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Regenerative and biological treatments for muscle injury

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Prevention of
and return to
play from
muscle injuries
List editors: Editorial Assistants:
Ricard Pruna Steffan Griffin
Thor Einar Andersen Johann Windt
Ben Clarsen
Alan McCall

Roald Bahr 1.4.4.A)
Maurizio Fanchini
Phil Glasgow Andrea Azzalin
Tero Jarvinen Andreas Beck

Lasse Lampeinen Andrea Belli
Andrea Mosler Martin Buchheit
James O’Brien Gregory Dupont
Tania Pizzari Maurizio Fanchini
Nicol van Dyk Duccio Ferrari Bravo

and Treatment
Markus Waldén Shad Forsythe
Arnlaug Wangensteen Marcello Iaia
Yann-Benjamin Kugel
Imanol Martin
Samuele Melotto

of Muscle
Jordan Milsom
Darcy Norman
Edu Pons
Stefano Rapetti

Abd-elbasset Abaidia Bernardo Requena
Natalia Bittencourt Roberto Sassi
Mario Bizzini Andreas Schlumberger
Ida Bo Steenhal Tony Strudwick
Martin Buchheit Agostino Tibaudi
Phil Coles
Aaron Coutts
Michael Davison
Gregory Dupont
Caroline Finch
Brady Green
Martin Hägglund
Shona Halson
Joar Harøy
Per Homlich
Franco Impellizzeri
Gino Kerkhoffs
Ozgur Kilic
Justin Lee
Matilda Lundblad
Nicolas Mayer
Bob McCunn
Prof. Tim Meyer


Juanjo Brau
Xavi Linde
Antonia Lizzaraga
Sandra Mecho List editors: Editorial Assistants:
Edu Pons Ricard Pruna Steffan Griffin
Jordi Puigdellivol Thor Einar Andersen Johann Windt
Xavi Valle Ben Clarsen
Xavi Yanguas Alan McCall

6 Summary 7




MD, PhD MD, PT, PhD,PM&R Msc, PhD

Ricard Pruna is a specialist Thor Einar Andersen is a Ben Clarsen is a specialist Alan is Head of Research
in Sport & Exercise Medicine Professor and Head of football sports physiotherapist at & Development for Arsenal
with a Masters in both medicine research at the Oslo the Norwegian Olympic Football Club and Co-head of
‘Traumatology and Sports’ Sports Trauma Research Centre Training Center and a Research & Innovation (with
and ‘Biology and Sports’ and in the Department of Sports postdoctoral research fellow Assoc Prof Rob Duffield) at
additionally holds a PhD Medicine at the Norwegian at the Oslo Sports Trauma Football Federation Australia.
in ‘Genetics and Injury in School of Sport Sciences, Research Center (OSTRC). Alan’s background is as a fit-
Football’. Ricard has a rich and Norway. He has a master degree He has a bachelor degree ness coach and sport scientist
vast experience in top-level in health administration from in physiotherapy from the with over ten years experience
football having been the first the University of Oslo. He is a University of Sydney and working in professional club
team doctor of FC Barcelona trained physiotherapist, consul- a master degree in sports teams competing in Ligue
for over 20 years. He is also tant physician, and specialist in physiotherapy and PhD 1, English Premier League,
the Head of Medical Services Physical and Rehabilitation Me- from the Norwegian School A-League, Scottish League
at FC Barcelona, overseeing dicine. His main research areas of Sport Sciences. He is a and European competitions.
the medical strategy and staff are football injury epidemiology, director of the IOC Diploma He was Head of Sport Science
of all medical aspects in the injury mechanisms and causes, in Sports Physical Therapies and fitness coach of the Aus-
club, including X professional as well as injury prevention. He and a lecturer on the sports tralian Socceroos at the 2014
sports in addition to his first has published more than 65 physiotherapy master FIFA World Cup and the U20
team football duties. peer-reviewed articles and book program at the Norwegian Young Socceroos at the 2013
chapters. School of Sport Sciences. Ben World Cup.
Ricard’s clinical interests lie has been physiotherapist
in football medicine, muscle Thor Einar is the Chief medical for a number of professional Alan’s research interests include
injuries, genetics, return to officer of the Medical Commit- road cycling teams, and the injury prevention, recovery
play, anatomy and injury tee in The Football Association of Norwegian and Australian and performance in football.
diagnosis. He has many Norway. He has served as team national programmes. He He holds a PhD in ‘Injury
scientific publications in physician for the senior male is a senior associate editor Prevention in Elite Footballers’
the football medicine areas national team from 2002-2014. of BJSM and was the senior from Université de Lille 2 and a
and has received various He is medical director at the editor of the 5th edition of Msc in Strength & Conditioning
awards for his scientific work, Norwegian FA Medical Centre Brukner and Khan’s Clinical from Edith Cowan University,
including, the Award for and is a member of the board Sports Medicine textbook. Australia.
Medical Excellence from the and director of elite sports in
Medical College University the football department at Alan is a member of the
of Barcelona, a National and Nordstrand IF. Football Research Group, Senior
UEFA Award for research in Associate Editor at British
sports medicine. Thor Einar has a strong con- Journal of Sports Medicine,
nection with high-level football Associate Editor at Science and
having played professionally Medicine in Football and on the
winning two Norwegian cham- editorial board of Apunts which
pionships with IK Start, and is a joint publication by the
represented Norwegian interna- Conseil Catala de l’Esport and
tional youth teams (U15-U23). Barca Innovation Hub.




PhD Candidate, MSc, CSCS MBChB BSc (Hons)
KNOWLEDGE FC Barcelona aims to help change the
Johann Windt is a Sports Steffan is a junior doctor at world through sporting excellence via
Medicine Data Analyst at Chelsea and Westminster Exchanging ideas with the greatest knowledge and innovation
the United States Olympic Hospital in London, who is minds around the world to develop
Committee. Before his passionate about pursuing a cutting edge applied research projects. We are looking to form an ecosystem to
current role at the USOC, career in Sport and Exercise We have the commitment to share this foster knowledge and innovation. This
he spent two years with Medicine. He sits on the British knowledge to the new generation of ecosystem is based on a model that
the Vancouver Whitecaps Journal of Sports Medicine’s sports industry professionals. promotes a culture of excellence and
Football Club (competing in editorial board as senior collaboration with prestigious brands,
the Major League Soccer) associate editor and helps universities, research centres, start-
as a sport science data lead the journal’s social media ups, entrepreneurs, students, athletes,
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,
injury aetiology. Johann is and society in general.
also a member of the Football
Research Group, which is an A RELEVANT ECOSYSTEM
international research group
collaborating closely with the Encouraging and connecting the sports HOW?
Union of European Football business ecosystem: industry leaders,
Associations (UEFA) on various sport organizations, research centers, Our knowledge and innovation
research projects related to universities, entrepreneurs and start-up. activities are structured in 5 areas:
football player health and
performance. 1. Medical services and nutrition
2. Sports performance
3. Team sports
4. Technology
5. Social science





There are many physical and mental health benefits to training and playing
football, however, there is also, unfortunately, one key adverse effect; an increased
risk of injury, with muscle injuries being one of the most common injuries we see in
elite football.
— With Ricard Pruna

12 Introduction There are many physical and mental health benefits to training and playing football,

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

1. Protect our players’ health

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

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

Our Muscle Injury Guide is not intended to be a ‘must follow recipe’, but rather to provide
some key ingredients that you can adapt and integrate appropriately into your own
practice. We hope you enjoy reading the combined knowledge and experiences of the
many valued contributors included throughout.

Dr Ricard Pruna
Head of Medical Services, FC Barcelona


0.2 0.3


The Oslo Sports Trauma Research Centre was established at the Norwegian School At Science and Medicine in Football, our mission is to advance the theoretical
of Sport Sciences in 2000 as a research collaboration between the Department knowledge, methodological approaches and professional practice associated
of Orthopaedic Surgery, Oslo University Hospital, Ullevaal, the Department of with the sport of football. In other words, we want to help bridge the gap between
Sports Medicine, Norwegian School of Sport Sciences, and The Norwegian Football science/research and the practical setting. Essentially, we are an international,
Association Medical Clinic (2015). Since 2009, the OSTRC has been recognised as a peer-reviewed journal interested in promoting evidence-based practice i.e. use of
FIFA Medical Centre of Excellence and selected as one of four IOC Research Centres quality research knowledge with current best practice.
for Prevention of Injury and Protection of Athlete Health. — With Prof Tim Meyer and Prof Franco Impellizzeri
— With Thor Einar Andersen and Roald Bahr

14 The main objective of Oslo Sports Trauma Research Centre has been to develop a long- 1. Arnason A, Andersen TE, We focus on many areas of football including, physiology, biomechanics, nutrition, training, 15
term research program on sports injury prevention (including studies on epidemiology, Holme I, Engebretsen L, testing, performance analysis, psychology and coaching. Additionally, sports science and
Bahr R. (2008) Prevention
risk factors, injury mechanisms, and interventions). The program focuses mainly on three of hamstring strains in eli- medicine in football is key for us and our readership, with injury prevention and return to
sports (football, handball, and alpine skiing/snowboarding). We have addressed the most te soccer: an intervention play current hot topics for us and our readers.
study. Scand J Med Sci
common (e.g. ankle, hamstrings) and the most serious (e.g. ACL, concussions) injuries seen Sports;18(1):40-8
in these sports. The FC Barcelona Muscle Injury Guide 4.0 corresponds to our vision of bringing research
2. Soligard T, Myklebust
G, Steffen K, Holme I, and practice together. In this resource, FC Barcelona have brought together over 60 of
In football, one focus has been on the preventive effect of eccentric hamstring training Silvers H, Bizzini M et al. some of the world’s leading applied researchers and practitioners to share and perhaps
(2008) Comprehensive
using the Nordic Hamstring exercise.1 We have, in partnership with FIFA, also developed warm-up programme to
most importantly, work together to combine their knowledge and experience into one
“The 11+”, a warm-up program with exercises focusing on core stability, neuromuscular prevent injuries in young voice.
control, strength, balance, hip control and knee alignment in football.2 In 2011, we female footballers: cluster
randomised controlled
conducted an intervention study in the Norwegian male professional league involving trial. BMJ;337:a2469 Not only will this Guide provide a great practical recommendations’ resource for football
sanctioning of two-footed tackles as well as tackles with excessive force and intentional 3. Bjørneboe J, Bahr R,
science and medicine practitioners worldwide, but should also help to drive forward
high elbow with an automatic red card to enforce the Rules of the Game.3 Dvorak J, Andersen TE. meaningful applied research to further improve our field.
(2013) Lower incidence
of arm-to-head contact
We have through several conferences, workshops, visits and meetings with FC Barcelona incidents with stricter It is with great pleasure that we support this initiative by FC Barcelona. One aspect that
(FCB) and its medical staff, been inspired by the clubs’ constant strive to implement best interpretation of the we are particularly excited about is that various contributors involved in the Guide will
medical practice and scientific knowledge into their daily practice. In particular, we have Laws of the Game in progress on some of the chapters written within, by preparing scientific articles and
Norwegian male profes-
been impressed by the FCB philosophy on training principles, diagnostic procedures and sional football. Br J Sports submitting these to enter the Science and Medicine in Football peer review process. So,
management of return to play after injury. Med;47(8):508-14 watch this space…

Both the Oslo Sports Trauma Research Centre and the FC Barcelona share a common
understanding that scientists and practitioners should collaborate closely to bridge the gap
between science and practice. We certainly believe developments in the area of football
medicine will benefit from improved on- and off-field teamwork to answer the key
research questions of the future.

Therefore, it is a great honour and pleasure for the Oslo Sports Trauma Research Centre to
contribute in an exciting partnership with FCB to produce the FC Barcelona Muscle Injury
Guide:Preventing and Treating Muscle Injuries. We are very much looking forward to this
mutual collaborative effort and to continued projects in the near future.


0.4 0.5


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

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

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

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

can be improved, and this as well in the preventive, pharmacological, surgical and
conservative sphere.

We must work together to improve our criteria for return to play, as the high number
of re-injuries confronts us sometimes with our own deficiencies.

That is why this scientific work, the great medical guide of muscle injuries, is a gift to
all practitioners, active in the field of football.

Many thanks to all the collaborators of this important book, which will greatly
improve our care for the injured player.

Countries represented Countires with

in the survey no responses/not
Australia Norway
Brazil Northern Ireland
Canada South Africa
Denmark Spain
Finland Sweden
France Switzerland
Germany UK
Holland USA



The objective of football is to win games. There are many factors (i.e. tactical,
technical, physical and mental) interacting to achieve thisobjective. However,
one key, contributing factorthat the medical and performance team can influenceis
player availability i.e. through a lower impact of injuries (incidence and severity).
— With Alan McCall and Ricard Pruna

18 General This makes sense, given that one benefits of preventative strategies to key 19

Principles of
wouldlogically agree that havingthe best stakeholders (players, coaches, board
players available to play, enhances the level administratorsetc) is essential if we
likelihood of winning. Ahigher player are to succeed in at least reducing the risk
availability means thatthe coach willhave and minimising the occurrence of injuries,

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

evidence to support this notion; less The purpose of this opening chapter
injuries have been associated with ofthe FC Barcelona Muscle Injury Guide
increased success in domestic league 4.0: ‘General Principles of Muscle Injury
competition1, 2 and UEFA Champions Prevention in Football’is to highlight,

in Football
/ Europa League.3 In addition to explain and delve intosomeof thekey
performance and success, injuriesalso general principles to consider when
carry with them a significant financial the goal is to prevent muscle injury
cost. It has been estimated that the in footballers. Specifically, wewill
financial cost of one player missing one providea new injury prevention
month due to injury equates toan average modelspecific to team sports, followed
of ~€500,000.4 Remember that this is by taking you through a journey of this
an average, imagine the costif this was model, providing practical guidelines
a star player. A third important potential along the way.
consequence of injury is an adverse
effecton players’ long term physical and
mental health.5

While in an ideal world, we would be able

to prevent all injuries from ever occurring,
this is, in reality, impossibleand our aim
is really to minimise the risk of players
suffering an injury. Life is full of risky
decisions, from mundane ones to matters
of life and death.6 Risk is something that
we must accept exists; even walking
down the street has a meaningful (albeit
small) risk for our safety.7 The fact is,that
injury is so complex, multifactorial
and dynamic8 that prevention
mustalsobecomplex, multifactorial
and dynamic. We shouldaim to
identify and minimise known risk
factors for injury while simultaneously
identifyingand maximising protective
factors. Communicating the risks and the


PHASE 1: EVALUATE This second phase also involves
identifying barriers and facilitators to
This phase involves evaluating the current implementing injury prevention strategies, EVALUATION AND
“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.


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


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
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
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
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
current situation, the identified injury
injury problem PREVENTION FACTORS AND individuals, at least two or three times

MECHANISMS? risk factors and implementation barriers/


A detailed understanding of all team per season.
2. Identifying the key risk factors facilitators, published injury prevention

NE members’ perceptions towards injury


and mechanisms of injury research and the team staff members’
risk and injury prevention is important to In the following chapters of this
previous experiences from working in the
3. Introducing preventive strategies inform subsequent phases in the cycle. opening section on preventing muscle
field. Implementation research highlights
to mitigate the risk of injury PLAN THE CONTENT WHAT ARE THE BARRIERS injuries we will take you through each
ANDDELIVERY OF & FACILITATORS TO the importance of securing administrative
INJURY PREVENTION DELIVERING INJURY In addition to establishing what is being of the 3 key phases in more detail.
4. Evaluating the effectiveness support for preventive strategies10 and
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.


1.2.1 40


Quadriceps injury represent 5% of
all time-loss injuries and 19% of all
muscle injuries in men’s professional
football (figure 1), which means that
(EPIDEMIOLOGY) a 25-player squad can expect about

three quadriceps injuries each season.
Similar to the findings for hamstring
Muscle injuries are one of the biggest medical problems in modern football, 20 injuries, the injury rate during match
regardless of the playing level.1 2 Specifically, muscle injuries represent almost one
play ishigher, approximately four
third of time-loss injuries and account for more than one-quarter of the overall
15 times, than during training (table 2).
injury burden as it was shown in the largest available study involving more than
Studies involving imaging modalities
9,000 injuries in men’s professional football players in Europe.2 Numbers from this
10 have shownthat rectus femoris is the
investigation also reveal that on average, an individual player will sustain a muscle
most common injury location in the
injury every other season.2
quadriceps.2 10
— With Markus Waldén, Tim Meyer, Matilda Lundblad, Martin Hägglund 5

Figure 1 Muscle injury location in men’s
(adapted from Ekstrand et al.2)


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




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

Table 3
Muscle injury severity Muscle injury severity
Hamstring 13 25 51 11 90,0
ADDUCTER BURDEN according to lay-off
according to lay-off
Injury severity is commonly based on Quadriceps 12 25 48 15 in men’s professional 80,0 CALF BURDEN in men’s professional
football players football players


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

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

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

Higher grade hamstring injuries, as Calf 16.5 per 1000 hours

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
(semimembranosus, semitendinosus
and biceps femoris).18 Two recent studies from the UEFA Elite
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
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.


