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http://muscletechnetwork.org/proyectos-id/publicaciones/

Clinical Practice Guidelines for Muscle Injury FC Barcelona and Aspetar Experience

XXIV International Conference on Sports Rehabilitation and Traumatology Clinical Practice Guidelines for Muscle Injury, FC Barcelona Aspetar

11th-12th April, 2015 - London

Clinical Practice Guidelines for Muscle Injury

(2015)


(2009)


(2018)

Previous consensus (2017)



(UCL Elite Club Injury Study. 2013/2014 Season Report)



11%

28%

61%

43%

25%

32%

0%

10%

20%

30%

40%

50%

60%

70%

Quadriceps Adductor Hamstrings

FCB 1st Team FCB Academy



1. Muscle injuries classification 2. Diagnosis and management of muscular injuries 3. Algorithm of rehabilitation 4. Return to play criteria 5. Primary and secondary prevention

CONTENTS



Introduction

Several grading and classification systems for muscle injuries have been published; indeed, no validated classification system exists.

To classify is necessary to have good epidemiological data, which are basic to find the best therapeutic option for an injury/disease.



The Proposal

In our opinion the evaluation of the amount of extracellular matrix (ECM) damaged and its impact in force generation and transmission is a key factor in muscle injuries clinics and prognosis; therefore the classification is based on this concept. We reviewed the literature to select and organize the knowledge about muscle injuries:

Mechanism. Clinic and imaging prognosis factors. Injury relation with MTJ and amount of connective tissue damage (indeed of

function). Evolution in time.

We organize and resume this concept in a 4 letters acronym structure.



Muscle Injury Mechanism

1. Direct injuries:

Located in the place of the trauma.

Size is not well correlated with the functional impairment.

Different clinical evolution than indirect injuries (shorter time loss).

2. Indirect muscle injuries are located close to a myotendinous junction (MTJ).

Lee J, Mitchell A, and Healy J. Imaging of muscle injury in the elite athlete. British Journal of Radiology 85: 1173-1185, 2012. Thorsson O, Lilja B, Nilsson P, and Westlin N. Immediate external compression in the management of an acute muscle injury. Scandinavian journal of medicine & science in sports 7: 182-190, 1997. Garrett WE, Nikolaou PK, Ribbeck BM, Glisson RR, and Seaber AV. The effect of muscle architecture on the biomechanical failure properties of skeletal muscle under passive extension. The American journal of sports medicine 16: 7-12, 1988.



Extracellular matrix (ECM) damage

The evaluation of the amount/severity of ECM damaged is done trough:

Muscle injury relation with the MTJ (proximal or distal).

% CSA as reflection of the amount of ECM damaged.

If there is tendon gap/retraction/loss of tension.

Structure and function of the skeletal muscle extracellular matrix Gillies 2011



Mechanism

Location

Grade

Re-injury



Mechanism

It describes the mechanism of injury, which could be a direct blow or an indirect strain:

Direct injuries D

Indirect injuries I



Location for direct injuries

Is a lowercase regarding the anatomical location:

p injuries located at the proximal third.

m injuries located at the middle third.

d injuries located at the distal third.



Is a capital letter followed or not by a lowercase regarding the Location.

It describes the connective tissue damage location, tendon or MTJ.

J for the injuries at the MTJ.

T for injuries affecting the tendon: gap/retraction/loss of tension.

After the T and J, as a sub-index, the proximal and distal location must be specified (p for proximal and d for the distal).

Location for indirect injuries



Grade

Is a number from 0 to 4 regarding the Grade. MRI based, is referred to the percentage of the cross sectional area (% CSA) of the affected muscle to total muscle belly, in the axial plane where the injury is greater.

The affected area is considered where there is a hyper-signal change on fat suppressed/STIR images.

If more than one muscle is injured, the muscle with the greater area of signal abnormality or architectural distortion will be considered the primary site of injury and the grading criteria will be taken for that particular muscle.



0 Grade 0: clinical suspicion of muscle injury with negative MRI.

1 Grade 1: 10% of CSA.

2 Grade 2: 11-25% of CSA.

3 Grade 3: 26-49% of CSA.

4 Grade 4: 50% of CSA.

In the future, the architectural distortion, more than the oedema, should be the key in the imaging evaluation to grade the muscle injuries.

