and 2) to avoid re-injury.There is a fine balance to this, whichis complex depending on the contextof each individual player, injury andcircumstance (figure 1).In football, the decision to progressor delay a players’ return to playfollowing muscle injury, could be thedifference between having a playerback two matches earlier (increasingthe chance to win 6 points) versuskeeping the player out an extra twoweeks, lowering his/her injury risk,but maybe gaining fewer pointsfrom those two matches.1 Essentially,it comes down to a decision on anagreed ‘level of risk’ (for re-injury)that the team is willing to accepti.e. a shared decision of medical,performance practitioners, the coachand the player him/herself.The purpose of this chapter on ‘GeneralPrinciples of Return to Play fromMuscle Injury’, as with the previousprevention section, is to bring togetherthe best of research knowledge anddemonstrate how we combine thiswith our practical experience andknowledge. Providing you with generalprinciple to follow during the return toplay process.CHAPTER 2 Figure 1 Objectives(and challenge) ofreturning a playerfrom injury.7
MUSCLE INJURY GUIDE:PREVENTION OF AND RETURN TOPLAY FROM MUSCLE INJURIES2.1.2RETURN TO PLAY IN FOOTBALL:A DYNAMIC MODELThere is a paradigm shift occurring in the way we think about return to play.Instead of return to play being the highly anticipated event occurring at the end ofa rehabilitation program, we now consider that return to play starts the momentthe injury occurs and continues beyond the point where the player is returningto unrestricted match play (Figure 1). This type of progression is individual andmalleable, allowing for faster and slower individual progressions throughout thereturn to play plan.— With Clare Ardern and Ricard Pruna8Early andaccuratediagnosisReturn to field(individualised)Return to teamtraining (partialparticipation /modified)Return to fullteam training(unmodified)The concept of return to play as acontinuum was introduced in the Bern2016 consensus on return to sport,1 andis something familiar to FC Barcelonaclinicians and practitioners, who havebeen practicing in this framework forthe past decade. The purpose of thissection is to outline 6 guiding principlesfor return to football after muscle injuryand highlight 4 key considerations forthe decision-making team.GUIDING PRINCIPLE 1Making an accurate diagnosis isthe cornerstone of effective injurymanagement and return to playplanning. Accurate diagnosis facilitatesan estimation of prognosis, and in turn,shared decision-making regardinginjury management. Imaging may beused judiciously at this step, but youmust be clear about what (if anything)imaging will do to change the returnto play plan.2 At FC Barcelona, wework backwards from the anticipatedtime to return to full match-play.Understanding biology will helpwhen estimating injury prognosis andplanning a strategy for appropriateloading through the return to playcontinuum.CHAPTER 2Return to matchplay (partial play /lower duration) Figure 1Football return to playcontinuum (adaptedfrom Ardern et al.1)Returnto desiredperformanceTHE BARÇA WAYWorking backwards from an anticipated return to desired performancedate – which is usually a specificgame – helps motivate the playerand facilitates effective communication with the manager and performance team. Progress towardsthe goal is continuously assessedusing the milestones in the return toplay continuum. In this way we cansee whether the player is on track,behind, or ahead of schedule.GUIDING PRINCIPLE 2Return to play plans must be tailored to theindividual player, who has an individualinjury and an individual return to playcontinuum. An individualised plan isresponsive to the needs of the player toappropriately consider factors that mightinfluence prognosis, and those that couldinfluence the risk for reinjury at any stagethrough the return to play. A one-size-fitsall approach is insufficient in professionalfootball, given the multifactorial natureof return to play, and the need to addressspecific individual factors based on theplayer’s needs.GUIDING PRINCIPLE 3Appropriate loading throughout thereturn to play continuum is importantto stimulate satellite cells to promotemuscle tissue healing, and (in laterstages of the return to play plan)to ensure the player is adequatelyprepared for the demands of return toperformance. Structuring the return toplay plan so that the player spends asmuch time as possible doing footballspecific, pitch-based training (withappropriate modification, according toimpairments and functional limitations)provides two important benefits. First,it facilitates appropriate and specificloading (when combined with awell-structured impairment-focused(e.g. strength, flexibility.) managementplan). Second, maintaining contactwith the team provides the injuredplayer considerable psychosocial andmotivation support.