NON-MODIFIABLE RISK In addition to the literature on senior PREVIOUS INJURY

RISK FACTORS AND FACTORS players, recent data from FC Barcelona

Leg dominance in football is usually
indicate that academy players have an
defined as the preferred kicking leg.
SEX increased frequency of rectus femoris
Interestingly, both adductor and quadriceps
injuries compared with professional
One study on elite players showed a injury rates are higher in the kicking
players, whereas the reverse is seen for
significantly higher rate of muscles leg,18 which probably is due to increased
hamstring injuries.23 No effect of age was,
strains in males compared with exposure of high-risk player actions
however, seen for groin muscle injuries in
females, but no sex-related difference (shooting, passing, crossing, blocking, etc).
— With Markus Waldén, Khatija Bahdur, Matilda Lundblad, Martin Hägglund that study.
for hamstring injuries.12 Similarly, a Conversely, leg dominance has not been
study on collegiate players also found identified as a risk factor for hamstring
a higher rate of muscle strains in injuries18 28 and calf injuries,18 probably due
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
number of risk factor studies on football muscle injury in football is somewhat and hamstring strains, respectively.21
players that have targeted hamstring inconclusive, but it appears that male Similarly, previous hamstring injury was Goalkeepers carry a lower injury risk in
injuries,1 whereas risk factor data on RISK FACTORS FOR players have similar or higher groin and associated with a significantly higher general compared with outfield players
quadriceps and calf muscle injuries
in football are scarce.2 3 Also, although
MUSCLE INJURY hamstring muscle injury rates compared
with female players.
hamstring muscle injury rate in another
study on male elite players,22 and in male
and this seems to be the case also for
adductor, hamstring, quadriceps and
there are many studies reporting on Risk factors in football have traditionally amateur players.20 Although not specified calf muscle injuries in male professional
groin injuries among football players,4 been divided into intrinsic (player- for muscle injuries, male amateur players football players.18 28 29 In one of these
the majority of these report on hip related), such as age and sex, and AGE with previous acute groin injury in the studies, it was also shown that forwards
and groin injuries combined and few extrinsic (environmental-related) ones.1 latter cohort had more than doubled had the highest hamstring injury rate of
Age is a frequently studied risk factor
studies on risk factors for groin injury They can, however, also be categorized odds of sustaining future groin injury.24 all player positions.29 Finally, goalkeepers
for injury per se but is also important
in sports have reported data on groin into non-modifiable (unalterable) and also had fewest muscle injuries in a study
to adjust for when analysing other
muscles separately.5 6 potentially modifiable (alterable) factors There are, however, also a few studies on male academy players aged 8-16 years
potential risk factors due to the apparent
which might be more relevant from a showing no association with previous where the highest thigh injury rate was
risk of confounding. The calf muscle
The majority of the studies with risk prevention perspective (table 1). muscle injury. One study on male seen among midfielders.31
injury rate was approximately doubled
factor data on muscle injuries in professional players showed in fact a
in male professional players older
football have been carried out on significantly increased hamstring injury
INJURED TISSUES NON-MODIFIABLE MODIFIABLE < than the average age (>26 years), but
professional or elite male senior players Table 1 rate with no previous injury,25 and two PLAYING ACTIVITY
there was no such age effect with
with considerably less literature on Intrinsic Sex Strength Examples of candidate studies on female players showed no
and non-modifiable adductor, hamstring and quadriceps It is well-known that the injury rate in
female and youth players. The findings association between previous injury
Age Flexibility risk factors for muscle injuries.18 Similar findings were found general is several-fold higher than during
on suggested risk factors are often injury and future muscle injury; for thigh
in male elite players where older training regardless of the setting and
identical or similar between studies Previous injury Fitness level muscle injuries in youth players,26 and
age (>23 years) was associated with playing level. Muscle injury rates are
but could occasionally be muscle- for hamstring injuries in elite players.27
Leg dominance Psychological factors a significantly higher percentage of also higher, of approximately the same
specific or even contradictory. Muscle In summary, a majority of studies have
calf muscle injuries, but again no magnitude, during match play; the
injuries are, however, unlikely to result Extrinsic Playing level Workload and congestion found previous injury to be a risk factor
association with adductor, hamstring adductor, hamstring, quadriceps and calf
from a single risk factor, but rather as for future muscle injuries even if there
and quadriceps injuries.19 Similarly, muscle injury rates were, for example, 4-9
a consequence of several risk factors Playing position Rules and regulations are a few exceptions.
increasing age was not associated with times higher during match play in male
interacting at the time of the inciting
Playing activity Equipment higher odds of sustaining hamstring professional players.32 A higher match
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


Figure 1 FLEXIBILITY increased the odds for sustaining The influence of congested match
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

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
Specifically, players with lower
loads, it seems that six days or more 29
For male professional players in teams FACTORS adductor muscles had four-fold
increased odds to sustain a future groin
adductor and gastrocnemius muscle fitness level were unable to tolerate
are needed between match exposures
to reach a baseline level of the muscle
with an autumn spring season, the rates injuries.45 Similarly, male professional acute:chronic workloads of at least
TIME OF SEASON injury.24 In addition, male elite and sub- injury rate.58
of adductor, hamstrings and calf muscle players with hip and knee flexor muscle 1.25 and had a five-fold higher odds to
elite players with ongoing adductor-
injuries are significantly higher during the Muscle weakness and strength strains had significantly lower range sustain a lower limb injury compared
related pain had lower hip adduction
competitive season, whereas the reverse imbalances are frequently suggested of motion in these muscle groups with players on a higher fitness level in
strength compared with asymptomatic RULES AND REGULATIONS
finding for quadriceps muscle injuries with risk factors in the sports injury compared with uninjured players.46 one of these studies.49 Future studies in
control players,42 a finding that was
a higher injury rate during the pre-season literature. A pioneer study carried out There is also more indirect evidence of this field and on other fitness variables The majority of all muscle injuries (>90%
also seen in male amateur players
period (figure 1).18 Another study on male on a mixed cohort of athletes, mainly muscle tightness as a risk factor in a are, however, needed. regardless of muscle group) in male
with current groin pain.43 In the latter
elite players showed that there was an consisting of high-level male football study where hamstring-injured male professional players occurred in non-
study, previous long-standing groin
accumulation of hamstring injuries in the players, with previous hamstring injury professional players had significantly contact situations with few match-related
pain (>6 weeks) during the preceding PSYCHOLOGICAL FACTORS
spring season after the winter break.36 and recurrent strains and discomfort shorter fascicles of the long head of the injuries being the result of foul play in
season was associated with lower hip
Similarly, most thigh muscle injuries in showed that muscle strength deficits biceps femoris than uninjured players.40 The literature in this field is still scarce the view of the referee.32 Consequently,
adduction strength.43
male youth players occurred in September were common and that a rehabilitation Moreover, two studies on male compared with studies on physical re-enforcements of the existing rules will
(after the summer break) and in January programme with normalisation of professional players have found that factors. A recent cross-sectional study probably have negligible impact on the
There is no published data yet on the
(after the winter break).31 the muscle strength reduced the risk found that decreased range of motion of male professional players, however, panorama and burden of muscle injuries.
potential association between muscle
of re-injury.38 Moreover, in a separate in the hip was significantly associated showed that players who had suffered However, as discussed further below,
strength deficits and/or imbalances and
study on male professional players, with muscle injury; lower hip flexion at least three severe (>28 lay-off days) muscle injuries might be associated
future calf muscle injury risk.3
WEATHER CONDITIONS the hamstring muscle injury rate was muscle injuries during their career with fatigue and regulations on reducing
increased four-fold in players with had 2.6 times higher odds of reporting individual playing time and/or increasing
Although insufficiently investigated,
thigh muscle strength imbalances distress than players without previous the recovery window between matches
there are currently no studies indicating
compared with players without any severe muscle injuries.51 might therefore be of value.
that weather conditions, such as air
muscle imbalances.39 Similarly, male
temperature and evaporation, are
professional players with eccentric
associated with increased or decreased WORKLOAD AND CONGESTION RULES AND REGULATIONS
hamstring strength asymmetries
muscle injury rates in football. However,
at pre-season had four-fold higher The influence of workload on sports Currently, there are no studies
one study on male professional players
odds of sustaining hamstring strain injury risk has received a lot of interest indicating that any particular
showed no regional differences in
during the following season.25 More in recent years with both high absolute equipment, such as taping or type of
adductor, hamstring, quadriceps and calf
recent research has shown that male and relative loads being associated footwear, are associated with increased
muscle injury rates between teams from
professional players with hamstring with increased injury risk as shown in or decreased muscle injury rates in
northern Europe compared with teams
injury were weaker during eccentric a recent review by the International football.
from southern Europe, indicating that
contractions than uninjured players, Olympic Committee.52 At the time of
weather (and pitch) conditions are not
but between-limb imbalances did the publication of that paper, there
equally important for muscle injuries as
not infer a higher rate of hamstring were only a few studies on workload
perhaps for other injuries such as ligament
injury.40 Conversely, only one of 24 and injuries in football, but thereafter a
sprains and tendinopathies.37
studied muscle strength variables was number of studies on male professional
associated with increased hamstring players have been added; these studies
muscle injury rate in a recent study on show essentially the same findings by
male professional players.41 Similarly, mainly including muscle injuries in their
hamstring strength had no association analyses.49 50 53-55
with future occurrence of hamstring
muscle injury in female elite players.27




While risk factor identification is important, athletic injuries do not occur because of
any single risk factor. Rather, injuries (muscle injuries included) occur as several risk
factors interact at the time of an inciting event during training or competition (Figure
1). 1, 2 In other words, athletic injury etiology is complex, dynamic, multifactorial, and
context dependent.
— With Natalia Bittencourt, Mario Bizzini, Johann Windt and Alan McCall

30 PLAYING TIME Repeat participation with modified internal risk factors based 31
on positive and negative effects of prescribed workload.
Muscle injuries in male professional
players tend to occur less frequently
in the beginning of a match (or match Previus Injury
halves);32 there were fewer quadriceps
injuries in the first quarter of the Modifable Factors
first half, fewer groin muscle injuries Internal (E.G. Aerobic capacity, “Fitness”
strength, neuromuscular
in the first quarter of the first and Risk control, tissue resilence)
Positive Training Effects

second halves, and more calf muscle Factors

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


Figure 2
Complex systems
approach to muscle
injuries in football.
Factors associated
with injuries
form a web of
determinants, and
certain associations
between these factors
will be regularities Figure 3
that contribute to an Theoretical web
emerged pattern/ of determinants
outcome (in this case for muscle injury
muscle injury). in football.
Redesigned by FC Redesigned by FC
Barcelona Barcelona
v v

32 MODIFIABLE RISK For football players, the main factors 33

Muscle Injury Muscle Injury
FACTORS (Emerged Pattern)
within our web of determinants (thicker
nodes) are: 1) previous muscle injury; (Emerged Pattern)

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

patterns in risk factor relationships that second level of nodes include: external and

Recursive Loop

Recursive Loop
Recursive Loop

Recursive Loop
may increase injury likelihood. 3 internal workload, movement efficiency,
In this model, risk factors and potential and psychological aspects. Within this
interactions result in a ‘web of theoretical web of determinants, players
determinants’ (figure 2). In each sporting who exhibit a profile including a previous
Regularities Regularities
context, one may use the model to muscle injury, high fatigue levels and (Football - Muscle Injury Risk Profile)
determine patterns of relationships low strength are considered to be at an
(interactions) between factors increased risk for muscle injury. Further,
(regularities), what certain interactions these three factors may interact, as Workload
produce (emerged patterns), as well as the previous muscle injuries will change the Age
regularities that may lead to injury (risk level of fitness, strength qualities, and External Previus
Workload Muscle Strength
profile). 3 Notably, multiple risk profiles may may alter the fatigue process. FATIGUE Injury Level Qualities
exist for the same outcome (i.e. injury), is the global result of the relationship of
since individual risk factors within the between external and internal workload. Congested
web of determinants may have varying The player’s external workload (work Reduced Schedule
Level of
Movement Joint
effects, depending on other factors. For completed) is modulated by factors such Recovery
and Efficiency Mobility
example, the consequences of factor A (i.e. as reduced recovery time and congested Stress

weak eccentric muscle strength) will differ match schedule, which increase workload
if it interacts with factor B (i.e., congested density and may add stress to the players,
match schedule), factor C (i.e., previous indirectly altering internal workload.
injury), or both. Ultimately, identifying these Internal workload is influenced by player’s
regularities (i.e. risk profiles) may improve internal characteristics, including physical
our understanding of injury etiology and fitness, strength qualities, and stress.
inform future preventative interventions. PREVIOUS MUSCLE INJURY can change
muscle tissue (e.g., scar and angle of peak
To our knowledge, there is currently torque), 5 which may produce muscle
no web of determinants that exists for weakness and imbalance. Movement
muscle injury in football. Until future efficiency could therefore be altered,
robust statistical analyses are carried out with other factors like joint mobility
that identify the relevant factors and risk contributing. Finally, several of these
profiles, we encourage a critical thought previous factors, along with age, have the
process and the creation of potential potential to modify STRENGTH QUALITIES.
webs of determinants. Below, we created
an initial example of what a web of
determinants for muscle injury in football
may look like. Whilst not validated, our
web is based on a combination of known
evidence in the scientific literature and our
practical experience, with the purpose of
illustrating this concept.


BUILDING THE PRACTITIONER-PLAYER MAIN COMPONENTS OF or training, and other external factors

SCREENING should be considered whenever possible
to ensure that the screening measures

IN FOOTBALL The relationship between the player Screening is usually performed at the used are consistent, and comparison with
and the medical team is essential beginning of a season, although additional previous results are meaningful.
to build trust and create a safe screening opportunities should be sought,
It is common practice in professional sport to perform some manner of periodic health environment where the player will such as a mid year review, or at the end Ideally, the entire medical team should be
evaluation (PHE), commonly referred to as “screening”. In elite football, 90% of the openly and honestly share his/her of the season to establish off-season involved in screening. Although the testing
teams do some form of screening throughout the season.1 Professional teams and concerns and physical information. programs. We recommend end-of- might be performed by specific members,
football governing bodies aim to protect the health of the player through screening and This allows an optimal shared season screening, which allows for the it is important to have the team doctor,
monitoring to identify potential risk of injury, which, if possible, could positively impact decision making process.9 It is also identification of ongoing musculoskeletal physiotherapist, and even manager present
performance, economical aspects at the club, and the health of players.2,3 an opportunity to provide education issues to receive attention before players to emphasize the value and importance
— With Nicol van Dyk, Robert McCunn, Phil Coles, Roald Bahr regarding certain health policies or resume training at the start of the next of the testing. Furthermore, it makes
injury prevention strategies and to season. direct and immediate communication
receive both subjective and objective and interpretation of the results possible,
feedback from the players on their Although the most comprehensive allowing greater transfer of the results in a
current health status. screening will likely still happen during the practically meaningful way.
pre-season, musculoskeletal screening
should sensibly be repeated throughout Screening includes both a review
the season to determine how variables and consideration of non-modifiable
respond to training and competition for information (age, previous injury, etc),
34 INTRODUCTION WHY DO WE SCREEN? DETECTING CURRENT each individual player, as well as at a team as well as modifiable potential risk 35
MUSCULOSKELETAL CONDITIONS level. This might assist the medical and factors (e.g. strength, flexbility, fitness,
Organisations such as the International At present, none of the tests used to
performance team to make better informed psychological status, workload, movement
Olympic Committee (IOC) and Fédération perform the musculoskeletal screening or Screening performed for each
decisions regarding the health of the quality, and performance tests). Although
Internationale de Football Association monitoring appropriately separate players individual player should focus on
players, as well as reducing their injury risk. many options are available, we have
(FIFA) have released guidelines on who are at high risk of injury from the rest early identification of current health
summarized some key components and
the screening of athletes and players, of the group.6 These tests simply do not problems and assessing the status
Once a battery of tests has been selected, their characteristics in table 1. Workload
attempting to set a standard of care that have the appropriate properties to perform of ‘old’ injuries to prevent their
it is important that tests are standardized monitoring will be explained in detail in
would assist in the early detection of such a function, and we continue to see recurrence.7,8 Of course not every player
and if repeated, done so in the same way. the upcoming `Preventative Strategies’
cardiovascular and other potential health the injuries that occur across all the players would need an individual follow-up
Time of day, influence of practice sessions section.
(medical) risks.4 Typically, this consists in the team, irrespective of their screening after screening. Value may be found in
of (i) a comprehensive cardiovascular results. For injury prevention in elite simply reassuring a player regarding
examination, (ii) a general medical football, large group based interventions the rehabilitation from a previous injury
evaluation (including blood tests) and are likely still key. or management of physical symptoms. TESTS AVAILABLE ADVANTAGES DISADVANTAGES CONSIDERATIONS
(iii) musculoskeletal assessment to be However, we might introduce a specific
Strength10-14 Isokinetic dynamometer (eccentric strength, side-to-side Moderate accuracy and Player buy-in, When interpreting Nordbord
performed on all players. Here, we will However, the interventions that we apply program for selected players, in imbalances, functional ratios e.g. hamstring:quadriceps) validity for all these tests difficult for players strength results, it may be important
focus on the musculoskeletal component should ideally be monitored for each particular those that have returned from Strength competing in 2 to normalise it to body mass
Field devices (Nordbord®)14 (eccentric strength, side-to-side Testing can be
of screening. individual player, as adaptation and previous injury, to ensure they reach imbalances) performed as part of
matches per week
Isometric testing might be a safe
reaction to these interventions might differ their optimal level of performance after Hand held dynamometer (HHD) (isometric strength)
training Cost alternative during congested
periods in the season and form part
Scientific evidence demonstrating how between players, and individualization return to play. Force platform (isometric strength, concentric power and/
Requires expertise
of recovery monitoring
valuable musculoskeletal testing is, which of these exercises might be necessary to to interpret the data
or eccentric duration e.g. during countermovement reactive
outputs e.g. graphs
are the best tests to use, and whether ensure effectiveness is maximised. strength e.g. from drop jump and between leg functional
these test results are actually associated ESTABLISH PERFORMANCE BASELINE
with muscle injury is unfortunately, scarce. The complex, multifactorial and dynamic AND HEALTHY STATE Flexibility3,16,17 Straight leg raise test Moderate accuracy and Player buy-in, When is the best time to perform
This section contains important factors to nature of muscle injuries is becoming more Sit and reach test
validity for all these tests difficult for players the test? Before or after training
Another reason to conduct screening Active & passive competing in 2
consider when building your own battery and more accepted by practitioners, 5 range of motion Passive and active knee extension test
Low cost, easy to
matches per week
Might be useful in return to sport
is to establish a performance baseline perform decision making
of tests where the objective is to screen for and explained in the previous section.
for the player in the absence of injury Bent knee fall out (BKFO)
Simple tests to inform Could form part of recovery
some of the potential risk factors such as Although screening to predict future injury
or illness. For example, if a player Hip internal/external range of motion daily physiotherapy monitoring battery
those identified in section 1.3.1. Importantly, is not possible,6 we screen each individual interventions e.g.
sustains a hamstring injury during Dorsiflexion lunge test Can form part of a simple daily
these test results should be interpreted player to detect ongoing musculoskeletal manual therapies
‚general medical screen’
the season, the strength or functional Thomas test
for the individual player, which allows conditions, identify health issues that
tests performed during screening can Standing forward flexion test
Selection - can’t use all of them
appropriate intervention and decision- may require intervention, create a rapport
represent a useful reference point
making by the medical staff, based on between practitioner and player, and Knee-to-wall
for the practitioner to determine
a combination of research evidence identify how these aspects may impact
responses/success throughout the Movement Functional Movement Screen (FMS) Low to moderate Large season to If used, consider the same assessors
and current best practice. Although no team performance. quality18-24 accuracy season variability in at minimum performing the scoring
return to play process, and can Functional movement test 9+
emperical evidence exists, there is a Holistic view of
Careful interpetation of the results
assist in decision making during Determine how Landing Error Scoring System (LESS)
growing consensus among practitioners well (controlled)
athleticism and Subjective (i.e. many of these have shown no
this period. Alternatively, if the club Soccer Injury Movement Screen (SIMS) movement patterns (excluding association with injury, and none of
that regular monitoring of risk factors movements are
decides to add a specific training/ performed23,24 Laboratory based jump-landing assessments Easy to administer
laboratory tests) shown predictive accuracy)
will allow more appropriate and timely
strengthening programme during the (once trained and Questionable link to
interventions. players familiarised) injury risk
season, a baseline test can assist the
performance team to establish whether
or not the program has been successful ^
Table 1. A summary of potential modifiable factors
and where to target future injury to consider when screening/monitoring for muscle
prevention programs. injury risk