Grade



Re-injury

Describes the injury chronology (first episode or a re-injury):

R0: First episode, R1: First re-injury, R2: Second re-injury and so on.

A re-injury is defined as injury of the same type and at the same site as an index injury occurring no more than 2 months after a players return to full participation from the index injury (Ekstrand 2011). If during the two months period after the RTP a new injury occur in the same muscle but in a different location, it will also considered a re-injury.



Proposal

Mechanism Location Grade Reinjury

D (direct)

D p proximal third direct injury

0 negative MRI

1 < 10 % CSA

2 11 25 % CSA

3 26 49 % CSA

4 >50 % CSA

R0 1st episode

R1 1st reinjury

R2 2nd reinjury

..and so on.

D m medial third direct injury

D d distal third direct injury

I (indirect)

I T p proximal tendon injury

I T d distal tendon injury

I J p proximal MTJ injury

I J d distal MTJ injury



Direct injury located in A: D-p-G-R0

Direct injury located in B: D-m-G-R0

Direct injury located in C: D-d-G-R0

A

B

C

Direct Injuries Codification



Indirect Injuries Codification

Indirect injury located in A: I-Jp-G-R

Indirect injury located in B: I-Jd-G-R

A

B



Indirect Injuries Codification

I-Tp-G-R



Take home messages

1. With an acronym we can describe the injury.

2. Allows communication among medical staff.

3. Flexible structure allowing to incorporate

knowledge in the future.

4. Easy to use.



Background

Most of them are treated non-surgically. The clinical appearance is not always clear. Determining the optimal treatment for any injury can be difficult. NEEDS Detailed history of the patient and about the injury mechanism. Careful examination. Imaging diagnosis:

Magnetic Resonance Imaging (MRI) Ultrasound (US)

Critical goal is to differentiate between those patients with injuries possibly requiring surgical treatment from patients with non-surgical injuries



1. Appropriate history

About the player:

Similar injuries before?

Medications?

Susceptibility

About the mechanism of injury:

Direct blow or indirect strain?

During training or competition?

When and how did it start?

About the initial progress:

Stop or continue playing?

Normal walk without pain?



2. Physical exam

Looking for asymmetries.

Pain.

Colour.

Muscle belly shape.

Strength.

ROM without pain.

The athlete is unable to walk at a normal pain-free pace.

BF injury is more painful during stretching than contraction while a injury in SM or ST will have more pain during contraction than during stretching.



3. Imaging of muscle injury

RX: limited value unless an avulsion fracture with bony fragment or apophyseal fracture in a skeletally immature individual.

US and MRI:

Describe the location (which muscle and tissue).

The lesion size.

The lesion nature (oedema/haemorrhage) by echotexture (US) and signal intensity (MRI)



3.1 Ultrasound

Cost effective.

Radiologist experience dependent.

Dynamic and interactive process allowing echopalpation of painful areas.

It enables progress monitoring.

Guide the evacuation of fluid collections.

Useful in distal hamstring injuries (superficial anatomy).



3.2 Magnetic resonance imaging

To evaluate the involvement of tendons, fascia and contractile tissue.

Routine MRI protocol:

At least two orthogonal planes (axial, coronal or sagital) and one of two pulse sequences (STIR or T2 fat sat).

Restricted in routine assessment of injuries (limited availability and high costs).

Its utilization in prognosis of return to play is controversial.



MRI advantages

To measure the size of injury (length and cross-sectional area).

Proximal hamstring injuries.

Groin area injuries.

In assessing the tendon retraction (preoperative planning).

In highlighting subtle edema.

In evaluating injuries to deep injuries of muscles.

In evaluating injuries when a previous injury is present (residual scarring).

Discovering concomitant image.



Management of a muscle injury

Clinical history

Physical exam

US MRI Treatment

Immediate X X

Could be made

anytime

Rest

Ice

Compression

Elevation

Analgesia

12 hours X X

24 hours X X

48 hours X X

Functional tests

1st week Monitorize

players feelings

X x To evaluate how the

progression of loads are assumed

Rehabilitation

progressive protocol

Weekly X X

Return to play X X

For follow-up the functional recovery and sometimes to help to decide return to play: Muscle: Tensiomyography, electromyography and strength tests. Player: GPS, HR and self administered scales during and after the rehabilitation sessions on field.

