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

• Protect our players’ health

• Maximize player and team performance

• Ensure the scientific integrity of medical and performance programs delivered in FC Barcelona

At FC Barcelona we believe that the creation, integration, and delivery of an effective and efficient medical and performance program requires an evidence-led approach, using the best of research knowledge combined with our many years of practical experience. We also believe strongly in sharing our knowledge and experiences among the football and sports community globally.

In 2009, we published the first FC Barcelona Muscle Injury Guide with the aim of providing an insight into our philosophy and methods of preventing and treating muscle injuries. Then in 2015, we released our second Muscle Injury Guide. With each Guide, we strive to progress on the last. We now have the great pleasure of launching our 2018 FC Barcelona Muscle Injury Guide: ‘Preventing and Treating Muscle Injuries in Footballers’. We see this Guide not as a progression on the previous two, but rather as a new concept and with a new direction. In the true spirit of FC Barcelona, we are ‘mes que un club’ (more than a club) and have welcomed into our football family, a number of internationally renowned sports medicine and performance practitioners and researchers to contribute with us on the practical recommendations that follow. We are truly grateful for the partnerships we have formed in the production of this Guide including; the Oslo Sports Trauma Research Centre and the Science and Medicine in Football Journal. Our aim is to provide you, the reader/practitioner with the most up to date knowledge and experiences from 60+ worldwide experts combined with the ‘Barça Way’.

Our Muscle Injury Guide is not intended to be a ‘must follow recipe’, but rather 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

1- AN INTRODUCTION TO PREVENTING MUSCLE INJURIES

The objective of football is to win games. 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

A NEW MODEL FOR INJURY PREVENTION IN TEAM SPORTS: THE TEAM-SPORT INJURY PREVENTION (TIP) CYCLE

Recently there has been growing interest in injury prevention for football and other team sports, including the development of models and frameworks to guide injury prevention efforts, and improve understanding of injury aetiology.

— With James O’Brien, Caroline Finch, Ricard Pruna, and Alan McCall

EVALUATING THE MUSCLE INJURY SITUATION(EPIDEMIOLOGY)

Muscle injuries are one of the biggest medical problems in modern football, regardless of the playing level. Specifically, muscle injuries represent almost one third of time-loss injuries and account for more than one-quarter of the overall injury burden as it was shown in the largest available study involving more than 9,000 injuries in men’s professional football players in Europe. Numbers from this investigation also revealed that on average, an individual player will sustain a muscle injury every other season.

— With Markus Waldén, Tim Meyer, Matilda Lundblad, Martin Hägglund

EVALUATING THE MUSCLE INJURY SITUATION IN YOUR OWN TEAM

— With Alan McCall, Markus Waldén, Martin Hägglund, and Ricard Pruna

RISK FACTORS AND MECHANISMS FOR MUSCLE INJURY IN FOOTBALL

— With Markus Waldén, Khatija Bahdur, Matilda Lundblad, Martin Hägglund

THE COMPLEX, MULTIFACTORIAL AND DYNAMIC NATURE OF MUSCLE INJURY

While risk factor identification is important, athletic injuries do not occur because of any single risk factor. Rather, injuries (muscle injuries included) occur as several risk factors interact at the time of an inciting event during training or competition. In other words, athletic injury etiology is complex, dynamic, multifactorial, and context dependent.

— With Natalia Bittencourt, Mario Bizzini, Johann Windt, and Alan McCall

MUSCULOSKELETAL SCREENING IN FOOTBALL

It is common practice in professional sport to perform some manner of periodic health evaluation (PHE), commonly referred to as “screening”. In elite football, 90% of the teams do some form of screening throughout the season. Professional teams and football governing bodies aim to protect the health of the player through screening and monitoring to identify potential risk of injury, which, if possible, could positively impact performance, economical aspects at the club, and the health of players.

— With Nicol van Dyk, Robert McCunn, Phil Coles, Roald Bahr

BARRIERS AND FACILITATORS TO DELIVERING INJURY PREVENTION STRATEGIES

Published information on barriers and facilitators to delivering injury prevention strategies is scarce, but initial research on injury prevention exercise programs has identified a wide range of factors, relating either to the content and nature of the program itself, or how the program is delivered and supported by players, coaches and team staff members.