1. Overview of the
players risk profile, BARRIERS AND FACILITATORS
and health status.
2. Compare to previous
The test results for each individual player
status or test results
may be compiled to form an overview or
holistic impression of the players’ current 3. Determinate specific
status. Ideally, previous data on a particular interventions Published information on barriers and facilitators to delivering injury prevention
player exists and allows comparison to a needed to address strategies is scarce,1 but initial research on injury prevention exercise programs has
previous time point, or a moving average any identified identified a wide range of factors, relating either to the content and nature of the
of ongoing monitoring of these factors, musculoskeletal program itself, or how the program is delivered and supported by players, coaches and
this may be used to determine whether a issues or risk factors team staff members.2 3
player has improved, worsened or stayed — With James O’Brien and Caroline Finch
the same. Alternatively, the player may
be compared with the rest of the team
or data on the entire league, if available.
This would indicate whether specific
action or intervention may be needed on
an individual level to improve his current
status to be on par with the rest of the
36 team (or league). In relation to the program, TARGET GROUP KEY MESSAGES < 37
examples of barriers include lack of Table 1
Club officials Injuries are expensive. The costs to a Key messages for
individualisation, progression, variation professional club for a player being injured promoting injury
and football specificity, along with for one month can reach 500 000 Euros.4 prevention strategies
in professional teams
the program being too long or too Teams with fewer injuries are more
FOR THE TEAM monotonous. Example of barriers successful in both their national league
and in UEFA competitons.5
1. Overview of the team relating to players include lack of
The results from the different screening
status and health acceptance/motivation regarding Coaches and team staff members Avoiding injury increases player availability
measurements may allow the medical for training and matches
the program, fatigue, absences (e.g.
team to identify trends throughout the 2. Identify trends that
national team, illness) and muscle Having more players available can help
season. For instance, if the entire squad develop during a in managing the physical demands on all
soreness. In the case of coaches and
displays lower strength compared to season. (i.e, lower players.6
team staff members, acceptance and
the previous season, coupled with an strenght compared to Injury prevention exercises can be easily
support of the prevention program is incorporated into team training (e.g. warm-
increase in muscle injury, it might indicate the previous season,
a key factor. Other factors, relating to up and cool-down) with minimal time cost.
effects of a pre-season training camp or coupled with an
the team staff members who design Lower injury rates correlate with team
inappropriate training methods. Such increase in muscle success5
and deliver preventive exercise
findings may help the overall management injury). Large randomised-controlled trials support
programs (e.g. fitness coaches and
of the squad to protect the players from the effect of injury prevention exercise
3. Design group physiotherapists), include lack of staff programs in elite and sub-elite teams.7-9
injury and avoid larger scale injury
based prevention continuity, teamwork, communication
patterns. Avoiding injury can protect players from
programmes that are and planning.2 both the short- and long-term negative
aimed at the entire effects of injuries.10
Furthermore, it might assist in the design
squad. Acceptance of and active support Players
of group-based prevention programmes Injury prevention is important to keep you
for injury prevention strategies on the pitch, extend your career and invest
that are aimed at the entire squad. Certain 4. Certain key areas in your long-term health.
are particularly important factors,
key areas may be identified that need may be identified
applicable to several different
priority. Although a prevention programme that is given higher
groups (e.g. players, coaches and
would still contain all the elements needed priority
administrators). Successfully addressing
to provide holistic prevention, some test
these factors in order to increase “buy-
data may help to tailor it to the team
in” may require tailoring messages to
profile, which may improve the overall
each of these different groups. Table 1
effectiveness of the intervention. It is
outlines some tips on what you could
important to present this information in a
do to overcome some of the barriers
way that is understandable to the medical,
that can limit the effectiveness of injury
performance and management team.25
prevention programs.


Although we cannot eliminate risk of
injury, the goal of screening is to aid in the
protection of our players, minimize risk,
and contribute to their overall well-being,
ultimately contributing to team success.



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

38 We only need to look at the playing During the process of putting the PREVENTATIVE STRATEGY EFFECTIVENESS RATING 39


schedule of elite level football teams FC Barcelona Muscle Injury Guide
to understand why we need to think 4.0 together, we realised that there Overall control of load / management +++
of the training week
bigger than just exercise alone. Elite was limited scientific evidence for
football teams are regularly required to preventative strategies in the elite Exercise based strategies +++
play in periods with 2 matches per week football environment. We therefore
3 x season 14 x season 25 x season throughout the season e.g. domestic decided to perform a Delphi Survey Recovery strategies ++

league, national cups, confederation of 18 elite teams from the Big 5 Consideration of previous injury ++
competitions etc. Figure 1 illustrates Leagues (England, France, Spain, Italy
EXTRA LONG CYCLE LONG CYCLE SHORT CYCLE the congested match schedule that FC and Germany) to ask performance Team communication and ability ++
to work together
Barcelona are typically exposed to. You practitioners what they do and
will see that the majority (25 matches) are what they consider to be important
played with only 2 full days recovery, 14 strategies to prevent muscle injury
THE BARÇA WAY Table 1 Perceived
with 3 full days and only 3 where the in their players. The Delphi survey effectiveness of
MD+1 / MD-4 MD+1 / MD-3 MD+1 / MD-2 recovery between matches is considered process involves various rounds of strategies to prevent
‘extra long’ i.e. 4 full days. With such a questionnaires in which we ultimately At FC Barcelona, we do not consider muscle injury in elite
footballers (EBMIP
congested match schedule it is difficult come to a consensus among the injury prevention to be made up of
MD+2 / MD-3 MD+2 / MD-2 MD -2 one specific strategy, but rather the
Delphi Survey results)
to plan any focussed, high-intensity respondents as to the most effective
exercise programs that may be able to strategies to prevent muscle injury simultaneous integration of many
MD -2 MD -2 MACH DAY help prevent muscle injury, at least for the and how to integrate these into strategies, which alone, cannot
regular playing squad. As such we need the football program. The following ‘prevent’ an injury.
MD -1 MACH DAY to look at other ways to minimise the risk chapters are based on the results of
Instead it is most likely, the combi-
of muscle injury and this calls for other this Delphi process in addition to what
‘preventative strategies’. Even for the non- we know from the scientific literature nation of many strategies inclu-
MACH DAY playing or substitute squad, preventative and our own practical experience. ding, controlling the training load,
strategies other than exercise-based maximising recovery, optimising
should be beneficial to optimise The overall results of our Delphi communication in addition to per-
the training process i.e. maximise survey1 of the Big 5 leagues revealed forming a variety of specific exer-
performance and minimise injury. the most effectively perceived cises etc as the best way to reduce
preventative strategies to prevent the risk of our players incurring a
muscle injury (table 1). We will now go muscle injury.
through each of these in more detail,
providing practical recommendations
on implementation in practice.

Figure 1.
Typical match schedule of FC Barcelona during an
in-season period



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

40 Response 41
thresholds7. To overcome this limitation, Heart rate measures may also be used
Injury it is recommended that averaging the to assess the internal training load
Risk acceleration/deceleration demands during football, but due to the technical
during training and match play may be a and practical issues such as the high
more appropriate method compared to risk of technical issues and data loss
Training Training Athlete Performance threshold-based methods.8 and a low level of player compliance in
Plan Dose Responses measurement, the session-RPE method
The internal training load is the response is the most widely recommended
of the player to the external load applied approach.12 An additional advantage of
Readiness and is usually measured using heart rate the session-RPE method over heart-rate
or the session-RPE method.9,10 The session derived approaches is that loads can
“Fiatigue” RPE-method requires players to rate their easily be obtained from all types of
Response perceived intensity of a session according training, including cross training and
to a standard rating of perceived exertion resistance training which are common
(RPE) scale (see Figure 2). The load for a in football. However, despite this a
^ session is then determined as the product recent report showed that heart rate
model for athlete
of the session duration and the players was more widely adopted in top level
(modified from Coutts,
RPE. For example, a 40-minute session
rated as being ‘hard’ by a player would
clubs than the session-RPE method,
likely due to the reservations of players
Crowcroft, Kempton 1).
The main aim of athletic training is to The training dose applied and experienced provide a load of 200 arbitrary units (i.e. 5 and coaches in providing RPE following
provide a stimulus that is effective in by athletes - commonly referred to as the x 40 min = 200 AU). match play.13
improving the players’ capacity to perform. training load – can be measured using
For positive training adaptations to occur, a variety of methods and is typically 0 Nothing at all “No I” Many performance practitioners
the balance between training dose categorised as either an internal or are many other variables that can be 0.3 measure these variables during each
and recovery (i.e. rest and/or recovery external training load 3. The external load obtained from various athlete tracking 0.5 Extremely weak Just noticeable training session use this information
interventions) needs to be obtained. At is the training dose applied to the athletes devices (e.g. estimated metabolic power, 0.7 to assess player output during training
simplest level, the performance responses and is commonly using microtechnology accelerometer loads, etc.), an approach 1 Very weak Light and to understand longitudinal changes
can be explained by the fitness-fatigue devices (e.g. GPS) and athlete tracking with relatively few variables that have 1.5 in training load for individual players.
model first described by Banister, Calvert, systems whilst the internal training load good measurement precision are 2 Weak However, the best use of these data is
Savage, Bach 2. The fitness-fatigue model is the load experienced by the athlete supported by a strong proof of concept are 2.5 when they are stored and the historical
is a simple approach to quantify a dose- and is measured using physiological recommended for load monitoring. 3 Moderate data are used to understand the loads
response relationship of training load (e.g. heart rate) and/or perceptual (e.g. 4 applied to players over the short and
to fitness, fatigue and performance. In perception of effort) tools. Due to the Unfortunately, the important activities that 5 Strong Heavy longer-term and this information can
its simplest form, the model estimates nature of the physical demands of football require high speeds and/or accelerations – 6 be used to identify risks of players who
performance outcomes as a result of the (i.e. it required players to complete high- which have been reported to be important 7 Very strong may be at risk of injury or reduced
fitness and fatigue responses that result of intensity, intermittent exercise), total constructs of load in football4 - tend to 8 performance.
the training dose applied through training. distance travelled, distances covered at be more difficult to accurately quantify 9
According to the model, fitness was higher running speeds (e.g. >14.5 km/h, with current technology. Indeed, despite 10 Extremely strong “Strongest I”
referred to as the average weekly training sprint efforts (i.e. efforts > 23 km/h) recent improvements with increased 11
dose completed in the previous 4 weeks and the number of accelerations and sampling rate and improved chipsets,5,6
whilst the fatigue was determined as the decelerations are the most commonly GPS devices cannot yet precisely assess ^
Figure 2 The category-ratio (CR10) scale
training load completed during the most used metrics used to quantify the external players accelerations/decelerations of perceived exertion 11 commonly used in
recent week. training load in football. Whilst there characteristics using intensity-based determination of the session-RPE training load.


Load monitoring systems can also be HIGH RISK SCENARIOS <

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

speed demands of match play. Underload / Under

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



Our Delphi survey revealed recovery as an effective strategy to prevent muscle
injury in elite footballers. Although fatigue has been highlighted by football
practitioners as one of the most important non-contact injury risk factors in
elite players, 1 it is surprising that the actual scientific level of evidence for
fatigue and injury is currently weak. 2
— With Abd-Elbasset Abaidia, Gregory Dupont, Antonia Lizarraga and Shona Halson

Day after the match:

Wearing compression upper limb strength
Hydration + foods Cold Bath garments training
End of with high glycemic *if 2 matches Massage
Have a good night sleep
the match index and proteins per week

44 However, there are several, indirect ACCELERATING factors (bright light, travel requirement, COMPRESSION GARMENTS MASSAGE Figure 1
Schematic representation of a
sources of evidence that can be
extrapolated to suggest a plausible link
RECOVERY: WHAT room environment). Optimizing sleep
may be possible by sleeping at least 8 to
Wearing compression garments following Massage can have a beneficial effect recovery protocol following a
football match
between fatigue and injury in footballers. RECOVERY STRATEGIES 10 hours, and increasing sleep hygiene
a match may have beneficial effects
on recovery kinetics. The effectiveness
on decreasing muscle soreness and on
increasing the perception of recovery. 12
For example, injuries are more common
at the end of each half during professional
TO USE (AND WHY) by measures such as switching-off lights,
decreasing the temperature of the room,
of compression garments on muscle The best results on muscle soreness are
force and power is underpinned by a obtained with a combination of effleurage,
matches, 3, 4, 5 whilst there is also a known limiting screen time and social media
TAKE HOME MESSAGE high level of scientific evidence. 18-20 It petrissage, tapotement, friction and
significant reduction in muscle force at use, and adapting the food ingested in
is recommended to wear compression vibration techniques and for a duration of 5
the end of matches. 4 A study of a French Consuming proteins after a match enables the afternoon by avoiding drinks such
garments with a high level of pressure to 12 minutes.
Ligue 1 professional football team 6 also repair of muscle damage following as coffee or tea. If the first night’s sleep
(for example: 15mm Hg at the thigh level
provides indirect evidence to support exercise. Scientific evidence has shown a is poor, it should be compensated with a
and 25 mm Hg at the calf level) until bed
the fatigue-injury belief of practitioners, beneficial effect of a protein dose of 20–40 nap the following day. 13
time and the days following the match. 21
in which the authors observed that a g, including 10–12 g of essential amino
Some individuals may prefer to sleep in the
significantly lower than normal recovery
time between high-intensity actions prior
acids and 1–3 g of leucine on muscle
protein synthesis rates. 10 Optimization
garments for additional recovery benefits, IMPORTANT
to injury was evident (35.6+/-16.8 s vs. of the resynthesis of muscle glycogen
however they should not be worn if sleep
is disturbed.
98.8+/-17.5s). stores is effective when consuming Immersing the body into water with
carbohydrates with a high glycemic index. a temperature of 10°C for an exposure INDIVIDUAL VARIATION
Finally, further support lends itself with the An intake of 1.2 g carbohydrate per kg period of 10 minutes immediately after
Due to the fact that individuals will
widely accepted and established finding per hour immediately after a match, at muscle-damaging exercise session is
that, periods of match congestion (e.g. 15-60 min intervals for up to 5h, enables beneficial for recovery. 14 Results have THE DAY AFTER THE likely have different levels of fatigue/
soreness, a different time course of
weeks with multiple matches) significantly
increases the risk of injury. 7, 8 Elite football
maximum resynthesis of muscle glycogen
stores.11 Post-game re-hydration is an
consistently shown a beneficial effect of
this strategy on force, sprint and jump
MATCH recovery and respond differently
to specific recovery strategies, an
teams are regularly exposed to periods of important issue, it is recommended to recovery. 15, 16 While the use of acute cold-
UPPER LIMB STRENGTH TRAINING individualized approach to recovery
match congestion (e.g. 2 to 3 matches per consume a fluid (150% of body mass lost) water immersion is supported by research,
may be necessary. Some players may
week with typically 3 to 4 days recovery with a high amount of sodium (500 to 700 the effect of chronic use of immersion Scientific evidence for effective recovery
respond positively or negatively to
between) in which the time allowed mg.l-1 of water). 12 has been questioned. 17 This is due to the strategies the day following a match
different strategies, and therefore
between matches may be insufficient to potential role that cold water immersion is scarce. Teams typically perform low
consideration should be given to
restore normal homeostasis within players may play in reducing adaptation. Therefore, intensity and low volume exercise based
finding the optimal strategy for each
i.e. to fully recover. A recent multi-team, a periodised approach is likely best, strategies such as active recovery run,
SLEEP player based on performance and
multi-year study performed by the UEFA whereby cold water immersion is used pool session, or bike and tend to avoid
perceptual data if possible.
Football Research Group 7 showed that The recovery process may be affected acutely to influence performance (for rigorous intense activities. While only
muscle injury rates were 21% lower and recovery kinetics slowed following a example during congested schedules) preliminary evidence, performing an
when there were 6 days or more recovery perturbed sleep at night.14 Indeed sleep and limited or reduced at other times (pre- upper-limb strength training session the
compared to 3 or less days. These results is often considered the best recovery season or weeks with only one match). day after fatiguing and muscle damaging
show that a recovery period from 48h to strategy available to athletes, and it is lower-limb exercise may accelerate the While the area of recovery research is
96h between two matches is associated critical to manage sleep disturbances recovery kinetics of concentric force. 22 This relatively new in comparison to other fields
with an increased injury risk, suggesting when playing multiple games per week. strategy may be implemented the day after in physiology and nutrition, future areas of
insufficient time to fully recover. Recovery Many elite footballers complain of sleep a match. It also represents a time-efficient interest include periodisation of recovery,
strategies aimed at accelerating the time difficulties after night matches, which may modality to enhance upper-limb strength individualisation of recovery, psychological
for players to fully recover may therefore be due to physiological factors (fatigue, in players that may not be possible later in recovery (meditation, relaxation,
be useful in the overall injury prevention soreness, temperature), psychological the week or allows an additional exposure mindfulness) and how athletes recovery
strategy. factors (arousal, stress) or environmental to such training. from mental fatigue.