MUSCLE INJURY GUIDE:PREVENTION OF AND RETURN TOPLAY FROM MUSCLE INJURIESGUIDING PRINCIPLE 4GUIDING PRINCIPLE 5GUIDING PRINCIPLE 6Use regular assessment and feedbackto reinforce and guide collaborative goalsetting. Repeat testing and monitoringcan help the player see progress, andthis is often especially helpful for playerswith injuries that have extended timeloss. Continual assessment of players’performance, in particular football-specificactions such as repeated sprints andexternal running loads as well as how theyare coping with these through internal loadmarkers (e.g. perceived exertion, fatigue,soreness) and psychological readinessand confidence, may help you and theplayer monitor the progressive restorationof strength, ability to perform footballactions and psychological readiness. Theinformation gathered from regular testingcan, in turn, guide goal setting about whenit is safe to resume restricted training,unrestricted training and unrestricted matchplay.How you communicate with the injuredplayer is important. Focus on usinglanguage that emphasises that returnto play is a progression that begins atthe time of injury. Return to play is notsomething that automatically happensonce rehabilitation is completed. Usepositive language that focuses on whatthe player can do – whether that ismodified individual field-based training,modified team training, or performing asdesired in the competitive environment.Focusing on the performance aspectin each phase of the return to playcontinuum is vital to helping the playermaintain the sense of being an athlete,3irrespective of whether he or she hasachieved the goal performance, or not.Keeping the player cognitively engagedin football, even when off the pitch,to maintain the high-level cognitivefunction required for football is essential.The unpredictable nature of footballrequires high-level cognitive function forreaction time, decision-making, shiftingattention, pattern recognition andanticipation.4 Keeping the football brainactive helps the player stay engagedin rehabilitation. Mental fatigue canimpact on performance,5 and trainingcognitive function should be part of astandard football conditioning program.5Therefore, it is also appropriate toinclude relevant cognitive challengesthroughout the return to play continuum.Strategies to consider include choosingtypical football movement patterns orskills where decisions have to be maderandomly and focusing on attention andtemporo-spatial control. Figure 2Football-specificd high cognitivedemands whileperforming rapidchanges of direction,passing and shooting.The player responds tolight signals indicatingrunning directionand whether he/sheshould pass or shoot.This challenges boththe players’ spatialawareness andreaction times. In amuscle injury with6-week prognosis,we would typicallyintroduce this drillfollowing the secondweek.FOUR KEY CONSIDERATIONS FOR EFFECTIVE RETURN TO PLAY PLANNING1.Many factors influence thereturn to play.1 Physical andmental readiness to returnto play are both importantaspects, and do not alwaysgo hand-in-hand.2.Use a group of sportspecific functional tests andplayer-reported outcomesto monitor progression andto judge when the playeris physically and mentallyready to return to play.1CHAPTER 23.Support the player to beconfident about returningto play by keeping himor her involved with theteam throughout the returnto play plan, by regularlymonitoring progress,6and by emphasisingfootball-specific elementsthroughout.4.Return to play planningis about managing risk.7,8 Careful planning andregular monitoring will helpthe decision-making teamappropriately consider riskand implement effective riskminimisation strategies fortimely return to play.9
MUSCLE INJURY GUIDE:PREVENTION OF AND RETURN TOPLAY FROM MUSCLE INJURIES2.1.3ESTIMATING RETURNTO PLAY TIMEWhen a footballer sustains a muscle injury, their first question is invariably: “howlong will this take to recover?” Answering this is not easy,1-5 but in elite-level footballit is vital to make an educated guess. As previously discussed, the RTP continuumbegins with the anticipated date of return to optimal performance in mind and worksbackwards, defining the milestones necessary to achieve that goal. This approachmotivates the player, allows the manager to plan effectively, and facilitates goodcommunication and realistic expectations from all involved.— With Ricard Pruna and Ben Clarsen10Recent research has shown that, whenused in isolation, both MRI and clinicalassessment findings are poor predictorsof RTP time.1-5 That is because evenwhen the same type of injury occurs,myriad individual and contextualfactors influence how quickly eachplayer will recover, and how muchrisk the player and team are willing totake. Nevertheless, it is our experiencethat when experienced practitionersconsider a range of important factorstogether, it is possible to estimate RTPtime surprisingly accurately.THE FC BARCELONAAPPROACHThe foundation for any RTP estimateis an accurate diagnosis. However, itis also essential to consider playerspecific (intrinsic) factors, footballspecific (extrinsic) factors and otherrisk tolerance modifiers. We highlightthat practitioners should continuouslyre-evaluate the initial RTP estimationthroughout the rehabilitation process,depending on how quickly the playerprogresses along the milestonesdefined in the RTP continuum. Keyindicators of whether the player ison-target to meet the anticipatedRTP date include regaining baselinestrength and flexibility