Initial acute phase

Subacute and

functional phase



Muscle injuries heal conservatively.

Indications of surgical treatment: Total or subtotal (>50%) rupture with few or no agonist muscles.

Large intramuscular hematoma.

Complains of chronic pain (>4-6 months) in a previously injured muscle, specially with ROM deficit.

Surgical procedure: Anatomic restoration when is possible.

Surgical release of adhesions from the nerve and scar debridement in

chronic cases.

Surgical treatment



Bony avulsions

Muscle Part of muscle Tendon Treatment

Quadriceps

Proximal ASIS AIIS

Conservative; unless > 2cm

Distal Patellar avulsion Surgical; (except non

displaced)

Hamstrings

Proximal Ischial tuberosity Gap < 2cm conservative

Bigger gaps: surgical

Distal All (rare)

( BF SM ) Surgical reattachment must

be considered



Proximal

Distal

Rectus femoris



Tendon-bone disinsertions

Muscle Localization Tendon Treatment

Quadriceps

Rectus Femoris Proximal

Direct head Surgical reattachment

Indirect head Little gap: Conservative

Big gap: Surgical

Direct + Indirect head Surgical

Hamstrings Proximal

Biceps Femoris Long Head and/or Semitendinosus

Surgical

Semimembranosus

Conservative. If there were symptoms after 4 months: surgical reattachment

must be considered

Distal All (rare) Surgical reattachment must be

considered



Ischion

Central Tendon



Reattached



Comin J, Malliaras P, Baquie P, Barbour T, Connell D. Return to competitive play after hamstring injuries involving disruption of the central tendon. Am J Sports Med. 2013;41(1):111-115.

Long recovery times.

Worse results.

Biceps femoris 45%

Recurrent injury.

New surgical indication for hamstring?



DISTAL

PROXIMAL

Proximal end of Central

Tendon

Distal end of Central

Tendon



Central Tendon injuries

MTJ injuries, when the Central Rectus Femoris Tendon or Common Hamstring Tendon is involved with loss of tension

Muscle Part of muscle-tendon Treatment

Quadriceps and

Hamstrings

< 2 cm from bone insertion Reattachment to the

bone and reduce tension at MTJ

More than 2 cm to bone insertion

Surgical treatment: Anatomical repair

with minimally invasive approach


Take home messages

1. Clinical expertise in muscle injuries.

2. US and MRI to confirm diagnosis.

3. Surgical treatment when tendon is

affected.



Rehabilitation Program

LITERATURE

SEARCH

SCIENTIFIC

EVIDENCE

EXPERIENCE

CONSENSUS

THERAPEUTIC



Proposal of Algorithm

ALLPARAMETERSDIAGNOSTICPHASE ACUTEPHASE SUBACUTEPHASE FUNCTIONALPHASE PHASETORTP

ANDCONTROLTEST DESTRUCTION REPAIR REMODELLING

PHISICALTHERAPY X X X

MANUALTHERAPY X X X

FLEXIBILITYANDROM X X X

PROPIOCEPTION X X X

CORE X X X

NEUROM-CONTROL X X X X

STRENGTH X X X

POWER X X

FITNESS X X

PAIN/FATIGUE X X X X X

BIOMECANICHS X X X X X

IMAGE X X X X X



Progression of exercises



Algorithm of Rhb

INJURY

DIAGNOSTIC PHASE

Goals

Criteria

Validation Test

Goals

Criteria

Validation Test

Goals

Criteria

Validation Test RTP



Diagnostic Phase

Kerkhoffs, G., et al. "Diagnosis and prognosis of acute hamstring injuries in athletes, 2013

INJURY !!!