Exercise is one of the most common preventative strategies implemented by football
teams to prevent muscle injury. 1 The following summary and recommendations are a
combination of relevant scientific research findings with current best practice.
— With Maurizio Fanchini, Eduard Pons, Franco Impellizzeri, Gregory Dupont, Martin
Buchheit and Alan McCall
*Special contribution from Nick van der Horst, Ida Bo Steendhal and the EBMIP Delphi Group

Table 1
the results of a systematic review and
our expert led Delphi survey of key High-speed running / sprinting +++
effectiveness of
football performance practitioners exercise strategies to During running and sprinting i.e. at high
Eccentric ++ prevent muscle injury
operating in teams from the Big 5 in elite footballers
velocities (HSR), lower limb muscles
Leagues (Bundesliga, English Premier Concentric + (EBMIP Delphi Survey experience high values of torque at
League, La Liga, Ligue 1, Serie A) and results) stance and late swing phases. During
Isometric +
combined with the philosophy and the stance phase, muscles of the hip
practices of FC Barcelona medical and Plyometrics (Horizontal & vertical orientations) + and knee work to counteract the ground
performance staff. reaction force. Muscles of the ankle
Activation / coordination (e.g. sprint +
movements & mechanic drills contract eccentrically and concentrically
Our systematic review showed that (with higher power compared to knee
there is no convincing evidence for Flexibility (dynamic & static) + and hip joints muscles) to absorb the recommended within the muscle injury producing moderate (> 6 to 10) exposures
many exercise-based strategies to Core stability +
ground reaction force and to push the prevention strategy. Exposure to targeted (i.e. the number of activity performed) of
prevent muscle injury in elite football body forward in the swing phase. 2 HSR and HIA can have the additional ≥95% of their maximal running velocity
players. Our results highlighted a Multi-joint exercises (e.g. Olympic lifting, Between + to +++ (no During the swing phase, muscles control benefit of developing physical qualities within the week were at reduced risk of
squats, functional strength) consensus as to precise
low quality of studies (systematic effectiveness)
the movement direction of the limb such as intermittent aerobic fitness that lower limb injury, while both low (<5) and
reviews and randomized control extremity with hamstrings muscles has been shown to protect players from high (>10) exposures increased the risk of
trials) and overall weak scientific Single leg strength and stability Between + to +++ (no responsible for both hip extension and lower limb injury. 7 injury. Importantly, a high chronic overall
consensus as to precise
evidence supporting eccentric exercise effectiveness)
knee flexion. 2 The high power expressed training load (all trainings) allowed players
to prevent hamstring injuries. The by the muscles results in high horizontal to tolerate higher exposures (between 10
Delphi survey revealed (Table 1) the Agility Between + to +++ (no force that maximize the forward and 15) ≥95% without increasing the risk
consensus as to precise THE FOOTBALL TRAINING PROGRAM?
perceptions of elite level practitioners effectiveness)
propulsion. 2 A lower contribution of of injury. Additionally, minimal exposure
regarding the effectiveness of various horizontal force during sprinting has The nature of football as a running based to HSR efforts (i.e. maximum speed and
exercise types to prevent muscle Kicking (shooting, crossing, long passes) Between + to +++ (no been proposed as a risk factor and sport means that the coaches’ normal sprint volume) has been shown to be a
consensus as to precise
injuries in footballers. The following effectiveness)
mechanism for hamstring muscle football training sessions inevitably risk factor for injury in Australian Rules
piece will focus primarily on the two injury in football. 3 Specific focus on involve a varied amount of contribution Footballers. Our chapter on‘controlling
most highly rated exercise types; Resisted sprints (e.g. sleds, parachutes) Between + to +++ (no HSR within the training program should of HSR and HIA depending on the load’with Professor Aaron Coutts will
consensus as to precise
high-speed / sprint running and effectiveness) therefore be considered important to type and duration of the session. We cover this in more detail.
eccentric exercise. A secondary expose and condition the lower limb recommend that wherever possible,
emphasis highlights the importance muscles in a specific manner to cope HSR and HIA should be integrated into Position specific HSR and HIA should be
of a multi-dimensional approach to with the demands of football training the coaches’ typical football drills. While, developed to contextualize running bouts
exercises based prevention and other and match-play. Importantly, reaching ideally HSR and HIA targeted sessions in relation to tactical activities, the work to
potentially effective exercises that can HSR velocities requires the player to are integrated seamlessly into normal rest ratio and method of recovery can be
be incorporated into the prevention accelerate and given the nature of training, it is also appropriate to prescribe manipulated as well as the introductions
program. football, then decelerate and change separate football specific drills and of change of direction and turns to
direction and change intensity with generic running (e.g. maximal aerobic simulate specific match patterns. 9 10 An
and without the ball (e.g. dribbling, speed, repeated straight line sprints integrated approach of physical, tactical
passing, shooting) according to the etc) to ensure players are exposed data and technical elements is also time
context of the game. 4 5 These situations, to sufficient amounts of this type of efficient and well accepted and liked by
requiring neuromuscular load 6 can preventative training. players and coaches. It is important to
present potentially injurious situations individualise the prescription of HSR and
and therefore exposing players to these While not in football (soccer), it has been HIA according to each player, there is not
high-intensity actions (HIA) is also shown in Gaelic Football 8 that players one size to fit all.


48 WHEN IN THE TRAINING WEEK, We recommended in general, (based on NON-STARTERS / SUBSTITUTES # Full days 49
between matches @M+3/+4 or M-3
TO PERFORM HSR AND HIA? our expert led Delphi survey) that during @M+3/+4 or M-3
periods of 1 match per week (i.e. >5 days It is important to remember that while the 1. Type #4 HIA 1. Type #6 Speed

There is no strong scientific evidence full recovery between matches), HSR and playing squad is 11 players, the typical elite >5 days SSGs 3-5 x 3-4min 5v5 + GKs* (Sprints via Football Sessions)
2. Type #2 HSR
to guide when the optimal time HIA specific exercise is performed on football squad comprises ~ 25 + players and HIIT Short 2 x 4-6 min 10s (110%)/20s (rest)*

is in the training week to perform Matchday -3 (M+4). During periods with not all can play. It is imperative that players Next match?
specifically focussed HSR and HIA ≤4 days recovery between matches, it is not playing regularly are also prepared for
training and there are likely various generally considered to perform football the rigorous demands of a match not only <5 days Football sessions only
possibilities depending on a number training only as the targets will most likely from an injury perspective but also from
of factors, including but not limited be achieved during the games. Within a performance standpoint. Carling and @M+1 @M+3/+4 or M-3 @M-2/-1
to; the number of days from the last even a congested fixture list, coaches colleagues 11 found that substitutes directly >60 min
1. Type #4 HIA 1. Type #6 Speed 1. Type #6 Speed
match and the next match (e.g. 2 to 6 normal training will involve higher winning more games was one of the <5 days SSGs 3-4 x 3-4min 4v4 + GKs Same as* (Sprints via Football Sessions)
+ days), starters versus non-starters/ running intensities (including sprints), potential contributors to a championship 2. Type #4 HSR
Played HIIT Short 1-2 x 4 min 20s (95%)/20s (rest)
substitutes, loads performed and and therefore it is likely not necessary to winning compared to 4 other non-winning last match?
experienced during the match, the perform any additional work. It is even seasons. Therefore careful consideration
planned content of the coaches possible to perform HIA drills i.e. short should be given to these players and @M+1/+2 (depending on rest day)
football session, individual players acceleration, deceleration and change although involved in the same main training Did not play /
played <35 min 1. Type #4 HIA
3-4 days
needs, strengths, weaknesses, likes of direction drills (typically coined speed sessions as the starting players, they will SSGs 3-4 x 2-3min 5v5 + GKs
or HIIT Short 2 x 4min 15s (95% passing, kicking, sharp CODs)/15s (rest)
and dislikes, current and on-going & agility by players) on the M-1 as long likely require additional and supplemental 2. Type #6 Speed:
medical issues, whether or not they as a low volume and adequate recovery HSR and HIA to ensure they are prepared if Next match? 4-6 progressive 40/60-m runs (build up to 90-95% MSS), r = >45s

are accustomed and adequately times between repetitions are respected. called upon. Specifically, it is recommended
prepared to be exposed to and tolerate Anecdotally, many players actually enjoy that non-starters and substitutes perform @M+1
such demanding exercise. performing these types of activities on the additional HSR and HIA exercise on M+1 or 1. Type #1
M-1 (e.g. as part of the warm up or after M+2 (but not on both), depending on the 2 days HIIT Short 1 x 4min 10s (105%, 45° CODs)/20s (rest)
2. Type #6 Speed
the session) as it makes them feel “sharp” training schedule e.g. days off, upcoming 4 progressive 40-m runs (build up to 90-95% MSS), r = >45s
for the match the next day. match etc.

Figure 1
Decision process when it comes to programming the different running e.g. High-intensity intermittent
training (i.e. HSR & HIA) drills with respect to competition participation and matches macrocycles.
Note that only HIIT sequences are shown – most sessions would also include technical and tactical
components and possession games. SSGs: small-sided games. HIA: high-intensity activities (> 2ms2
accelerations, decelerations and changes of directions). HSR: high-speed running (>19.8 km/h). The
different HIIT types are the following: Type #1) aerobic metabolic, with large demands placed on
the oxygen (O2) transport and utilization systems (cardiopulmonary system and oxidative muscle
fibers), Type #2) metabolic as 1) but with a greater degree of neuromuscular strain, Type #3) metabolic
as 1) with a large anaerobic large glycolytic energy contribution but limited neuromuscular strain,
Type #4) metabolic as with 3) but with both a large anaerobic glycolytic energy contribution and a
high neuromuscular strain, Type #5) a session with limited aerobic demands but with a anaerobic
glycolytic energy contribution and high neuromuscular strain Type #6)not considered as HIIT) with a
high neuromuscular strain only, which refers to typical speed and strength training for example. Note
for all HIIT Types including a high neuromuscular strain, possible variations exist in the form of this
neuromuscular strain, i.e. more oriented toward HSR (likely associated with a greater strain on hamstring
muscles) or HIA (acceleration, decelerations and changes of directions, likely associated with a greater
strain of quadriceps and gluteus muscles). Note for example that Type #1 can be achieved while using
45°-CODs, is likely the best option to reduce overall neuromuscular load (decreased absolute running
velocity and no need to apply great force to change of direction, resulting in a neuromuscular strain lower
than straight line or COD-runs with sharper CODs.) Reference (for both HIIT types and Figure): Science
and Application of High Intensity Interval Training, Laursen P, Buchheit M. Human Kinetics, In Press.


estimation. It is also vital to consider if
players are accustomed to performing
of performing such exercises before or
after the session. This is best done at the EXERCISES
One potentially modifiable risk factor
In our expert led Delphi survey, exercises EXERCISES? eccentric exercise as this may allow individual player level also. It has been
for muscle injury are increases in Plyometric exercises are commonly used
with an eccentric focus were rated as the them to perform such exercise on a M-3 recommended that eccentric exercise
fascicle.19 Performing eccentric exercise to improve sprint and jump performance
2nd most important exercise mode to As with high-speed running and in a 5 day week without experiencing performed both before (fresh) and after
before the training session has revealed in team sport in addition to increasing
prevent muscle injury in elite footballers. sprinting exercise, there is no clear any muscle soreness. (fatigued) are likely optimal to the injury
fascicle length increases but not when the neuromuscular control and lead to
This is in line with the perceptions of scientific evidence as to when is the best prevention program.23 This is in line
performed after the session. 20 Similar less torque working on the knee.24 The
worldwide Premier League,1 UEFA period to perform the main eccentric During periods with ≤4 days it is with the actual practices of the expert
chronic adaptation of peak torque introduction of plyometric exercises into
Champions League12 and National teams exercises during the football training generally considered that specific practitioners from the Big 5 leagues.
production of the hamstring muscles has the injury prevention program could be
competing in the FIFA World Cups.13 week. There are a number of similar high-intensity type eccentric exercise
been shown to be similar when eccentric promising however several parameters
Eccentric exercise may be particularly contextual factors running based training is not necessary. There may however
exercise is performed before and after of load (volume, intensity, frequency)
useful as it targets various modifiable that need to be considered surrounding be options to include low intensity, low
the training session.20 should be accurately evaluated during
risk factors including; eccentric strength,
optimal angle of peak torque and
the decision of when is most appropriate
to include eccentric exercise.
volume eccentric type exercises coined
as ‘activation’ exercises.. The specific
EXERCISE-BASED INJURY the design of the training program.
muscle architecture e.g. fascicle length14. muscle section of this Guide will provide
PREVENTION STRATEGIES Specific exercises targeting the motor
control of the core muscles have been
It is likely that these reasons explain
why this exercise mode is favoured by
In general, when playing 1 match per
week and 6 days recovery between
further details on specific eccentric
exercise types e.g. for the hamstring, A training intervention where eccentric
SHOULD BE MULTI- found to result in fewer games missed in
practitioners not only in football but also matches, the most appropriate day is adductor, quadriceps and calf. exercise is performed after the session DIMENSIONAL Australian Footballers,25 however, multi-
joint exercises such as the squat and
in many other team sports.15 Importantly, perceived to be on M+ 3 (M-4 from the has shown to increase muscle thickness
deadlift are at least and in some cases
player buy in and the quality to which next match). This timescale likely allows and pennation angle21 as well as a While this section has focussed
more effective in the activation of core
the exercises are performed are likely opportunity for muscles to recover from PERFORMING ECCENTRIC EXERCISES chronic adaptation towards an improved on running and eccentric exercise
muscles.26 An important consideration
key to ensuring optimal adaptations and the previous match and enough time BEFORE OR AFTER THE FOOTBALL ability of players to maintain their specifically, in reality, the injury
for the practitioner is that the inclusion
beneficial effects on muscle injuries.12-16 for them to recover again before the SESSION? eccentric strength at half-time and upon prevention program is and should be
of other exercise modes such as
As such, exercise with an eccentric focus next match 4 days later e.g. Saturday – cessation of a simulated football match multi-dimensional that includes various
Once we have decided on the day to plyometrics and multi-joint exercises
should be considered in the overall Tuesday – Saturday. versus those performing in a fresh state other exercise modes. Therefore, the
perform the eccentric session, another should be performed in both vertical
injury prevention program for footballers before training.22 global injury prevention program should
key question for practitioners is when to and horizontal orientations. Using both
and buy in and quality execution of When the recovery between matches not be limited to high-speed running /
implement it i.e. before (non-fatigued) orientations in the football training
these should be encouraged and is 5 full days (e.g. Saturday – Friday) sprinting or eccentric exercise alone but
or after (fatigued) football training? program has been shown to improve
monitored by practitioners. the preferred day is again on the M+3, CONSIDERATIONS WHEN DECIDING involve the addition of other exercises
While scientific evidence is limited neuromuscular performance of players
however this will also correspond to a BEFORE OR AFTER THE FOOTBALL targeting modifiable risk factors. Table
currently, there are some preliminary in comparison to vertically oriented only
M-3 i.e. 3 days before the next match. SESSION 1 illustrates the wide array of exercise
findings suggesting that specific timing exercises.27
While only preliminary evidence, it types available to the practitioner
of the eccentric exercise around the An important consideration when
has been shown in semi-professional who wants to reduce injury in his/her
football session may result in different planning the timing of the eccentric
football players that performing eccentric team. While there is limited evidence
adaptations that could contribute to exercise session is that an acute effect
exercise on the M+3 i.e. M-3 during a for many of these exercise types e.g.
reducing muscle injury risk. of eccentric exercise performed before
week with 5 full days recovery resulted plyometrics, flexibility, core stability, static
the training session may result in muscle
in elevated levels of creatine kinase and and dynamic flexibility, activation etc
fatigue that could actually increase
hamstring muscle soreness 24h before to prevent muscle injuries of the lower
the probability to sustain an injury in
the next match.17 However, perhaps limbs in footballers, they should also
the subsequent session.21 Therefore,
importantly was that muscle function (i.e. be considered due to their perceived
as a practitioner you should consider
muscle force) was not affected. Muscle effectiveness and widespread use in elite
carefully the context surrounding the
force is considered the gold standard football teams i.e. current best practice.
planned eccentric exercise; in particular
measure of muscle damage18 and may
consideration of the coaches training
be more useful to inform injury risk
session and determine the risk:benefit



Table 2 Perceived 53

There is no clear evidence for lower

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

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

dimensional prevention program in
Single leg strength and stability Between + to +++ (no
consensus as to precise
INJURY PREVENTION elite European footballers incorporating effectiveness)

PROGRAMS ON MUSCLE eccentric, general strengthening

exercises, dynamic flexibility, core,
Agility Between + to +++ (no
consensus as to precise
INJURY IN FOOTBALLERS balance, coordination and agility based effectiveness)
runs into the overall football training Kicking (shooting, crossing, long passes) Between + to +++ (no
Although scarce, there is some program resulting in significantly less consensus as to precise
scientific evidence for the use of multi- muscle injuries in players. effectiveness)
dimensional injury prevention programs Resisted sprints (e.g. sleds, parachutes) Between + to +++ (no
in elite footballers. In 2005, Verrall consensus as to precise
and colleagues30 found that a global effectiveness)
prevention program incorporating sport
specific running drills, high-intensity
interval anaerobic training, strength
training and flexibility resulted in a
significant reduction in hamstring muscle
injuries and the number of competition
games missed. Owen et al. (2015)28
implemented a multi-dimensional
prevention program in elite European
footballers incorporating eccentric,
general strengthening exercises, dynamic
flexibility, core, balance, coordination and
agility based runs into the overall football
training program resulting in significantly
less muscle injuries in players.