measures,completing high-intensity trainingsessions comparable to (or evengreater than) their anticipated matchdemands, and demonstrating anappropriate level of football-specificcognitive skills and psychologicalreadiness.CHAPTER 2THE STARTING POINT: LOCATION ANDEXTENT OF TISSUE DAMAGEKnowing the exact injury location isarguably the most important factor inpredicting RTP time. This is why, at FCBarcelona, clinical assessments areperformed and high-quality MRI imagesare taken as soon as possible aftermuscle injuries occur. Knowing whetherany tendon or bony tissue is involved isvital, as injuries involving these tissuesgenerally heal more slowly and mightneed referral to a surgeon. In addition, itis necessary to identify injuries to muscleregions that are highly stressed duringfootball, as these need to be managedmore conservatively than injuries locatedin less-stressed regions.Although the patient history often providesvital information towards making anaccurate diagnosis, the initial amount ofpain and functional impairment can bemisleading when estimating RTP time.Knowing where the injury is located andwhich tissues are affected provides muchmore information. For example, hamstringstrains located in the middle third of themuscle belly are often severely painfuland cause a large haematoma, yet mostplayers return to desired performancewithin one month – some as quickly as 3weeks. In contrast, partial ruptures of theproximal hamstrings tendons often initiallyappear to be minor injuries; they are lesspainful and their onset is less dramatic.However, these injuries generally take farlonger to recover – often up to 10 weeks.The expected return to play times forspecific injury locations in the hamstrings,adductors, quadriceps and calf musclescan be found later in this guide.PLAYER-SPECIFIC FACTORSEvery football player has unique anatomythat will affect his or her recovery froma muscle injury. For example, due todifferences in free tendon length, a bicepsfemoris injury located 5cm from theischial tuberosity might involve mostlytendon tissue in one player, and muscletissue in another. Careful examination ofeach MRI image is therefore necessary.Variations between players’ connectivetissue quality may also affect an injury’srecovery time. Although this may bedetermined by genetic factors that we arecurrently unable to identify with certainty.A history of frequent muscle injury canbe a good indication of poor connectivetissue quality. More conservative RTPplans should therefore be made forfrequently injured players.
MUSCLE INJURY GUIDE:PREVENTION OF AND RETURN TOPLAY FROM MUSCLE INJURIESFOOTBALL-SPECIFIC FACTORSEach player’s unique role on thepitch needs to be considered whenestimating the RTP time. For example,wide defenders and wingers performmore high-speed running thanother players so hamstring injuryrehabilitation may take longer forplayers in those positions. Similarly,central midfielders frequently performrapid direction changes, which placeshigh demands on their adductormuscles. Key positional demands andtheir consequences for muscle injuryrehabilitation are summarised in Table 1.Additionally, each player has a uniqueplaying style that may also affect his orher RTP plan. For example, some playershave an aggressive style, chasing everyball and pressing opponents throughoutthe whole game. Others are moretactical and therefore more economicalwith their energy expenditure.Finally, muscle injuries located inplayers’ dominant and non-dominantlegs may have markedly differentrecovery time, and even differentmanagement plans. For example, partialruptures of the proximal rectus femorisdirect tendon are possible to treatconservatively if they are in the nondominant leg, but the same injury in thedominant leg is a clear case for surgery.CHAPTER 2POSITIONKEY DEMANDSCONSEQUENCES FORMUSCLE INJURYGoalkeepers,central defendersLong kicks and jumpsHigh stress on rectusfemorisFull backs,wingersHigh speed running,rapid acceleration anddecelerationHigh stress on hamstringsCentralmidfieldersFrequent directionchangesHigh stress on soleusStrikers,attackingmidfieldersHigh speed running,acceleration anddeceleration anddirection changesHigh stress hamstringsand adductorsRISK TOLERANCE MODIFIERSWhenever a player returns to footballafter a muscle injury, there is always arisk that the injury will recur. Generally,the sooner the player returns, thehigher the re-injury risk. However, itis impossible to know the exact riskin each situation. Therefore, every RTPdecision is a “judgment call”, ideallymade by the player, the medical team,and the coaching and performance teamtogether.6 The decision is based on arange of factors, such as: Whether the injured tissues arelikely to have healed sufficiently totolerate the loads of competitivefootball Whether the milestones along theRTP continuum have been achieved If the player feels psychologicallyready to return Table 1Key positionaldemands andtheir potentialconsequenceson muscle injuryrehabilitationImportantly, the RTP decision is alsohighly dependent on the level of reinjury risk that the player and others(e.g. medical and performance team,team manager) are willing to take.Will they accept a re-injury higher riskand return to play early, or reduce therisk by returning more slowly? This isinfluenced by a wide range of contextualfactors called risk tolerance modifiers.7These include factors directly relatedto football, such as the importance ofthe upcoming games, the importanceof the player, and the availability ofreplacement players, as well as otherssuch as financial factors (e.g. the playeris currently negotiating a new contract)or psychological factors (e.g. pressurefrom self, family, agents etc).A number of risk tolerance modifiers, inparticular those that are directly footballrelated, can be identified as soon asthe injury occurs. These should beconsidered when estimating RTP time.11