PRESSION (together with Cryotherapy 3 times/day, every 3h, 20-30) REST (sporting, not total) ICE (Cryotherapy 3 times/day, every 3h., 20-30) IMMOBILISATION (3-4 days, every 3-4h, between 15-20) ELEVATION (upper the heart level and different positions)

ANAMNESIS (Injury analysis, antecedents,...) COMPLEMENTARY PROOFS (RN, ECO, ...) GENERAL TESTS (Assessment muscular, articular,...) SPECIFIC TESTS (types of pain, localisation, function) PSICOLOGIC SUPPORT OF PLAYER DIFFERENTIAL DIAGNOSTIC FINAL DIAGNOSTIC



Algorithm of Rhb

INJURY

DIAGNOSTIC PHASE

Goals

Criteria

Validation Test

Goals

Criteria

Validation Test

Goals

Criteria

Validation Test

RTP



Acute Phase



Goals and Criteria

Acute Phase

- NO PAIN or discomfort during exercises

- During exercises to maintain neutral spine in static position to Bosu or Board

- To work from Low to Moderate Intensity

- Isometric knee flexion 15, decubitus prono (ISOM)/(CONC)/(ECC)

- Work with flexion knee to 45 and hip 0>50% (CKC) / (OKC)

- Uninjured leg (dynamometer or similar 50%.)

- (SBET) with 30 Flexion Knee +(SLS) +(ESH)



Algorithm of Rhb

INJURY

DIAGNOSTIC PHASE

Goals

Criteria

Validation Test

Goals

Criteria

Validation Test

Goals

Criteria

Validation Test RTP



Subacute Phase



Goals and Criteria

Subacute Phase

- NO PAIN or discomfort during exercises.

- Not tilting the pelvis or flattening the spine during dynamic exercises

- To work from Moderate to High Intensity

- Isometric knee flexion strength decubitus supine knee flexion 25

- hip flexion 45, less than 10% asymmetry (OKC)/(CKC)

- Work uninjured leg (dynamometer or similar 70%.)

- Isometric hip extension strength, knee 0, Hip 70 less than 10%

- (ESH) Stretch < 70 +(SLS) +(DST) painless

- Start Walking on the treadmill to



Algorithm of Rhb

INJURY

DIAGNOSTIC PHASE

Goals

Criteria

Validation Test

Goals

Criteria

Validation Test

Goals

Criteria

Validation Test RTP



Functional Phase



Goals and Criteria

Functional Phase

- No PAIN or discomfort during exercises.

- Correct spine control and strength transfer during exercises

- To work from High to Explosive Intensity

- Integrate strength, neuromuscular and proprioceptive work

- Achieved in contralateral leg no asymmetry (dynamometer/encoder 100%)

- Uninjured leg (Encoder or isokinetic 100%.)

- Isokinetic criteria: We should avoid differences higher than 20%

- (RPT)+(AHFT)+(AKET) No asymmetry

- Test of the feed and games

CKC: Close Kinetic Chain, OKC: Open Kinetic Chain, ISOM: Isometric, CONC: Concentric, ECC: Eccentric, ROM: Range of Motion; ESH

(Elongation Stress on Hamstrings.). DST: (Deep squat test). SLS: Single leg squat. RPT: Runner post test. AKET: Active Knee Ext Test:



Algorithm of Rhb

INJURY

DIAGNOSTIC PHASE

Goals

Criteria

Validation Test

Goals

Criteria

Validation Test

Goals

Criteria

Validation Test RTP

Criteria-based progression

Development of an approach



Ph

ysio

On

-fie

ld

100%

0%



Physio On-field

Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 Stage 6

Painless single leg squat Painless bike 150W, 5 mins

Full knee Ext supine

Run > 70% ROM SLR & HS > 75%

100% running Painless direction change

Light Football Training Session

In-between Football Training Session

Heavy Football Training Session



Passive movement

Massage no pain

Massage - discomfort

Active range of motion

Eccentric outer range

Slow run Concentric

through range Fast run

Direction change Isometric inner

range Eccentric inner

range Outer range

ballistic

Stretching Trunk control Cardio (bike) Isometric outer

range

Painless single leg squat Painless bike 1.5*BW, 5 mins


Run > 70% ROM SLR & HS > 75%




Gait

Walk

Jog

Run

Triple extension

Late swing (A drill)