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

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




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

• Injury severity corresponds to the

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


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


Table 1
Suggestions for
Players Surveys As part of routine team How many of the planned NHE sessions were carried out? employing qualitative
meetings evaluation in a team
Football coaches Focus groups Were the correct number of sets and repetitions performed?
Formal injury prevention setting
Medical and Interviews What was the quality of exercise execution?
evaluation sessions
performance staff
Do you see any benefits of using the NHE program?
Individual player
Club officials
performance reviews Does the program have any negative side-effects?
Are there any barriers for using the NHE program?
Was the program modified? (Why?)
Do you use alternate strategies? (Why?)
Do you intend to continue using the NHE program?
Could the NHE program be adapted to better fit your team’s

* It is important to ask individuals from all the

groups involved in the injury prevention strategy; Acknowledging the fast and frenetic
players (who perform the program); team staff pace of football, continual evaluation
members (who deliver the program) football is crucial in this phase of the Team
coaches (who often act as “time-keepers”) and
club officials (who determine club policy and Sport Injury Prevention cycle. This will
provide resources e.g. financial). allow the medical and performance
team to audit and identify emerging
patterns in the injury situation and take
subsequent action. Although it may be
normal to discuss the injury situation in
daily and weekly medical meetings, we
recommend a more formal evaluation
performed 2 to 3 times per season,
including coaches, other support staff
and even some players. During this
evaluation, injury statistics, qualitative
analyses and reviews of injury
prevention research and innovative
strategies can be discussed in depth.


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The previous section on preventing muscle injury in football has outlined various
strategies and tools that can be adopted to minimise the risk of players incurring a
muscle injury. While in an ideal world we would be able to prevent all muscle injuries
from occurring this is unfortunately, impossible. As outlined in our ‘Injury Landscape’
article (see Section 1, Chapter 2.1.c) a professional football can expect around 16
muscle injuries in a season.
— With Ricard Pruna, Alan McCall and Thor Einar Andersen

66 General As such we need to be optimally 67

principles of
prepared to deal with muscle injuries TO RETURN
when they come. Following a muscle THE PLAYER TO
injury (or any injury for that matter) MATCH-PLAY
there are 2 main objectives (and at POSSIBLE

Return to Play
the same time challenges); 1) to return
the player to match-play as soon as
possible and 2) to avoid re-injury. Figure 1 Objectives
There is a fine balance to this, which (and challenges) of

from Muscle
is complex depending on the context Returning a player
from injury.
of each individual player, injury and
circumstance (figure 1).

In football, the decision to progress
or delay a players’ return to play
following muscle injury, could be the
difference between having a player
back two matches earlier (increasing
the chance to win 6 points) versus
keeping the player out an extra two
weeks, lowering his/her injury risk,
but maybe gaining fewer points from
those two matches.1 Essentially, it
comes down to a decision on an
agreed ‘level of risk’ (for re-injury)
that the team is willing to accept
i.e. a shared decision of medical,
performance practitioners, the coach
and the player him/herself.

The purpose of this chapter on ‘General

Principles of Return to Play from
Muscle Injury’, as with the previous
prevention section, is to bring together
the best of research knowledge and
demonstrate how we combine this
with our practical experience and
knowledge. Providing you with general
principle to follow during the return to
play process.


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

The concept of return to play as a

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




When a footballer sustains a muscle injury, their first question is invariably: “how
long will this take to recover?” Answering this is not easy,1-5 but in elite-level football
it is vital to make an educated guess. As previously discussed, the RTP continuum
begins with the anticipated date of return to optimal performance in mind and works
backwards, defining the milestones necessary to achieve that goal. This approach
motivates the player, allows the manager to plan effectively, and facilitates good
communication and realistic expectations from all involved.
— With Ricard Pruna and Ben Clarsen

used in isolation, both MRI and clinical EXTENT OF TISSUE DAMAGE MUSCLE INJURY Table 1
Key positional
assessment findings are poor predictors Every football player has unique anatomy Each player’s unique role on the Goalkeepers, Long kicks and jumps High stress on rectus demands and their
of RTP time.1-5 That is because even Knowing the exact injury location is that will affect his or her recovery from pitch needs to be considered when central defenders femoris consequences
on muscle injury
when the same type of injury occurs, arguably the most important factor in a muscle injury. For example, due to estimating the RTP time. For example, rehabilitation
Full backs, High speed running, High stress on hamstrings
myriad individual and contextual predicting RTP time. This is why, at FC differences in free tendon length, a biceps wide defenders and wingers perform wingers rapid acceleration and
factors influence how quickly each Barcelona, clinical assessments are femoris injury located 5cm from the more high-speed running than deceleration
player will recover, and how much performed and high-quality MRI images ischial tuberosity might involve mostly other players so hamstring injury
Central Frequent direction High stress on soleus
risk the player and team are willing to are taken as soon as possible after tendon tissue in one player, and muscle rehabilitation may take longer for midfielders changes
take. Nevertheless, it is our experience muscle injuries occur. Knowing whether tissue in another. Careful examination of players in those positions. Similarly,
that when experienced practitioners any tendon or bony tissue is involved is each MRI image is therefore necessary. central midfielders frequently perform Strikers, High speed running, High stress hamstrings
attacking acceleration and and adductors
consider a range of important factors vital, as injuries involving these tissues rapid direction changes, which places midfielders deceleration and
together, it is possible to estimate RTP generally heal more slowly and might Variations between players’ connective high demands on their adductor direction changes
time surprisingly accurately. need referral to a surgeon. In addition, it tissue quality may also affect an injury’s muscles. Key positional demands and
is necessary to identify injuries to muscle recovery time. Although this may be their consequences for muscle injury
regions that are highly stressed during determined by genetic factors that we are rehabilitation are summarised in Table 1.
football, as these need to be managed currently unable to identify with certainty. FOOTBALL-SPECIFIC FACTORS Importantly, the RTP decision is also
THE FC BARCELONA more conservatively than injuries located A history of frequent muscle injury can Additionally, each player has a unique highly dependent on the level of re-
APPROACH in less-stressed regions. be a good indication of poor connective
tissue quality. More conservative RTP
playing style that may also affect his or
her RTP plan. For example, some players
Whenever a player returns to football
after a muscle injury, there is always a
injury risk that the player and others
(e.g. medical and performance team,
The foundation for any RTP estimate Although the patient history often provides plans should therefore be made for have an aggressive style, chasing every risk that the injury will recur. Generally, team manager) are willing to take.
is an accurate diagnosis. However, it vital information towards making an frequently injured players. ball and pressing opponents throughout the sooner the player returns, the Will they accept a re-injury higher risk
is also essential to consider player- accurate diagnosis, the initial amount of the whole game. Others are more higher the re-injury risk. However, it and return to play early, or reduce the
specific (intrinsic) factors, football- pain and functional impairment can be tactical and therefore more economical is impossible to know the exact risk risk by returning more slowly? This is
specific (extrinsic) factors and other misleading when estimating RTP time. with their energy expenditure. in each situation. Therefore, every RTP influenced by a wide range of contextual
risk tolerance modifiers. We highlight Knowing where the injury is located and decision is a “judgment call”, ideally factors called risk tolerance modifiers.7
that practitioners should continuously which tissues are affected provides much Finally, muscle injuries located in made by the player, the medical team, These include factors directly related
re-evaluate the initial RTP estimation more information. For example, hamstring players’ dominant and non-dominant and the coaching and performance team to football, such as the importance of
throughout the rehabilitation process, strains located in the middle third of the legs may have markedly different together.6 The decision is based on a the upcoming games, the importance
depending on how quickly the player muscle belly are often severely painful recovery time, and even different range of factors, such as: of the player, and the availability of
progresses along the milestones and cause a large haematoma, yet most management plans. For example, partial replacement players, as well as others
defined in the RTP continuum. Key players return to optimal performance ruptures of the proximal rectus femoris • Whether the injured tissues are such as financial factors (e.g. the player
indicators of whether the player is within one month – some as quickly as 3 direct tendon are possible to treat likely to have healed sufficiently to is currently negotiating a new contract)
on-target to meet the anticipated weeks. In contrast, partial ruptures of the conservatively if they are in the non- tolerate the loads of competitive or psychological factors (e.g. pressure
RTP date include regaining baseline proximal hamstrings tendons often initially dominant leg, but the same injury in the football from self, family, agents etc).
strength and flexibility measures, appear to be minor injuries; they are less dominant leg is a clear case for surgery.
completing high-intensity training painful and their onset is less dramatic. • Whether the milestones along the A number of risk tolerance modifiers, in
sessions comparable to (or even However, these injuries generally take far RTP continuum have been achieved particular those that are directly football-
greater than) their anticipated match longer to recover – often up to 10 weeks. related, can be identified as soon as
demands, and demonstrating an The expected return to play times for • If the player feels psychologically the injury occurs. These should be
appropriate level of football-specific specific injury locations in the hamstrings, ready to return considered when estimating RTP time.
cognitive skills and psychological adductors, quadriceps and calf muscles
readiness. can be found later in this guide.



When an injury occurs during training or match play, the essential questions to
answer as clinician on-field are: where is the localisation of the muscle injury, what
type is the injury and, can the player continue to play? In most cases, the player
should be taken off the field for further assessments and acute injury management
according to the PRICE principle (protection, rest, ice, compression, elevation).
— With Thor Einar Andersen, Arnlaug Wangensteen, Justin Lee, Noel Pollock, Xavier Valle

72 The first step off-field is a 73

comprehensive clinical examination
including detailed patient injury
history taking and careful physical
assessments. In cases where the
clinical appearance and severity
is unclear and determining the
optimal treatment can be difficult,
supplementary radiological imaging
can provide important additional
information to confirm the radiological
severity of the injury and guide
further treatment. Making an accurate
diagnosis is essential to ensure that ^
injured players receive appropriate Figure 1
Schematic overview
treatment and correct information of the different types
regarding their prognosis.1 This chapter of muscle injuries.
Tendon and bone
will discuss the initial and subsequent injuries (avulsion
clinical and possible radiological fractures) are included
assessments to enable the clinician to as sub-classifications
of muscle strain
confirm an accurate diagnosis. injuries, as they
PLAYER 1 PLAYER 2 may appear to be
muscle injuries with
As illustrated in Table 2, making the RTP
Table 2
Example of how the ON-FIELD MANAGEMENT similar mechanisms
Injury location Biceps femoris tear Biceps femoris tear same injury can lead and often similar
estimate for a specific muscle injury and severity involving the intramuscular involving the intramuscular to markedly different Working on-field as a clinician, with Signs that the player may be able to clinical presentation.
tendon rupture, located tendon rupture, located (Reprinted with
involves adjusting the normally expected in the middle third of the in the middle third of the
RTP time estimates the pressure of limited time and the continue to play include for example muscle permission from
RTP time upwards or downwards, based thigh thigh requirement to act quickly when an cramps that resolve quickly with no residual Wangensteen 20182).
on player-specific factors, football-specific acute injury happens, the point of the symptoms, or mild contusion injuries with
“Normal” RTP 4 weeks 4 weeks
factors, and risk-tolerance modifiers. time for this
initial assessment is to answer some no loss of function and minimal pain.
injury important questions: Is there a muscle However, we encourage the practitioner to
This process requires medical knowledge, injury and where and what type is the err on the side of caution. If in doubt, take
Player-specific 1st injury in this location 3rd injury in this location
football knowledge and experience, factors (no change to initial RTP (Indicates poorer quality
injury? And can the player continue to them out.
and should be considered an art just as estimate) connective tissue: +1 week) play or not?
much as a science. We highlight that The acute management should be initiated
Football- Central midfielder, tactical Wing back, aggressive
throughout this section we have used the specific factors playing style (no change) playing style (High sprint
Typical signs of an acute muscle injury as soon as possible. Despite little evidence
term estimation, rather than prediction. demands: +1 week) to identify include an acute onset of basis for the early management of acute
None of us owns a crystal ball. However, pain where the player is able to recall muscle (strain) injuries3, the PRICE principle
Risk-tolerance Key player in the team. Player not normally in
using a guiding framework can help even modifiers Injury occurred in starting 11. Injury occurred the inciting event, pain or discomfort is traditionally considered the cornerstone
inexperienced practitioners make more February, 3 weeks before in October (Lower risk with isometric contraction, stretching, for treating acute soft tissue injuries.4,5
accurate and consistent RTP estimations. Champions League strategy: +1 week) and palpation of the injured muscle. In POLICE (protection, optimal loading, ice,
semi-final (Higher risk
acceptable: -1 week) many cases the range of motion (ROM) compression, elevation) is suggested as an
is restricted. In the section below, we alternative acronym, where optimal loading
Estimated RTP 3 weeks 7 weeks present a guide in how to establish a means replacing rest with a balanced and
tentative diagnosis. incremental RTP program where early ≥


74 activity encourages early recovery.6 It Later in this section, we describe PATIENT HISTORY Injury When did the injury occur? Table 1 75
is important to initially differentiate specific clinical examination tests situation General patient history
During game or training? (timing)
between the contact and non-contact for the most common muscle injury A thorough injury history forms the questions for muscle
First, middle or last part? (register minutes of the game) injuries
injuries. In contusion injuries, such locations in football – the hamstrings, foundation of diagnosis. In fact, in Season: beginning, middle, end, out of season
as quadriceps contusions, the injured adductor, quadriceps and calf muscles. many cases it is possible to accurately How did the injury occur? Injury mechanism
muscle is recommended to be stretched The initial clinical examination diagnose the injury based only on
Contact or non-contact? (i.e. contusion or strain?)
towards maximum during compression in should be performed as soon as the the injury history. The most important
Exact movement; high speed running – acceleration/deceleration (typically hamstring); kicking (typically adductor and
order to minimise hematoma formation player leaves the field and with daily questions regarding the injury situation rectus femoris), stretching; changing directions/cutting; jumps/take offs/landings; towards excessive outer ranges (NB total
(by increasing the counterpressure),7–9 follow-up examinations until the and mechanism, symptoms, previous ruptures!)
whereas muscle strain injuries should not correct diagnosis is established. In injury history and workload are shown Forced to stop immediately? Weightbearing impossible or restricted? (might indicate severity)
be elongated towards outer ranges during the following section, we outline a in Table 1. More detailed information Able to continue? Able to continue with restrictions?
the initial management to avoid additional systematic approach to the clinical specific to each muscle injury location ‘Popping’ feeling and/or sound at time of injury? (might indicate severity and suspicion of total rupture)
strain and damage. examination of muscle injuries. can be found later in this section.
Pain Location (where does the player report pain)
Onset: acute or gradual?

OFF-FIELD EXAMINATIONS Severity (a visual analogue scale or a numeric rating scale of 0-10 can be helpful):
• at the time of injury onset
• today (at time of examination)
Clinical examination, including patient • at rest
history taking and physical assessments, Time to pain free walking?
is the cornerstone in the diagnosis of Function:
any muscle injury and should be the first • pain with walking?
step before any further investigations • pain with ascending/descending stairs?
• specific activity provoking pain?
are performed.10–12 The primary aim of
Other aggravating factors?
the clinical examination is to determine
the type, location and extent of the injury Previous Is this a re-injury?
and whether imaging and/or other injury
Any feeling of tiredness/discomfort/pain last 7 days before injury onset?
investigations are needed. In addition, Previous injury of same type (location) and side?
clinical examinations form the basis for
Previous injury of same type (location), other side?
further RTP decisions, and are valuable
Other muscle injury? (specify)
as the foundation for re-testing and
Other injuries and/or complaints
comparison when considering information • low back pain
to be provided for the RTP decision- • fractures
making process. The clinical examination • other
may provide a rough estimate of the Workload Previous last training and games played (last week/month)
severity and time needed to RTP, although Intensity/workload last week/month
further evaluation and observation is likely
Other Initial treatment received
to increase the accuracy of this estimation. questions Factors that might influence general recovery – e.g. poor sleep, nutrition, recent long-haul flights
Clinical assessment, in conjunction with
imaging, can also identify the rare cases
when early surgery is required.