— With James O’Brien and Caroline Finch

STRATEGIES TO PREVENT MUSCLE INJURY

When we think of prevention strategies for muscle injuries, we typically think of exercises targeted at strengthening the muscles and related modifiable risk factors that exercise can influence. However, in contemporary professional football, we are moving away from the thought that preventing muscle injury means implementing specific exercises and looking at it as a more holistic strategy that is multifaceted.

— With Alan McCall and Ricard Pruna

CONTROLLING TRAINING LOAD

Athlete monitoring is now common practice in high-performance football. Fundamentally, athlete monitoring involves quantifying the players training load and their responses to that training. The main reasons for monitoring athletes are that it can provide information to refine the training process, increase athlete performance readiness and reduce risks of injury and illness. Through a systematic approach to data collection and analysis an improved understanding of the complex relationships between training, performance and injury can be obtained.

— With Aaron J Coutts

RECOVERY STRATEGIES

Our Delphi survey revealed recovery as an effective strategy to prevent muscle injury in elite footballers. Although fatigue has been highlighted by football practitioners as one of the most important non-contact injury risk factors in elite players,  it is surprising that the actual scientific level of evidence for fatigue and injury is currently weak.

— With Abd-Elbasset Abaidia, Gregory Dupont, Antonia Lizarraga, and Shona Halson

EXERCISE-BASED STRATEGIES TO PREVENT MUSCLE INJURIES

Exercise is one of the most common preventative strategies implemented by football teams to prevent muscle injury. The following summary and recommendations are a combination of relevant scientific research findings with current best practice.

— With Maurizio Fanchini, Eduard Pons, Franco Impellizzeri, Gregory Dupont, Martin Buchheit, and Alan McCall

*Special contribution from Nick van der Horst, Ida Bo Steendhal and the EBMIP Delphi Group

COMMUNICATION

Another of the most important injury prevention strategies as highlighted by elite football practitioners from the ‘Big 5’ Leagues in our Delphi Survey was ‘communication’. A common opinion among football practitioners is that to maximize the preventative effects of strategies such as controlling load and implementing exercise and recovery strategies, we must be able to communicate effectively with key stakeholders such as players and coaching staff, as well as among ourselves.

— With Mike Davison and Ricard Pruna

CONTINUOUS (RE) EVALUATION AND MODIFICATION OF PREVENTION STRATEGIES

A key phase of the Team Sport Injury Prevention (TIP) cycle is ongoing (re) evaluation of the injury situation to find out whether prevention strategies are actually having an impact. Are any new or different injury patterns emerging? This information is essential to allow the medical and performance team to adapt to a constantly changing injury landscape and ensure maximum prevention effectiveness over time.

— Alan McCall, Ben Clarsen, James O’Brien and Robert McCunn

2- RETURN TO PLAY FROM MUSCLE INJURY: AN INTRODUCTION

The previous section on preventing muscle injury in football has outlined various strategies and tools that can be adopted to minimize the risk of players incurring a muscle injury. While in an ideal world we would be able to prevent all muscle injuries from occurring this is, unfortunately, impossible. As outlined in our ‘Injury Landscape’ article a professional football can expect around 16 muscle injuries in a season.

— With Ricard Pruna, Alan McCall and Thor Einar Andersen

RETURN TO PLAY IN FOOTBALL: A DYNAMIC MODEL

There 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 of a rehabilitation program, we now consider that return to play starts the moment the injury occurs and continues beyond the point where the player making his or her return to unrestricted match play. This type of progression is individual and malleable, allowing for faster and slower individual progressions throughout the return to play plan.

— With Clare Ardern and Ricard Pruna

RETURN TO PLAY IN FOOTBALL: A DYNAMIC MODEL

When a footballer sustains a muscle injury, their first question is invariably: “how long will this take to recover?” Answering this is not easy, but in elite-level football, it is vital to make an educated guess. As previously discussed, the RTP continuum begins with the anticipated date of return to optimal performance in mind and works backward, defining the milestones necessary to achieve that goal. This approach motivates the player, allows the manager to plan effectively, and facilitates good communication and realistic expectations from all involved.

— With Ricard Pruna and Ben Clarsen

MAKING AN ACCURATE DIAGNOSIS

When an injury occurs during training or match play, the essential questions to answer as clinician on-field are: where is the localization of the muscle injury, what type is the injury and, can the player continue to play? In most cases, the player should be taken off the field for further assessments and acute injury management according to the PRICE principle (protection, rest, ice, compression, elevation).