Direction change

4 laps =8 sprints X 3 sets ~ 700m 11s 3.1 s 10% 100%

3 reps 12s 9s 60% 100%



Physio On-field

Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 Stage 6

Painless single leg squat Painless bike 150W, 5 mins


Run > 70% ROM SLR & HS > 75%


Light Football Training Session

In-between Football Training Session

Heavy Football Training Session



020

40

60

80

100

120

140Pe

rcen

t o

f u

nin

jure

d s

ide

Inner range

Mid range

Outer range


Take home messages

1. Sequential and progressive.

2. Dynamic and open.

3. Adaptable to each player.

4. Criteria-based progression

5. Based on knowledge and experience.



The decision-making process of returning an injured or ill player to competition



All clear to play

Huge reinjury risk (14-16%)

Criteria

1. Clinical/ Anatomical 2. Imaging (US) 3. Functional

Specific Physical Test

High workloads Highest competition level No reinjury

HEALTHY INDIVIDUALS

WHEN?



Return to play

Anatomical, imaging and functional CRITERIA have to be taken into

consideration in order to provide:

Personalized return to play:

1. Injury location/connective tissue involved

2. Anatomical variability

3. Imaging

4. Player position/GPS



1. Injury location/connective tissue



Return to play






3. Imaging




A

B

C

Semimembranosus injuries



Return to play






3. Imaging




3. Imaging



Return to play






3. Imaging




4. Player position / GPS



COMPARISON THE PLAYERS SAME POSITION WITH THE PLAYER INJURED

0 50 100 150 200 250 300

AVE HSR SET 5PLAYER INJURY

AVE HSR SET 6PLAYER INJURY

AVE SPRINT SET 5PLAYER INJURY

AVE SPRINTS SET 6PLAYER INJURY

AVE ACEL SET 5PLAYER INJURY

AVE ACEL SET 6PLAYER INJURY

AVE DEC SET5PLAYER INJURY

AVE DEC SET 6PLAYER INJURY

AVE VEL.MAX SET5PLAYER INJURY

AVE VEL.MAX SET6PLAYER INJURY

SUMMARY

DA

TA W

EEK

S 5

/6

Comparision with the same players injured player position return to train with the group



COMPARED TO OTHER DEFENDER SAME POSITION DURING 60 MINUTS THE FRIENDLY MATCH

43 51 32 37 38

55

49 45 45 44 42

59

020406080

100120

HIGH ACEL/DESA


Take home messages

1. Personalized.

2. Technology and experience.

3. Six training sessions.

4. Friendly matches.



PRIMARY PREVENTION

Prevent the onset of muscle injury

Addressing risk factors Enhancing resistance to exposure

Part of the general football training (all players)



Avoidance of a new muscle injury when the player has suffered a previous injury

SECONDARY PREVENTION

Individual, personalized, specific program



PREVENTION SNAPSHOT

PLAYER INDIVIDUAL STRENGTH PROGRAMME

SQUAD PREVENTION PROGRAMME (SPECIFIC EXERCISES)

WARM UPS PREVENTION OBJECTIVES DAILY

STRENGTH CIRCUITS

FOOTBALL CIRCUITS

GYM

GY

M

P

ITC

H

SMALL GROUPS CIRCUITS

PITCH



PRIMARY PREVENTION


SQUAD PREVENTION PROGRAMME (SPECIFIC EXERCISES) GY

M

strength training

of the hamstringsImage Code Description weight Ser/Repet weight Ser/Repet frequency When

Musculador belt STh1

Eccentric working with variants in dop:

drop with rotation, different angles of

flexion..

body weight or body

weight with 3kg3x4

body weight or body

weight with 3kg 3x8

1x7 (1 competition)/10

days( 2 competitions)

Before or afther 48

hours to match

Splits with body

flexionSTh2 Work hamstring body weight 4 repetitions body weight 8 repetitions once or twice a week

Alternate days ,

never before or

afther to match

Angel STh3 Work hamstring body weight 4 repetitions body weight 8 repetitions once or twice a week

Alternate days ,

never before or

afther to match

minimum stimulus maximum stimulus

StrengthTraining

PrimaryPrevention



PRIMARY PREVENTION

DAY -4. ECCENTRIC STRENGHT.