Gait and Walking:
function - antalgic gait pattern?
- need for crutches?
The physical examination should Imaging investigations assist in AND CLASSIFICATION
start with careful inspection and an
assessment of function, followed by
Imaging investigations assist in
confirming the initial clinical diagnosis
confirming the initial clinical diagnosis
and may help guide the RTP estimation.
- able to jog?
Other functional movements (observe ability to and quality, register pain):
palpation, active and passive ROM and may help guide the RTP estimation. MRI and ultrasonography are normally
- two leg squat testing, isometric pain provocation MRI and ultrasonography are normally the best modalities to assess muscle Following the initial examinations,
- one-leg squat and muscle strength testing. the best modalities to assess muscle injury, although X-ray and CT are clinicians commonly assign a grade
- trunk flexion (hamstrings)
- calf raises (gastrocnemius) Finally, additional tests (such as injury, although X-ray and CT are occasionally indicated.15,16 or classify the muscle injury based on
- jumping, kicking and change of directions (minor injuries) neural sensitive structures, pulse occasionally indicated.15,16 the clinical and/or radiological signs
etc.) can be performed (Table 2). and symptoms. An injury ‘classification’
Inspection Visible ecchymosis (bleeding / hematoma) X-RAY AND CT
We recommend starting with the refers specifically to describing or
Swelling? MRI
uninjured side, as this provides the X-ray of the affected limb is indicated in categorising an injury (for example
Visible disruption? player with a reference as to what Magnetic Resonance Imaging (MRI) using two situations: by its location, injury mechanism
‘Bulk’ / ‘gap’? feels ‘normal’, before examining fluid-sensitive techniques (fat-suppressed or underlying pathology), whereas
the injured side. Normally, pain spin-echo T2 weighted) is ideally suited a ‘grade’ provides an indication for
Palpation Tenderness / pain provocation with palpation is useful for identifying the specific 1. When bony avulsion of the
region/muscle injured, as well as the presence or absence of a palpable defect in the experienced during the different tests since it allows the detection of oedema clinical and/or radiological severity
tendon attachment is suspected.
musculotendinous junction. Importantly, detection of any discontinuity or ‘gap’ at the is recorded, where pain indicates a and fibre disruption (tear) at the site of the of the injury.19 Using a grading
proximal or distal tendinous insertion should lead to suspicion of a total rupture and This is particularly relevant to the
should be further investigated and confirmed or disproved by MRI. positive test and no pain indicates damage in the first hours after the injury or classification may ease the
adolescent athlete where one
a negative test. Visual analogue and to provide an objective assessment communication between clinicians.
Location and length of pain might suspect an apophyseal
scales (VAS) or numeric pain rating of the intramuscular and extra-muscular Although there has been several
Palpable disruption/discontinuity of muscle/tendon avulsion injury.17,18 A cortical
scales (NRS)13,14 are commonly used tendon of the muscle. MRI provides clinical and radiological grading- and
Insertional pain avulsion may not be visible on
in order to quantify the player’s pain. a complete assessment of the whole classification systems purposed for
MRI as the fragment is often low
Active and ROM is assessed as the presence of pain, the intensity of pain (VAS or NRS) and/or Objective measurements, for example muscle-tendon-bone unit.15 muscle injuries, there are currently no
passive range objective in grades with goniometer/inclinometer (°). signal within a retracted low-
using goniometers and hand-held uniform approach or consensus to the
of motion signal tendon.
(ROM) testing
Active ROM: the player is asked to perform an active ROM exercises without assistant dynamometers, might be useful At FC Barcelona, MRI is initially used categorization and grading of muscle
and the restriction of ROM compared to unaffected side is registered. The tests depend
on the muscle suspected to be injured but are always instructed to be performed first
in order to quantify side-to-side to identify the location and extent of 2. Full-delineation of myositis injuries.19,20 An overview of the some
with a slow motion, thereby with increased speed if appropriate. differences or deficits, and to track tissue damage. In addition, MRI is used ossificans. CT scans may confirm of the most common grading- and
Passive ROM: is used to elicit muscle stiffness/ assess muscle length. By applying excessive progression during the RTP process. at specific time points during the RTP a diagnosis of myositis ossificans classification systems purposed are
stress/overpressure at the end range, the test might reproduce the player’s symptoms. In section 2, specific physical tests process to ensure there is no increased following direct muscle trauma.15 discussed below and summarized in
and objective measurements for each oedema or connective tissue gap (see The CT demonstrates classic Tables 3-7. Radiological systems have
Isometric The affected muscle or muscle group is tested isometrically at different ranges, commonly
pain by the clinician applying resistance that the player is asked to withstand. Often, a ‘brake’ of the specific muscle injury locations Section 3 – Return to Play from Specific “egg-shell” appearance of the historically categorized muscle injury
provocation test is performed at the end of the test (f.ex after 3 seconds) to assess the eccentric are elaborated and discussed. Muscle Injury) calcification. with simple grading systems based on
component. The amount of force required to provoke pain can be quantified using a HHD.
the severity/extent of the injury ranging
Muscle Muscle strength of the affected muscles or muscle group is tested either manually or from 0-3 representing minor, moderate
strength/ objectively by HHD to detect any weakness / deficit compared to the unaffected side. and complete injuries,19,21–23 and
these have been widely used among
clinicians and researchers.24 The four
Neural The mobility of pain-sensitive neuromeningeal structures might be assessed by relevant < grade modified Peetrons classification
tension tests neural tension tests related to the specific muscles or muscle groups tested. Straight Table 2
leg raises (SLR) and slump tests are for example used after hamstrings injuries, as Overview of general
is based on an ultrasound ordinal
involvement of the sciatic nerve is a potential source of pain in the posterior thigh. physical examination severity grading system,22 first described
tests for muscle for MRI findings after hamstring injuries
Other Clinical examination of the joints above and below the injury may provide injuries used to
information about contributing factors for the muscle injury. establish a diagnosis. among European professional football
for muscle players in a ≥


78 larger study from the UEFA Elite Club be expected by an understanding GRADE CLINICAL EXAMINATION ULTRASONOGRAPHY MRI Table 3
Injury Study.(12) It has also been of tendon healing and adaptation Overview of
applied for other muscle groups25 to load. The British Athletics Muscle O’Donoghue (1962)43 Järvinen (2005)10 Peetrons (2002)22 Modified Peetrons simple clinical and
Ekstrand et al. (2012)23 radiological grading
(see Table 3). Radiological grading Injury Classification has been assessed systems for muscle
using modified Peetrons have shown for reliability in two radiological 0 Lack of any ultrasonic lesion Negative MRI without any injuries
correlations with lay-off time after acute studies,37,38 and shown associations visible pathology

hamstring injuries23,26,27 and quadriceps with RTP in one retrospective I No appreciable tissue Mild (first-degree): strain/ Minimal elongations with Oedema but no architectural
injuries.26 However, this grading clinical review,33 but further work is tearing, no loss of function contusion represents a tear less than 5% of muscle distortion
system has been criticised for being required to investigate its prognostic or strength, only a low-grade of only a few muscle fibers involved. These lesions can
inflammatory response with minor swelling and be quite long in the muscle
too simplistic, without considering the significance and relevance among discomfort accompanied by axis being usually very
anatomical location and specific tissue football players. The Munich consensus no or only minimal loss of small on cross-sectional
strength and restriction of the diameter (from 2 mm to 1 cm
involvement.19,28 Thus, the diagnostic statement classification system39 was movements maximum)
accuracy and prognostic value of these developed for muscle injuries in 2012,
grading systems are questionable 19 differentiating between functional II Tissue damage, strength, Moderate (second-degree): Partial muscle uptures; Architectural disruption
only a low-grade strain/contusion with greater lesions involving from 5 to indicating partial muscle tear
and the prognostic value of MRI has muscle disorders and structural muscle inflammatory response damage of the muscle with a 50% of the muscle volume or
recently been reported as limited.29,30 injury (Table 4). It has shown a positive clear loss in function (ability cross-sectionaldiameter. The
prognostic validity among professional to contract) patient often experiences a
“snap” followed by a sudden
New MRI classification systems football players in a correlation study.40 onset of localized pain.
including both the extent (severity However, the differentiation between Hypo-and/or anechoic gap
grading) as well as the anatomical ‘functional’ and ‘structural’ has been within the muscle fibers

site/location of the injury has been criticized.28,41 III Complete tear of Severe (third-degree) Muscle tears with complete Total muscle or tendon
proposed.28,31 For example, Chan et al.31 musculotendinous unit, strain/contusion: tear retraction. rupture.
complete loss of function extending across the entire
described a comprehensive system to A strength with using more detailed cross section of the muscle,
classify acute muscle injuries based on classification systems including resulting in a virtually
the severity of imaging assessments grading and severity, is that they complete loss of muscle
function is termed.
using MRI or ultrasound and the force a more accurate description
exact anatomical site (including the of the injury with a more diagnostic
proximal or distal tendon, proximal precision and defined tissue
or distal musculo-tendinous junction involvement, which may aid clinicians
and muscular injuries). The British when communicating with other
Athletics Muscle Injury Classification28 professionals, athletes or coaches.
grades muscle injuries from 0-4, However, more comprehensive
based on MRI parameters of the classification systems may
extent of injury and classifies the compromise on the ability to provide
injuries according to their anatomical an accurate prognosis. One of the
site within the muscle (Table 5). In problems is that there are large
total, the classification constitutes individual variations in time RTP
11 grading categories combining the within each of the categories,42 and
severity grading and the anatomical the evidence here is scarce. The most
site classification. There is evidence important may be that clinicians specify
in hamstring and soleus muscle which classification or grading system
injuries that those injuries which they are using to avoid misinterpretation
involve the tendon are associated with and/or miscommunication in clinical
longer time to RTP32–36 which would practice and research.


< <
The Munich The British Athletics
FUNCTIONAL MUSCLE DISORDER consensus statement GRADE 0: a. Myofascial 0a: MRI normal Muscle Injury
classification of acute NEGATIVE MRI Classification28
b. Musculotendinous 0b: MRI normal or patchy HSC throughout one or more muscles.
Type 1 Overexertion-related muscle disorder Contusion muscle disorders and GRADE 1:
injuries39 c. Intratendinous 1a: HSC evident at the fascial border <10% extension into muscle belly. HSC of CC length <5 cm.
Type 1A: Fatigue-induced muscle disorder INJURIES 1b: HSC <10% of CSA of muscle the MTJ. HSC of CC length <5 cm (may note fibre disruption of <1
(TEARS) TO cm).
Type 1B: Fatigue-induced muscle disorder THE MUSCLE”
2a: HSC evident at fascial border with extension into the muscle. HSC CSA of between 10%-50% at
Type 2 Neuromuscular muscle disorder GRADE 2: maximal site. HSC of CC length >5 and <15 cm. Architectural fibre disruption usually noted <5 cm.
2b: HSC evident at the MTJ. HSC CSA of between 10%-50% at maximal site. HSC of CC length >5
Type 2A: Spine-related neuromuscular Muscle disorder and <15 cm. Architectural fibre disruption usually noted <5 cm.
TO THE 2c: HSC extends into the tendon with longitudinal length of tendon involvement <5 cm. CSA of
Type 2B: Muscle-related neuromuscular Muscle disorder MUSCLE” tendon involvement <50% of maximal tendon CSA. No loss of tension or discontinuity within the
“EXTENSIVE 3a: HSC evident at fascial border with extension into the muscle. HSC CSA of >50% at maximal site.
Type 3 Partial muscle tear TEARS TO THE HSC of CC length of >15 cm. Architectural fibre disruption usually noted >5 cm
3b: HSC CSA >50% at maximal site. HSC of CC length >15 cm. Architectural fibre disruption usually
Type 3A: Minor partial muscle tear GRADE 4: noted >5 cm
3c: HSC extends into the tendon. Longitudinal length of tendon involvement >5 cm. CSA of
Type 3A: Minor partial muscle tear TEARS TO
tendon involvement >50% of maximal tendon CSA. May be loss of tendon tension, although no
discontinuity is evident
Type 4 (Sub)total tear Subtotal or complete muscle tear MUSCLE OR
TENDON” 4: Complete discontinuity of the muscle with retraction
Tendinous avulsion 4c: Complete discontinuity of the tendon with retraction



The FC Barcelona muscle injury classification proposal44 is an evidence-informed and expert consensus-
based classification system for muscle injuries developed by experts from three institutions (FC Barcelona
Medical Department, Aspetar, and Duke Sports Science Institute); it is based on a four-letter initialism system:
MLG-R, respectively referring to the mechanism of injury (M), location of injury (L), grading of severity (G),
and number of muscle re-injuries (R) (see Table 7).

SEVERITY (G) RE-INJURIES (R) Summary of the
proposed FC
Hamstring direct injuries P Injury located in the proximal third of the muscle belly 0–3 0: 1st episode Barcelona muscle
T (direct) classification system44
M Injury located in the middle third of the muscle belly 1: 1st reinjury
D Injury located in the distal third of the muscle belly 2: 2nd reinjury...

Hamstring indirect injuries P Injury located in the proximal third of the muscle belly. 0–3 0: 1st episode
I (indirect) plus sub-index s The second letter is a sub-index p or d to describe the
1: 1st reinjury
for stretching type, or sub- injury relation with the proximal or distal MTJ, respectively
index p for sprinting type 2: 2nd reinjury...
M Injury located in the middle third of the muscle belly,
plus the corresponding sub-index
D Injury located in the distal third of the muscle belly, plus
the corresponding sub-index

< Negative MRI injuries (location N p Proximal third injury 0–3 0: 1st episode
82 GRADE ACTIVE KNEE GAIT TYPICAL Table 6 is pain related) N plus sub-
FLEXION (°) PATTERN PRESENTATION Classification of N m Middle third injury 1: 1st reinjury
index s for indirect injuries
Quadriceps contusion. stretching type, or sub-index p N d Distal third injury 2: 2nd reinjury…
MILD <90° Normal May or may not remember incident Adapted from Jackson for sprinting type
(Grade I) & Feagin (1973), in
Can usually continue activity
Kary et al. (2010)7
Sore after cooling down or next morning and Brukner & Kahn Grading of injury severity
Minimal pain w/resisted knee straightening (2017)12
0: When codifying indirect injuries with clinical suspicion but negative MRI, a grade 0 injury is codified. In these cases, the second letter
Might be tender with palpation describes the pain locations in the muscle belly
Full prone ROM 1: Hyperintense muscle fiber edema without intramuscular hemorrhage or architectural distortion (fiber architecture and pennation
angle preserved). Edema pattern: interstitial hyperintensity with feathery distribution on FSPD or T2 FSE? STIR images
+/- Effusion
2: Hyperintense muscle fiber and/or peritendon edema with minor muscle fiber architectural distortion (fiber blurring and/or pennation
+/- Increased thigh circumference
angle distortion) ± minor intermuscular hemorrhage, but no quantifiable gap between fibers. Edema pattern, same as for grade 1
Moderate 45-90° Antalgic Usually remembers incident, but can continue activity, although may stiffen up 3: Any quantifiable gap between fibers in craniocaudal or axial planes. Hyperintense focal defect with partial retraction of muscle fibers ±
(Grade II) (slight limp) with rest (half-time or full-time) intermuscular hemorrhage. The gap between fibers at the injury’s maximal area in an axial plane of the affected muscle belly should be
documented. The exact % CSA should be documented as a sub-index to the grade
Mild/moderate swelling
r: When codifying an intra-tendon injury or an injury affecting the MTJ or intramuscular tendon showing disruption/retraction or loss of
Pain w/palpation tension exist (gap), a superscript (r) should be added to the grade
Pain w/resisted knee straightening
Limited ROM
+/- Effusion
+/- Increased thigh circumference THE BARÇA WAY: CLASSIFYING MUSCLE INJURIES
Severe >45° Severe limp Usually remembers incident. Assisted ambulation, difficulty with full weight-bearing
(Grade III)
Severe pain
The FCB muscle injuries proposal has several key points; the starting point was to incorporate the
scientific evidence about muscle injuries at this time in the proposal, the classification was build
Immediate swelling/bleeding
up within this idea, together with the medical experience of the three sports medicine institutions
Pain with static contraction
involved in the project. It is also very important that the structure of the proposal is flexible; the
+/- Bulge in the muscle
proposal has the capability to adapt to future scientific evidences within the muscle injuries field
+/- Increased thigh circumference and grow with the future knowledge.

The role and function of connective tissue in force generation and transmission is in our opinion
a key factor in the signs, symptoms and prognosis of muscle injuries. Thus, it was one of our
purposes to create a grading item that could classify injuries based on a quantifiable parameter
(exact % CSA) based on the principle that the more connective tissue is damaged, the greater the
functional impairment and the worse the prognosis of the injury will be. The history of an injury
plays also an important role, it will not be the same to face a first injury episode than a re-injury or
a second reinjury, so the chronology of the injury is included in our proposal.

The fact to avoid confusing terminology will help to have and easy communication. The classifi-
cation is still a theoretical model that needs to be tested and see if it shows an adequate grouping
of injuries with similar functional impairment, and prognostic value. The goal of the classification
is to enhance communication between healthcare and sports-related professionals and facilitate
rehabilitation and RTP decision-making.



When a player sustains a muscle injury, the chances of it recurring are high. In
fact, epidemiological research consistently identifies previous injury as the most
powerful risk factor for muscle injuries.1 Fortunately, the risk of recurrence can
be reduced through careful management of the return to play process, including
appropriate prescription of therapeutic and football-specific exercises.
— With Phil Glasgow, Thor Einar Andersen and Ben Clarsen

84 A carefully planned exercise STRUCTURED, BUT throughout return to play process to ensure < 85
Figure 1
programme is not only essential to
optimise the quality of healing tissues,
FLEXIBLE the programme aligns with their functional
ability, psychological readiness and specific
What Are the Goals of
Loading? MUR = Motor
but also to maintain the player’s fitness, The RTP process is a dynamic continuum performance demands. Unit Recruitment,
RFD= Rate of Force
skills and football cognition so that during which the nature and difficulty of Development
when they do return to play, they are exercises are progressed in response to
ready to perform optimally. tissue healing and the functional abilities
of the player. Every player is unique, and TARGET SPECIFIC
This chapter outlines the general
principles of exercise prescription for
no two injuries are exactly the same.
As such, the RTP process should be
muscle injuries, including strategies individualised. The multi-dimensional When designing an exercise programme,
to optimise structural adaptations nature of return to play means that the practitioners should ask a number of
and maintain football-specific fitness, therapists, strength and conditioning simple questions (Figure 1):
skills and cognition. The chapter is not and technical staff must organize several
intended as a recipe; practitioners need concurrent phases with different goals • What is happening at a tissue level?
to consider each player individually and and milestones.
assess their progress throughout the • What outcomes are you trying
entire RTP process. to achieve with your exercise
The most common way of measuring • What is the specific adaptation
BEGIN WITH THE END progress in the RTP process is the player’s associated with different exercise or
IN MIND perception of pain.2 The amount of
discomfort tolerated during training should
football activity types?
In top-level football, the medical
and performance team is under
be guided by the rationale for the specific
exercise. For example, when the primary
• Is the goal of the exercise to
reduce symptoms, stimulate tissue
ADAPTATIONS Muscle tissue is highly sensitive and Adequate strength is essential for safe
constant pressure to return the player goal of the exercise is tissue loading, some adaptation (tissue capacity) or The RTP process commences almost adaptable to mechanical loading. and effective return to football. During the
to competition safely, in the shortest discomfort may be acceptable. In contrast, enhance function (movement immediately following injury with Following injury, muscle undergoes a return to play process, strength training
possible time. To accomplish this, they when the focus is to restore movement capability)? attention given to graduated loading of number of changes in structure and should concentrate on the restoration of
need to manipulate a range of training quality, exercises should be pain-free. the injured tissue to facilitate healing. function both as a direct consequence injury-related deficits. Lieber8 has suggested
variables to ensure that the player is Once the desired outcome of an exercise While the main focus of management of tissue insult and as an indirect that during the first two weeks of strength
working at the limit of their capacity, Other tests of muscle function (e.g. Askling’s or football activity is clear, it is possible to during the early stages of the RTP process consequence of reduced loading training in uninjured, untrained individuals,
while simultaneously allowing sufficient H-test and Isokinetic testing) can also plan progressions to maximise adaptation. will be directed towards resolving the and recruitment. These changes only 20% of strength increases may be
time and restitution for tissue healing. To help inform RTP readiness. However, it For example, where the goal of loading is clinical signs and symptoms, targeted include, reduced fascicle length and attributed to structural changes. This implies
define the necessary tissue capacity and is important to recognise that no single increased fascicle length, the intervention loading of the tissue should also be physiological cross-sectional area (PSCA) that initial strength gains are primarily due
functional requirements, practitioners test can determine the player’s ability to may be eccentric loading and progression included. Early loading is an effective as well as alterations in neuromuscular to neuromuscular adaptations. Given that
need a detailed understanding of the progress. Instead, practitioners should will include addition of load, increased stimulus for regeneration and has been activation.4-7 The RTP process should following injury neuromuscular capacity can
football-specific activities and level to use a battery of tests assessing different speed and range of motion. In contrast, shown to result in better outcomes therefore focus on restoring muscle be significantly diminished, it is reasonable
which the player must return. We refer to aspects of function. Execution of sport where the desired outcome is to increase in terms of capillary ingrowth, less structure (especially fascicle length and to suggest that it may be more effective
this as beginning with the end in mind. specific skills with good technique also rate of force development, the exercise (or fat infiltration, fibre regeneration, cross-sectional area). during the early stages of return to play
At FC Barcelona, this involves a close helps guide progression. Clinical testing football activity) may be a jump squat and more parallel orientation of fibres, to carry out strengthening exercises ‘little
collaboration between the player and for specific muscle groups is discussed progressions involve a move from high less intramuscular connective tissue, and often’ in order to avoid neural system
medical, coaching and performance in the relevant sections. It is necessary load power (80% 1RM load) to low load improved biomechanical strength and fatigue and facilitate both structural and
analysis specialists. to communicate closely with the player power (30% 1RM load). less atrophy.3 neuromuscular adaptations.