MUSCLE INJURY GUIDE:PREVENTION OF AND RETURN TOPLAY FROM MUSCLE INJURIES12PLAYER 1PLAYER 2Injury locationand severityBiceps femoris tearinvolving the intramusculartendon rupture, locatedin the middle third of thethighBiceps femoris tearinvolving the intramusculartendon rupture, locatedin the middle third of thethigh“Normal” RTPtime for thisinjury4 weeks4 weeksPlayer-specificfactors1st injury in this location(no change to initial RTPestimate)3rd injury in this location(Indicates poorer qualityconnective tissue: 1 week)Footballspecific factorsCentral midfielder, tacticalplaying style (no change)Wing back, aggressiveplaying style (High sprintdemands: 1 week)Risk-tolerancemodifiersKey player in the team.Injury occurred inFebruary, 3 weeks beforeChampions Leaguesemi-final (Higher riskacceptable: -1 week)Player not normally instarting 11. Injury occurredin October (Lower riskstrategy: 1 week)Estimated RTPtime3 weeks7 weeksPUTTING IT ALL TOGETHERAs illustrated in Table 2, making the RTPestimate for a specific muscle injuryinvolves adjusting the normally expectedRTP time upwards or downwards, basedon player-specific factors, football-specificfactors, and risk-tolerance modifiers.This process requires medical knowledge,football knowledge and experience,and should be considered an art just asmuch as a science. We highlight thatthroughout this section we have used theterm estimation, rather than prediction.None of us owns a crystal ball. However,using a guiding framework can help eveninexperienced practitioners make moreaccurate and consistent RTP estimations.CHAPTER 2 Table 2Example of how thesame injury can leadto markedly differentRTP time estimates
MUSCLE INJURY GUIDE:PREVENTION OF AND RETURN TOPLAY FROM MUSCLE INJURIES2.2.1MAKING AN ACCURATEDIAGNOSISWhen an injury occurs during training or match play, the essential questions toanswer as clinician on-field are: where is the localisation of the muscle injury, whattype is the injury and, can the player continue to play? In most cases, the playershould be taken off the field for further assessments and acute injury managementaccording to the PRICE principle (protection, rest, ice, compression, elevation).— With Thor Einar Andersen, Arnlaug Wangensteen, Justin Lee, Noel Pollock, Xavier ValleThe first step off-field is acomprehensive clinical examinationincluding detailed patient injuryhistory taking and careful physicalassessments. In cases where theclinical appearance and severityis unclear and determining theoptimal treatment can be difficult,supplementary radiological imagingcan provide important additionalinformation to confirm the radiologicalseverity of the injury and guidefurther treatment. Making an accuratediagnosis is essential to ensure thatinjured players receive appropriatetreatment and correct informationregarding their prognosis.1 This chapterwill discuss the initial and subsequentclinical and possible radiologicalassessments to enable the clinician toconfirm an accurate diagnosis.Macrotrauma· Sudden onsetNon-contact(internal forces)Strain/tears· Tendon ruptures· Avulsion fracturesCrampsAcuteOveruseContact(external forces)Typical signs of an acute muscle injuryto identify include, an acute onset ofpain where the player is able to recallthe inciting event, pain or discomfortwith isometric contraction, stretching,and palpation of the injured muscle. Inmany cases the range of motion (ROM)is restricted. In the section below, wepresent a guide on how to establish atentative diagnosis.CHAPTER 2Microtrauma· Gradual onset· Chronic compartment· Delayed onset musclesoreness (DOMS)· Focal tissue thickening /fibrosisContusions· Mytosis ossificans· Acute compartmentLacerationsON-FIELD MANAGEMENTWorking on-field as a clinician, withthe pressure of limited time and therequirement to act quickly when anacute injury happens, the purpose ofthe initial assessment is to answer someimportant questions: Is there a muscleinjury and where and what type is theinjury? And can the player continue toplay or not?13MUSCLE INJURIESSigns that the player may be able tocontinue to play include, for example,muscle cramps that resolve quickly withno residual symptoms, or mild contusioninjuries with no loss of function andminimal pain. However, we encourage thepractitioner to err on the side of caution. If indoubt, take them out.The acute management should be initiatedas soon as possible. Despite little evidencebasis for the early management of acutemuscle (strain) injuries3, the PRICE principleis traditionally considered the cornerstonefor treating acute soft tissue injuries.4,5POLICE (protection, optimal loading, ice,compression, elevation) is suggested as analternative acronym, where optimal loadingmeans replacing rest with a balanced andincremental RTP program where early Figure 1Schematic overviewof the different typesof muscle injuries.Tendon and boneinjuries (avulsionfractures) are includedas sub-classificationsof muscle straininjuries, as theymay appear to bemuscle injuries withsimilar mechanismsand often similarclinical presentation.(Reprinted withpermission fromWangensteen 20182).