TIRANTE MUSCULADOR

DAY -3. RUNNING

TECHNIQUE & PROPIOCEPTION

EXERCISES.

DAY -2. AGILITY AND

COORDINATION SKILLS.

DAY -1. SPEED REACTION

AND FEET WORK


SQUAD PREVENTION PROGRAMME (SPECIFIC EXERCISES) GY

M


P

ITC

H



PRIMARY PREVENTION

DAY -4. ECCENTRIC STRENGHT.

TIRANTE MUSCULADOR



PRIMARY PREVENTION

DAY -2. AGILITY AND

COORDINATION SKILLS.



PRIMARY PREVENTION

W/O BALL

BOXES

PASSING DRILLS

POSSESSION GAMES

HAMSTRINGS QUADRICEPS

ADDUCTOR MUSCLES CORE STABILITY

COORDINATION / AGILITY PROPIOCEPTION

UPPER BODY




STRENGTH CIRCUITS

GY

M

P

ITC

H



PRIMARY PREVENTION

MULTISTATIONS WITHOUT BALL

MULTISTATIONS WITH BOXES

MULTISTATIONS WITH PASSING

DRILLS

MULTISTATIONS WITH POSSESSION

GAMES




UPPER BODY

STRENGTH CIRCUITS ON THE FIELD



PRIMARY PREVENTION

STRENGTH CIRCUITS ON THE FIELD

MULTISTATIONS WITHOUT BALL

MULTISTATIONS WITH BOXES

MULTISTATIONS WITH PASSING

DRILLS

MULTISTATIONS WITH POSSESSION

GAMES




UPPER BODY






STRENGTH CIRCUITS

FOOTBALL CIRCUITS

GY

M

P

ITC

H

PRIMARY PREVENTION



RELATIONSHIP BETWEEN TECHNICAL, TACTICAL AND CONDITIONING CIRCUITS.

CONDITIONING OR PREVENTION STATION PREVIOUS TO THE

FOOTBALL ACTION.

DECISSION MAKING + MULTIPLE OPTIONS

CLOSER TO OUR STYLE OF PLAY/

GAME PLAN

PRIMARY PREVENTION



LEVEL

PROGRAMME FREQUENCY CATEGORIES

OBJECTIVE EXERCISES

1. Indoor Prevention Squad Prevention Programme 1 p week Stretching

STrength

St 1

STq1, STq2 Player Individual Strength Programme 2 p week

2. Daily Prevention

Warm Ups

Eccentric Training 1 p week Stretching

STrength

PRoprioception

CoreStability

AGility

St2, St3, St4

STh1, STh3

PR2

CS1, CS2, CS3

AG 2

Proprioception 1 p week

Agility & Coordination 1 p week

Speed Reaction 1 p week

3. Multi Stations

Prevention Circuits

Multi Station Circuit Not Ball

1-2 p week

Stretching

STrength

PRoprioception

CoreStability

AGility

MultiInterv

St2,

STh1, STh2,ST

q3

PR2, PR3

CS1,CS2,CS3

AG 1

MI 1, MI 2, MI 3

Multi Station Circuit with Boxes

Multi Station Circuit with Passing Drills

Multi Station Circuit with Pos Games

4. Football Circuit

Drills Football Specific Strength Circuits 1-2 p week

STrength

PRoprioception

AGility

STh1, STq3

PR 3

AG 1

PRIMARY PREVENTION



SECONDARY PREVENTION




STRENGTH CIRCUITS

FOOTBALL CIRCUITS

GYM 2

PITCH 2

GY

M

P

ITC

H



Hamstrings injury prevention

Seated eccentric knee flexor stretch (Seated Straight-Leg Raise)




Eccentric hip extensor stretch with inertial technology (VersaPulley)




Eccentric knee flexor extension with inertial technology (Yo-Yo Knee Extension)


Take home messages

1. Evolving knowledge.

2. Primary prevention linked with

training.

3. Secondary prevention: personalized.



It has been demonstrated that hamstring injuries typically occur at this musculotendinous junction: either at the proximal or distal free ends or, more commonly, at

the central intramuscular tendon... Comin et al. Am J Sports Med. 2013;41(1):111-115

isokinetic2015versifinal 150427023055 conversion gate02

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