86 EARLY IN THE RTP PROCESS: study reported adverse effects with the At the injury site, the injured muscle and football-specific performance benefits such range of purposeful movements during Introduction of unanticipated 87
MOVEMENT IS KEY early inclusion on eccentric training. its agonists will lose strength, power, and as increased muscular endurance, running a sporting event can have a significant movements is essential for effective
endurance capacity. The extent to which speed or jump height, as well as protection influence on football performance and the restoration of function. The ability to
Simple isotonic training may be necessary
Although protection of the injured muscle each of these attributes is affected should from recurrence. potential for (re)injury. It is also recognized respond to a dynamic and variable
to facilitate motor recruitment in the early
is paramount, low-level, controlled be identified using specific testing, for that that functional ranges of motion during environment is often a key driver in the
stages of the RTP process. The recruitment
eccentric exercises have the potential to example isokinetic and jumping tests. Muscle injuries also have consequences on activities such as kicking and long passes perpetuation of symptoms. Gradual
of muscles throughout range during
further reduce pain inhibition and facilitate Thereafter, exercise prescription should the player’s general conditioning, including exceed those normally measured during introduction of physical perturbations
functional movements often help to restore
tissue adaptation without causing any specifically address the identified deficits. their cardiovascular fitness and their clinical assessment.17 The role of flexibility facilitates reactive neuromuscular
pain free range of motion and normalise
further damage. Practitioners must take general load tolerance. A comprehensive in the site of muscle injury has been the adaptations as well as sudden responses
pain. While there is some evidence that
care to ensure that the player can tolerate Muscle injury results in both structural and RTP programme must therefore include source of debate for many years with to verbal or visual commands. At all
isometric contractions may reduce pain in
the resistance, complexity and range of neuromuscular deficits. During football general conditioning strategies that conflicting findings for all major muscle times the quality of the movement is
tendinopathy, more dynamic movements
motion. They should seek to identify ways sporting activities, muscle is constantly replicate the player’s normal football groups. monitored and where maladaptive
tend to be more effective in muscle injury
to stimulate the muscle under lengthening ‘tuned’ to enable an individual to maintain demands as much as possible, both in patterns are adopted, exercises and
management. Some principles for early
conditions while providing appropriate position, move voluntarily and react to terms of the metabolic pathways involved, Tests of multi-segmental whole body football activities should be regressed to
strengthening of muscle following injury
support and safety. Examples of early perturbations.13 Neuromuscular control and the stresses on musculoskeletal mobility18 and dynamic flexibility17 have ensure correct form.
are summarised below.
stage eccentric training are included in (NMC) is the product of the complex system. shown strong correlations with injury
the relevant muscle specific sections and integration of afferent proprioceptive input, presentation and may be more useful Reintroduction of sport-specific skills,
As soon as the player can effectively
football specific exercises below. central nervous system (CNS) processing An intelligently designed return to measures (and interventions) of flexibility competition and other environmental
recruit the muscle without significant
and neuromuscular activation. While great play programme that has the correct during the RTP process. It is suggested constraints should focus on widening the
pain or inhibition, it is important to
Eccentric training should be maintained attention has been given to the role of NMC combination of contraction type (concentric, that mobility training during the RTP movement repertoire of the athlete and
incorporate eccentric (lengthening)
throughout the entire RTP process in ligament rehabilitation, it has often been eccentric, isometric, plyometric), exercise process reflects the range and direction allow sufficient time for skill acquisition
contractions. Eccentric contractions have
and should target movement-specific overlooked in muscles. choice (e.g. free weights vs. machine of the movements carried out during the and consolidation through practice. It
consistently been shown to result in
adaptations for the affected muscle. For weights and football activities), load, football activities. Rather than a reductionist is important to incorporate cognitive
greater morphological and neuromuscular
example, for hamstring training should There is evidence that prolonged deficits number of sets, repetitions, speed of approach that views flexibility in isolation, challenges and decision making into the
adaptations than both isometric and
include both knee-flexion dominant and in NMC following muscle injury may have contraction and frequency of training clinicians should consider whether a rehabilitation programme.
concentric training.9,4,5
hip-extension dominant movements. a role to play in recurrence. Reduced can significantly enhance the benefits muscle group has adequate flexibility
Similarly, for quadriceps injury, eccentric activation of previously injured biceps of training. Principles for progression of combined with increased strength at longer At FC Barcelona, every effort is made
exercises should focus on both hip flexion femoris long head at longer muscle lengths strengthening during the mid to late stage lengths for safe and effective function. to return the injured player to modified
and knee extension. Examples are included may be related to shorter fascicles, eccentric of the RTP process include: Max Strength training participation on the pitch and
in the muscle specific sections. weakness and reduced ability to protect the > Longer Muscle Lengths > Rate of Force with the team as early as possible to
Eccentric exercise has become the mainstay muscle at longer lengths.14,15 Reduction in Development Training > Move from preserve football technical and tactical
of the muscle injury return to play process. the ability of the muscle produce, transfer Moderate to High Speed with and without skills and cognition abilities. As much as
Traditionally, clinicians often delay the or modulate load will likely result in an ball and on and off field. Hence, the nature As the RTP process develops, the complexity possible should be done with a ball as
introduction of eccentric training until late RESTORING FOOTBALL- increased risk of reinjury. The RTP process of training used should minimise stress on of the task should be increased to involve soon as possible and drills should reflect
stage rehabilitation due to perceived risks
associated with increased muscle tension
SPECIFIC FITNESS, should therefore seek to improve the central
nervous system’s ability to fine tune muscle
the injured tissues while simultaneously
exercising muscle groups involved in
multiple segments through multiple planes
of movement. Early examples of this include
the demands of the player, such as team
tactics, position and role in the team.
and associated muscle soreness. This is SKILLS AND COGNITION coordination and improve the football skill football. This is essential towards the end football -specific tasks such as dribbling, Data derived from Global Positioning
also reflected in most RCTs, where eccentric execution; this is discussed below. of the RTP process to adapt to the high passing and receiving a ball, snake runs Satellite (GPS) systems during training
training is often not included until halfway Muscle injuries have a range of demands of match play. The footballer must and basic training drills. Particular attention drills and match play is used to tailor the
through the RTP process. However, two consequences on a player’s football It is important when designing strength have trained enough and specific to return should be given to facilitating effective on-field RTP process individually in close
protocols have included eccentric training performance that need to be addressed training programmes that the content to football and performance safely.16 loading of tissues through functional collaboration between medical staff,
from day 5 onwards, and both reported throughout the RTP process. Therefore, reflects how the muscle functions during patterns as well as release and attenuation performance analysts and coaching staff.
favorable outcomes in terms of RTP time you have to think wider than just the football. Careful manipulation of training It is widely accepted that the ability to move of force; for example, deceleration and Specific examples are discussed in the
and recurrence rates.10-12 Importantly, neither injured muscle. load, volume and frequency can achieve part or parts of the body through a wide change of direction. next section.




Restoring the players’ specific fitness and performance capacity before joining the
team for collective training sessions and competitions is essential
— With Martin Buchheit and Nicolas Mayer

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

THE BARÇA WAY: unrestricted football training and play, style of play and match context,
the players generally train individually we have chosen to use the average
The above schematic (figure 2) provides an overview of the Return to with a physical/rehabilitation coach demands of those 2 playing positions
Play process in FC Barcelona in regards to managing and rehabilitating who ensures that the player’s as a starting point to illustrate our
the injured player. The various components are not step by step i.e. you locomotor and technical loads are methodology. In real-life scenarios,
do not need to complete one before moving to the next; this process is progressively built in relation to match we recommend the systematic use of
dynamic and components can overlap as the player progresses throu- demands (Figure 1), while respecting each player’s unique locomotor and
gh the RTP process. indices of load tolerance, well-being technical profile based on historical
(i.e. how the player is coping with club data (i.e. from match analysis
The key point is to get the player moving as soon as is safely possible. those loads) and psychological data) and personal observations (style
1. The acute stage following the injury can last anywhere from readiness. Importantly, since these of play and technical demands).
approximately 1 to 3 days. At this very early stage, the focus is on individual RTP sessions should prepare
ice and compression. the players to train/play with the
team within a few days, it is of utmost
2. Table treatment is the time to stimulate the muscle and promote importance for the ball to be integrated
healing and gain mobility – e.g. passive and active muscle stret- as much as possible, and that specific MATCH DEMANDS
ching, isometric and eccentric types of contractions. movement coordination and muscle
actions, decision-making, mental The physical activity performed during However, we use this to illustrate the
3. As soon as possible, it is time to get the player moving in the gym. fatigue and overall self-confidence are matches should be considered as target for importance of the distinction between
This component can be (and usually is) a combination of table considered continuously. the conditioning programming. Assuming HSR and HIA in relation to individualising
treatment and gym based exercises, from basic through to more that the building up of minutes of play the RTP program according to the muscle
advanced functional exercises (as the progression of the injured To illustrate our approach, we provide during matches may be progressive as injury location and player demands.
player allows). The key is to progress continuously from passive example of sequential RTP load well following an injury (i.e., playing 25-35
workouts to active workouts. progressions, i.e., designed for two min as a sub for the first match post injury),
common muscle injuries (hamstrings the demands of 1 full half (45 min) to 60
4. Basic field work – In this component of the RTP process, we start and rectus femoris) for two different minutes could be considered as the initial
to introduce field based sessions, with varying surfaces. It is playing positions in the field (wide pre-competition target. To assess those
important to maintain the gym work here, but to reduce the table defender, WD full back - FB and central specific physical demands, we recommend
treatment. Basic football skills are reintroduced and trained and midfielder (playing as a ‘6’), CM) assessing the injured player’s locomotor
position specific movements are included. (Figure 2). The re-conditioning of both load with respect two distinct types of
muscle groups requires the targeting demands; high-speed running (HSR, which
5. Complex field work – In this part of the RTP process, the basic of different locomotor patterns (with essentially put constrains on the hamstring
work in the field is phased out in favour of more advanced skills reference to the selective activation of muscles) and high-intensity actions (HIA)
and movements with decision-making tasks at higher intensities those muscles in relation to specific which encompasses all acceleration,
and more challenging. Gym work is still maintained here, in parti- running phases1); playing positions deceleration and changes of direction
cular as a pre field session activation. are also associated with distinct activities and put major constrains on
locomotor and technical demands the quadriceps, adductors and the gluts)
6. As the player has sufficiently progressed through this RTP process, (Figure 1), which all need to be taken (Figure 1). In the example given, we use
he/she is ready to return to training, starting partial training with into account when designing the RTP mechanical work (MW) as the metric
the team (maintaining additional work with the physical coaches). program. While we acknowledge to measure HIA. It is important to note
With appropriate management of loads, the players demands will that there exist large differences in that this metric currently has preliminary
be increased until he/she is ready to join 100% with the team. locomotor and technical demands validity and reliability only and needs to be
within the same positions due to tested further in scientific investigations.


90 91
paradigm, allowing the physiological quality targeted
a given day to recover the following day 6). This should
avoid creating excessive muscle soreness / residual
fatigue from one day to the other, and helps players
to train every day, which in turn may accelerate their
full return to train/competition. Figure 2 illustrates
how the locomotor contents of the sessions, in terms
of HSR and MW may be modulated in response to
1) the muscle injured and 2) the position-specific
locomotor demands. Table 1 and 2 provide the details
of the sessions both in terms of locomotor load and
technical orientations. For example, after a typical
introductory session (S1) the focus/building up of
HSR vs. MW differs in relation to muscle injury (with a
greater emphasis on progressively building HSR after
hamstring (HS) injury (S2HS) vs. building MW after
a quadriceps injury (S2Q)). After some progressions
^ in terms of HSR and MW, the locomotor targets are
Figure 1 further adapted based on the player’s playing position.
Summary of the worst case-scenarios for locomotor volume demands (± standard deviation, SD) during League 1 and Champions League matches (1st half) for a wide
defender (WD) and a midfielder (playing as a ‘6’, CM), in terms of volume (left panel) and intensity (right panel) of high-speed running (HSR) and HIA expressed as Following those final individual sessions (S1-S4),
mechanical work (MW). Volume refers to the greatest running distances covered during halves (± SD). Intensity is expressed, over exercise periods from 1 to 15 min, as 1) when it to transition with the team, we request players
peak distance ran > 19.8 km/h per min, which is used as a proxy of HSR intensity and 2) peak MW per min (adapted from2). For example, over block periods of 4 min, CM
can cover a maximum of 20 m of HSR / min. Similarly, WD can cover up to 55 m of HSR over 1 min-periods. For figure clarity, SD (̃ 25%) are not provided for peak intensities.
to participate in some (but not all) team training
Adapted from Lacome et al.3 The 4 coloured circles refer to 4 of the specific training drills within S4 sessions, as indicated in Table 1 (HSR) and 2 (WM). #2/4 refers to the sequences, and to perform some extra/individualized
types of high-intensity training sequences with both a high neuromuscular strain and a metabolic component (mainly oxidative energy, Types #2; oxidative and anaerobic conditioning work. When taking part to in some of
energy contribution, Type #4). #6 refers to Type #6 drills involving a high neuromuscular strain (but a low metabolic component), referring to quality high-speed and
mechanical work training (long rests in between reps). The HSR and mechanical work intensity of 4v4 game simulations (with goal keeper, GS) and 6v6, 8v8 and 10v10 the game situations, we have them playing as jokers
possession games (PO, without goal keeper) in which player participate at the end of the RTP process (S5, Table 1 and 2) is also shown. HSR intensity is not mentioned for (or floaters, being systematically with the team in
such GSs, since the size of the pitch prevents player to reach such high speeds. possession of the ball) for a few days, which has
been shown to decrease their locomotor demands by
30% compared with the other players.2 This offers a
MUSCLE INJURED, It is essential to build the cognitive and change of direction (i.e. measured MW relatively safe (less contacts, no defensive role and no
LOAD PROGRESSION technical aspects alongside the locomotor
demands. The sessions detailed in Figure
as a proxy of HIA), speed and strength
training which primarily relies on the
shots) and progressive loading for RTP players, while
allowing them to be exposed to the most specific
AND INTEGRATION 2 and Table 1 are designed to target, performance of the neuromuscular types of locomotor (especially decelerations and
OF POSITION-BASED alongside the integration of player-
and position-specific technical tasks
system. Metabolic conditioning refers
to the contribution and development
turns), technical and cognitive demands. This last
phase of the RTP process is crucial since it allows
PHYSICAL AND i) neuromuscular components in an of the aerobic and/or anaerobic energy players to regain their confidence and in turn, their
TECHNICAL MATCH isolated manner (“quality” sessions, such
as Type #6 4, see Table 1 legend) as well
systems.4 It is important to consider
that the progressions in load should be
full match-performance capacity. Finally, before
their participation with the team as jokers/floaters,
DEMANDS as ii) metabolic conditioning that often subtle to avoid excessive spikes.5 We RTP players need sometimes to be exposed to
also integrates important neuromuscular believe that the progressions should specific warm-up and. They should also perform
demands (such as Types #2 or #44 see also be aimed at building up locomotor some individual conditioning work post session (in
Table 1 legend). Neuromuscular training loads with alternations in session main relation to the injury and individual game demands)
refers to acceleration, deceleration, objectives (cf tactical periodization (Table 1 and 2).