MUSCLE INJURY GUIDE:PREVENTION OF AND RETURN TOPLAY FROM MUSCLE INJURIES14activity encourages early recovery.6 Itis important to initially differentiatebetween contact and non-contactinjuries. In contusion injuries, suchas quadriceps contusions, the injuredmuscle is recommended to be stretchedtowards maximum during compression inorder to minimise hematoma formation(by increasing the counterpressure),7–9whereas muscle strain injuries should notbe elongated towards outer ranges duringthe initial management to avoid additionalstrain and damage.OFF-FIELD EXAMINATIONSClinical examination, including patienthistory taking and physical assessments,is the cornerstone in the diagnosis ofany muscle injury and should be the firststep before any further investigationsare performed.10–12 The primary aim ofthe clinical examination is to determinethe type, location and extent of the injuryand whether imaging and/or otherinvestigations are needed. In addition,clinical examinations form the basis forfurther RTP decisions, and are valuableas the foundation for re-testing andcomparison when considering informationto be provided for the RTP decisionmaking process. The clinical examinationmay provide a rough estimate of theseverity and time needed to RTP, althoughfurther evaluation and observation is likelyto increase the accuracy of this estimation.Clinical assessment, in conjunction withimaging, can also identify the rare caseswhen early surgery is required.CHAPTER 2Later in this section, we describespecific clinical examination testsfor the most common muscle injurylocations in football – the hamstrings,adductor, quadriceps and calf muscles.The initial clinical examinationshould be performed as soon as theplayer leaves the field and with dailyfollow-up examinations until thecorrect diagnosis is established. Inthe following section, we outline asystematic approach to the clinicalexamination of muscle injuries.PATIENT HISTORYA thorough injury history forms thefoundation of diagnosis. In fact, inmany cases it is possible to accuratelydiagnose the injury based only onthe injury history. The most importantquestions regarding the injury situationand mechanism, symptoms, previousinjury history and workload are shownin Table 1. More detailed informationspecific to each muscle injury locationcan be found later in this section.
MUSCLE INJURY GUIDE:PREVENTION OF AND RETURN TOPLAY FROM MUSCLE INJURIESInjurysituationWhen did the injury occur?During game or training? (timing)First, middle or last part? (register minutes of the game)Season: beginning, middle, end, out of seasonHow did the injury occur? Injury mechanismContact or non-contact? (i.e. contusion or strain?)Exact movement; high speed running – acceleration/deceleration (typically hamstring); kicking (typically adductor andrectus femoris), stretching; changing directions/cutting; jumps/take offs/landings; towards excessive outer ranges (NB totalruptures!)Forced to stop immediately? Weightbearing impossible or restricted? (might indicate severity)Able to continue? Able to continue with restrictions?‘Popping’ feeling and/or sound at time of injury? (might indicate severity and suspicion of total rupture)PainLocation (where does the player report pain)Onset: acute or gradual?Severity (a visual analogue scale or a numeric rating scale of 0-10 can be helpful): at the time of injury onset today (at time of examination) at restTime to pain free walking?Function: pain with walking? pain with ascending/descending stairs? specific activity provoking pain?Other aggravating factors?PreviousinjuryhistoryIs
General Principles of Return to Play from Muscle Injury 2.1.1 RETURN TO PLAY FROM MUSCL E INJUR Y: AN INTRODUCTION P 7 2.1.2 RETURN TO PLAY IN FOOTBALL: A DYNAMIC MODEL P 8 2.1.3 ESTIMATING RETURN TO PLAY TIME P 10 2.2.1 MAKING AN ACCURATE DIAGNOSIS P 13 3. RTP from Specific Muscle Injury 3.1 RETURN TO PLAY FOLLOWING HAMSTRING MUSCLE INJURY
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Data Collection Techniques: Manual Muscle Testing 1. State the purpose of manual muscle testing in physical therapy. 2. Explain the principles of manual muscle testing.* 3. Describe concepts related to the reliability and validity of manual muscle testing. 4. Define muscle test grades.* 5.
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