— With Thor Einar Andersen, Arnlaug Wangensteen, Justin Lee, Noel Pollock, Xavier Valle

EXERCISE PRESCRIPTION FOR MUSCLE INJURY

When a player sustains a muscle injury, the chances of it recurring are high. In fact, epidemiological research consistently identifies previous injury as the most powerful risk factor for muscle injuries.

Fortunately, the risk of recurrence can be reduced through careful management of the return to play process, including appropriate prescription of therapeutic and football-specific exercises.

— With Phil Glasgow, Thor Einar Andersen and Ben Clarsen

RESTORING PLAYERS’ SPECIFIC FITNESS AND PERFORMANCE CAPACITY IN RELATION TO MATCH PHYSICAL AND TECHNICAL DEMANDS.

Restoring the players’ specific fitness and performance capacity before joining the team for collective training sessions and competitions is essential

— With Martin Buchheit and Nicolas Mayer

REGENERATIVE AND BIOLOGICAL TREATMENTS FOR MUSCLE INJURY

Despite the substantial regenerative potential that skeletal muscle possesses in the form of its own stem cells, injured skeletal muscle still heals, like most of our tissues, by a repair process, not by complete regeneration. Thus, the healing will result in the formation of non-functional scar tissue. The outcome of this repair process is that the ruptured skeletal muscle fibers remain terminally separated by the scar tissue that has formed at the site of the injury, i.e. inside the injured skeletal muscle.

— With Tero AH Järvinen, Haiko Pas and Jordi Puigdellivol

SURGERY FOR MUSCLE INJURIES

When dealing with muscle injuries, the main principles of non-operative treatment should be used as a common guideline. There are, however, more severe muscle injuries in which surgical treatment should be considered. Especially in athletes, but also in other physically active people, if misdiagnosed and/ or improperly treated, a complete or even a partial muscle rupture can cause considerable morbidity and lead to decreased performance.

— Lasse Lempainen and Janne Sarimo

3- RETURN TO PLAY FOLLOWING HAMSTRING MUSCLE INJURY

In this section, we build upon the general principles described earlier in the guide, with specific reference to hamstring muscle injuries.

— With Thor Einar Andersen, Arnlaug Wangensteen, Nicol van Dyk and Ricard Pruna

SURGICAL TREATMENT OF HAMSTRING INJURIES

Most hamstring injuries do not require surgery. However, in some cases, surgery should be performed immediately after the injury occurs. Surgery may also be necessary if conservative treatment fails to achieve a satisfactory result – for example, if the player has chronic symptoms or recurrent injuries.

— With Lasse Lempainen, Sakari Orava and Janne Sarimo

RETURN TO PLAY FOLLOWING QUADRICEPS MUSCLE INJURY

In this section, we build upon the general principles described earlier in the guide, with specific reference to quadriceps muscle injuries.

— With Phil Glasgow, Mario Bizzini and Andreas Serner

SURGERY FOR RECTUS FEMORIS MUSCLE INJURIES

Rectus femoris muscle injuries are common in sports. Most of these injuries are strains or direct contusions which are treated by conservative means with good results. There are, however, also more severe rectus femoris injuries which can result in impaired athletic performance and long rehabilitation times. In these severe rectus femoris injuries, the decision of optimal treatment method is not always so evident.

— With Lasse Lempainen, Sakari Orava and Janne Sarimo

RETURN TO PLAY FOLLOWING GROIN MUSCLE INJURY

In this section, we build upon the general principles described earlier in the guide, with reference to acute groin muscle injuries, specifically, injuries to the adductor, hip flexor, and abdominal muscle groups.

— With Andrea Mosler, Andreas Serner, Joar Harøy, Jonas Werner and Adam Weir

RETURN TO PLAY FOLLOWING CALF MUSCLE INJURY

In this section, we build upon the general principles described earlier in the guide, with specific reference to calf muscle injuries.

— With Tania Pizzari, Brady Green, Karin Silbernagel, and Anthony Schache

SURGERY FOR CALF MUSCLE INJURIES

The vast majority of calf muscle injuries can be successfully managed conservatively. In some cases, however, surgical intervention is warranted. Given the high pressure on players and medical and performance staff to return to the pre-injury level as fast as possible, it is paramount to recognize these cases as early as possible. Failure to do so could potentially result in suboptimal outcome, persistence or worsening of dysfunction and complaints, or recurrent injury.

In this section, we review the specific injuries for which surgical intervention should be considered, surgical technique, and prognosis.

— Özgür Kilic, Anne van der Made and Gino Kerkhoffs

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