92 < 93
Figure 2 <
S1: Introduction session
Example of four sequential RTP load Table 1
progressions in terms of volume and • Low-intensity running sensations (6-8’) Example of session
intensity of locomotor demands, details of the
• Hip mobility + Running drills
i.e., high-speed running (HSR) and hamstring injury
mechanical work (MW). The sessions • Agility closed-drills sequential RTP load
are designed for two very common progressions.
• Functional work (without the ball)
muscle injuries (i.e., hamstrings, see
details in Table 1 and rectus femoris, • Type #1: 2x 4-min set: 6x 20s (slalom run 45° 80m) /20s (jog) (TD > 14.4 km/h ≈ 1000m, MaxV < 16 km/h).
see details in Table 2) for two different • Cool down (3-5’)
playing positions in the field (wide
defender, WD and central midfielder, S2HS: S3HS:
MD). The size of the battery represents
the actual/absolute volume of • Monitoring (1): 4-min run at 12 km/h • Hip mobility + Running drills
match demands (one half), while the • HIP mobility + Running drills • Agility closed to open-skills + Technical work
coloured part within each battery
represents the relative portion of • Agility closed-skills (quality) • Monitoring (2): 4 straight-line high-speed runs(box-to-
one-half demands that is completed box), 70m in 13s, 30-s passive recovery (> 19.8 km/h ≈
• Functional work with the ball (preparation)
during the given session. Note that 200m)
the total number of sessions required • Technical Work with a Metabolic component
• Technical Work Metabolic component + Neuromuscular
within each phase is obviously injury • Type #1: 1 x 3-min set: 15s (slalom run 65m) /15s (jog) (> 19.8 constraints
and context-dependent. km/h ≈ 250m, MaxV < 22 km/h)
• Type #2: 1 x 6min 40s set: 10s (50 m) /20s (passive) + 5s
• Cool down (3-5’) (28 m) /15s (passive) (> 19.8 km/h ≈ 250m, MaxV < 24
• Cool down (3-5’)

• Mobility + Technical work (short pass/volley) • Mobility + Technical work (short pass/volley)
• Running drills + Technical work (control/pass) • Running drills + Technical work (control/pass)
• Agility (<10m) + decision (quality) • Agility (<10m) + decision (quality)
• Type #6: Speed progression: 1x 10m, 1x 15m, 1x 20m (MaxV • Type #6: Speed progression: 1x 10m, 1x 15m, 1x 20m (MaxV
> 25km/h, rest between reps: 45s) > 25km/h, rest between reps: 45s)
• Technical work: being orientated (3/4), dribbling and • Technical work: taking information, controlling and COD
crossing with the ball, passing (5 to 20m)
• I. Type #2: 1 x 4-min set: 10s (slalom 55 m) /20s (passive) • I. Type #2: 1x 4-min set: 10s (COD = 2x 25m)/ 20s (passive)
(>19.8km/h ≈ 400m) * + 5s (constraints)/25s (passive) (>19.8km/h ≈ 200m)
• II. Type #2: Specific WD: 1 x 4-min set: 10s (technical • II. Type #2: Specific CM: 1x 4-min set: 10s (with technical
demand: dribbling, passing, crossing) / 20s (passive) demand: turning, dribbling, passing) / 20s (passive)
(>19.8km/h ≈ 300m) (>19.8km/h ≈ 150m)

S5HS-WD and SHS-CM: in addition to taking part into possession games (without goal keeper) and game situations (with goal keepers)
with the team as jokers/floaters initially, we recommend players to do some extra Type #6 high-speed runs aiming at reaching close-
to-max velocities (with the volume adjusted with respect to distance of the following match).


94 < 95
S1: Introduction session
Table 2
• Low-intensity running sensations (6-8’) Example of session
details of the
• Hip mobility + Running drills
quadriceps injury
• Agility closed-drills sequential RTP load
• Functional work (without the ball)
• Type #1: 2x 4-min set: 6x 20s (slalom run 45° 80m) /20s (jog) (TD > 14.4 km/h ≈ 1000m, MaxV < 16 km/h).
• Cool down (3-5’)

S2Q: S3Q:
• Monitoring (1): 4-min run at 12 km/h • Hip mobility + Running drills
• Hip mobility + Running drills • Agility closed to open-skills + Technical work
• Agility closed-drills (quality) • Type #6: Mechanical work (45-90°): 2x 5+5+5m
45° CODx1 / 2x5+5+5m 90° CODx2 (r: 45s between
• Type #6: Mechanical work (45-90°): 6x 5+5m 45° CODx1 / 6x
5+5m 90° CODx1 (r: 45s between reps)
• Technical work with Metabolic component
• Functional work with the ball (sensations)
• Type #6: Mechanical work (130-180°): 4x5+5m 130° CODx1
• Type #1: 1 x 4-min set: 10s (slalom 45m) /10s (passive) (>
/ 4x5+5m 180° CODx1 (r: 45s between reps)
19.8 km/h ≈ 250m, MaxV < 22 km/h)
• Technical work with Metabolic component
• Cool down (3-5’)
• Cool down (3-5’)
Distance to run are provided for player response but with a large anaerobic See Table 1 for
legends. Note: for the
with an average locomotor profiles glycolytic energy contribution and S2Q session, 10s/10s S4Q-WD: S4Q-CM:
(i.e., maximal aerobic speed 17.5 km/h, high neuromuscular strain; and Type is preferred to other • Mobility + Technical work (short pass/volley) • Mobility + Technical work (short pass/volley)
velocity reached at the end of the 30-15 #6 (not considered as HIIT) involving HIIT formats for the
fact that it requires • Running drills + Technical work (control/pass) • Running drills + Technical work (control/pass)
Intermittent Fitness test (VIFT 7) of 20 a high neuromuscular strain only, a greater number • Agility (<10m) + decision (quality) • Agility (<10m) + decision (quality)
km/h and maximal spring speed of 32 referring typically to quality high-speed of accelerations
km/h8). Note that the physiological and mechanical work training (long than with longer • Monitoring (2): 4 straight-line high-speed runs(box-to-box), • Monitoring (2): 4 straight-line high-speed runs(box-to-
intervals, which 70m in 13s, 30-s passive recovery (> 19.8 km/h ≈ 200m) box), 70m in 13s, 30-s passive recovery (> 19.8 km/h ≈
objectives of each locomotor sequence rests in between reps). Extended from may help building 200m)
• Technical work: spreading, being orientated, controlling +
(in terms of metabolism involved and figure 1 in Buchheit & Laursen.4 Red up this capacity in a passing backwards, inside, forwards • Technical work: COD with the ball, being orientated,
controlled and safe
neuromuscular load) is shown while font: emphasis on HSR running. Blue manner. • I. Type #6, Mechanical work: 5+10m CODx1 + Finishing on
repeating short passes, playing between 2 lines and
using one of the 6 high-intensity font: emphasis on MW. Green font: behind the defensive line
small-goal, 2x 45°, 90°, 130°, 180° (r: 45s between reps)
training Types as suggested by monitoring drills (see below). Text • I. Type #6, Mechanical work: 5+5+5m CODx2 + Finishing
• II. Type #2/4: Specific WD Mechanical work: 2x 3min 30s-
on small-goal, 2x 45°, 90°, 130°, 180° (r: 45s between reps)
Buchheit & Laursen.4 Type #1, aerobic highlighted in orange refers to the HSR set: 6 x ≈10s (specific) /≈25s (walk)
• II. Type #2/4: Specific CM Mechanical work: 2x 2min 55s
metabolic, with large demands placed drills shown in Figure 1 (right panel); set: 5 x ≈10s (specific) /≈25s (walk)
on the oxygen (O2) transport and Text highlighted in blue refers to the
utilization systems (cardiopulmonary MW drills shown in Figure 1 (right S5Q-WD and S5Q-CM: in addition to taking part into possession games (without goal keeper) and game situations (with goal keepers)
with the team as jokers/floaters initially, we recommend players to perform some additional acceleration/speed work with specific
system and oxidative muscle fibers); panel). Note: Slalom runs with 45° movement patterns of high quality (Type #6) including some kicking exercises (long balls and shoots).
Type #2, metabolic as type 1 but with angles are often used (e.g., S1, S2HS)
a greater degree of neuromuscular to decrease the actual neuromuscular
strain; Type #3, metabolic as type 1 with load: turning at 45° requires to
a large anaerobic glycolytic energy decrease running speed (less HSR) and
contribution but limited neuromuscular doesn’t requires to apply strong lateral
strain; Type #4, metabolic as type #3 forces (less MW), which in overall make
but a high neuromuscular strain; Type the neuromuscular demands of these
#5, a session with limited aerobic runs very low.1


Figure 3
Schematic illustration
of each of the Type #2
sequence described
in Table 1 for session
S4Q-WD and S4Q-CM.

96 97
The monitoring of the responses DURING RTP
to these types of RTP sessions is
1. Consider the muscle injury type
performed using both objective and
as a guide for RTP progression,
subjective measurements. More
e.g. Hamstring muscle requires
specifically, toward the end of the
more progressive loading of HSR,
sequence progression, as a part of one
whereas Quadriceps muscle
of the specific session, we conduct
likely requires greater focus on
a standardized running test9 (4-min
HIA progressions and loading
run at 12 km/h where HR response is
monitored in relation to historical data 2. Individualise further, the target
and used as a proxy of cardiovascular physical loads (in terms of both
fitness, followed by 4, 60-m straight- volume and intensity, Figure
line high-speed runs where both stride 1 right panel) and technical
balance and running efficiency are demands based on the players’
examined via accelerometer data10) position on the field (using
(See Table 1, e.g., green fonts, session individual data if possible and
S2HS and S3HS). Daily wellness knowledge of his playing style).
assessment and medical screening are
3. Facilitate players transition from
conducted daily to guide/adjust the
individual to team work while
loading of each session.
adjusting the initial team sessions
(individual warm-up, extra
conditioning post session, and
more importantly playing as joker
during game-based sequences).
4. Monitor internal load to
determine how the player is
coping with these demanding
final sessions before returning to
5. Consider the players’
psychological readiness to a) re-
join the team and b) return to full




Despite the substantial regenerative potential that skeletal muscle possesses in
the form of its own stem cells, injured skeletal muscle still heals, like most of our
tissues, by a repair process, not by complete regeneration. Thus, the healing will
result in the formation of non-functional scar tissue.1-4 The outcome of this repair
process is that the ruptured skeletal muscle fibers remain terminally separated
by the scar tissue that has formed at the site of the injury, i.e. inside the injured
skeletal muscle1-4.
— With Tero AH Järvinen, Haiko Pas and Jordi Puigdellivol

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

As some regenerative medicine products

ANTI-INFLAMMATORY as in DOMS. Care must be taken with
prolonged or frequent use of NSAIDs RECOMMENDATION
recurrence rate of the injury.20,21 Furthermore,
are in clinical use and are being offered DRUGS however, due to their potential gastric
Not recommended (based on vast
it was recently shown in experimental
skeletal muscle injury-model that both PRP Losartan has been recently studied on
to football players, we will review the (and other) side-effects.
BACKGROUND experimental data showing significant, and early rehabilitation accelerate skeletal injured human skeletal muscle in RCT.22 No
scientific evidence supporting their use
almost complete, retardation of the muscle regeneration, but they do not effect on regenerating skeletal muscle was
in injured athletes as well as provide Non-steroidal anti-inflammatory drugs
healing process). have any synergy when both treatments identified for Losartan after DOMS-type
evidence-based recommendations for (NSAIDs) are a class of drugs that provide
are prescribed together.18 This may be the of mild skeletal muscle injury in the RCT.22
their usage. analgesic (pain-killing), antipyretic (fever-
explanation why PRP has failed in the RCTs Furthermore, losartan has also been tested
reducing) and anti-inflammatory effects.
to stimulate skeletal muscle regeneration in in large RCTs as an anti-fibrotic molecule in
NSAIDs are widely used in athletes to
ACTOVEGIN provide pain-relief after injuries. NSAIDs
athletes with an injury.18 other human diseases where fibrosis and
scar formation take place. Losartan has
have been extensively studied on injured
BACKGROUND failed in all these RCTs to inhibit and fibrosis/
skeletal muscle. Short-term use of different RECOMMENDATION
scar formation.23-25
Actovegin® is a deproteinized NSAIDs in the early phase of healing leads
Not recommended
hemodialysate of ultra-filtered (<6 to a decrease in the inflammatory cell
kDa) calf serum from animals under 8 reaction, with no adverse effects on the RECOMMENDATION
months of age. It has been used widely healing process or on the tensile strength or
Not recommended


interest and financial resources devoted
to the field of regenerative medicine,
Stem cells are cells with the ability to Extracorporeal shockwave therapy HBOT is the medical use of oxygen at TUS is widely used in the treatment of A series of experimental studies have most of the recent and the promising
differentiate into a multitude of cell types. (ESWT) is based on abrupt, high greater than atmospheric pressure to muscle injuries, although the scientific established that early, active mobilization innovations have failed to live up to their
Among the different populations of stem amplitude pulses of mechanical energy, increase the availability of oxygen to the evidence on its effectiveness is somewhat started after a short period immobilization/ billing in clinical trials. For some of the
cells, mesenchymal stem cells (MSCs) similar to soundwaves, generated by body. HBOT has been used to treat various vague. The micro-massage produced by rest (duration: inflammatory period of new, basic research-derived innovations
have received most interest in sports an electromagnetic coil or a spark in conditions such as gas gangrene, chronic high-frequency TUS waves are proposed healing) is ideal therapy for injured skeletal such as stem cells, the jury is still out
medicine. MSCs are stem cells that are water. “Extracorporeal” means that the wounds, carbon monoxide poisoning. to have analgesic properties, and it has muscle.38 the as they have not progressed from
able to differentiate into cells of one germ shockwaves are generated externally As the supply of oxygen is crucial for the been proposed that TUS could somehow pre-clinical studies to clinical studies,
line, mesenchyme, i.e. to osteoblasts to the body and transmitted from a pad repair of sports injuries, HBOT has been enhance the initial stage of muscle and as such fail to truly address their
(bone), chondrocytes (cartilage), tenocytes through the skin. ‘Shock wave’ therapies advocated for skeletal muscle rupture. regeneration. However, TUS does not potential clinical value in the care of
(tendon), myocytes (skeletal muscle) or are now extensively used in the treatment There is indeed preliminary, experimental seem to have a positive (muscle-healing A recently published randomized injured athletes.
adipocytes (fat).26 of musculoskeletal injuries and have been evidence supporting the use of HBOT to enhancing) effect on the final outcome of controlled trial showed that early
advocated also or skeletal muscle injuries. treat skeletal muscle injuries.27-30 muscle healing in experimental skeletal rehabilitation produces significantly We still rely on rehabilitation protocols
The mode of action of MSCs is considered muscle injury models.34-36 faster return to sports than delayed started early after the injury in the
two-fold: firstly, their differentiating potential rehabilitation protocol without any treatment of the ruptured skeletal
would theoretically allow them to replace significant risk of re-injury.1 muscle. What is both encouraging
lost or injured tissue.22-24 Secondly, MSCs No clinical studies addressing the effect HBOT was shown to improve the as well as helpful, is that substantial
produce a vast number of growth factors of ESWT or “shock waves” on injured recovery from less severe skeletal Randomized controlled trial showed scientific progress has been made in
that could augment tissue regeneration. In skeletal muscle exist. muscle injury, i.e. delayed-onset that TUS reduced pain and improved terms of validating early rehabilitation
addition, MSCs have an immunoregulatory muscle soreness (DOMS), in one recovery after DOMS37. No clinical Recommended. Athletes should as the gold standard therapy for injured
effect (suppression of chronic, detrimental randomized controlled trial31, but study are available on TUS on severe be encouraged to start early, active skeletal muscle. Standardized, “battle-
inflammation) on their environment.25,26 another two randomized controlled skeletal muscle injuries. rehabilitation immediately after the tested” rehabilitation protocols have
Not recommended (based on total lack trials found no or very little beneficial inflammatory period (3 – 5 days). Safe been introduced to the field recently
of clinical evidence) effects.32,33 There are no clinical studies and effective treatment protocols have to provide a framework for safe and
addressing the effects of HBOT on been developed and scientifically efficient rehabilitation.1-4 By adhering
To our knowledge, stem cells of any severe skeletal muscle injuries. Recommended for DOMS-type of tested (proven to work without to these protocols, the injured athletes
kind, have not yet been tested to treat injuries, no evidence available to increased risk of re-injury) for certain can recover from serious skeletal
muscle injuries in clinical trials. Some support the use in severe skeletal muscle groups such as hamstrings, calf muscle injuries as fast and effectively as
sports medicine organizations, such as muscle injuries. and quadriceps muscles.1-4 possible.1-4
The Australian College of Sports and May have a slight benefit in treating
Exercise Physicians, strongly advise DOMS, but no clinical studies on
against the use of stem cell-therapies, “severe”/”real” skeletal muscle injuries
and there is no definitive evidence have been published.
ruling out a potential increased cancer
risk with these cell therapies.

Not recommended (based on total lack
of clinical evidence)




When dealing with muscle injuries, the main principles of non-operative treatment
should be used as a common guideline. There are, however, more severe muscle
injuries in which surgical treatment should be considered. Especially in athletes,
but also in other physically active people, if misdiagnosed and/ or improperly
treated, a complete or even a partial muscle rupture can cause considerable
morbidity and lead to decreased performance.1,2
— Lasse Lempainen and Janne Sarimo

102 The indications for surgery in muscle They could however also be considered 103
injuries are not always generally as tendinous injuries, as the site of the
acknowledged. However, there are rupture often involves both the muscle
certain clear indications in which surgical and tendon tissue itself, like in the cases
treatment is beneficial even though no of complete avulsions or central tendon
evidence-based treatment protocol exists.3 ruptures.4-6 Early and correct diagnosis, as
These indications include the athlete with well as accurate classification of muscle
a complete rupture of a muscle with few injuries, are the basic elements for proper
or no agonist muscles (e.g. hamstring, treatment and recovery from injury.7 The
pectoralis, adductor), or a large tear where tendon area involved in the muscle injury
more than half of the muscle is torn. has to be taken into account when making
Furthermore, surgical treatment should a decision of possible surgical intervention
be considered if an athlete complains of and also when deciding the surgical
permanent extension pain (e.g. rectus technique itself.6
femoris) in a previously injured muscle. In
such a case, formation of scar restricting In the later section on ‘Specific Muscle
the movement of the injured muscle has to Injuries’ section of this Guide, we and
be suspected and surgical deliberation of other experts will provide further
adhesions should be considered. information and guidelines related to the
surgical indications and management of
In literature, muscle injuries are often specific muscle injury types; hamstrings,
categorized as isolated muscle injuries. quadriceps, adductor and calf.


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In this section, we build upon the general principles described earlier in the guide,
with specific reference to hamstring muscle injuries.
— With Thor Einar Andersen, Arnlaug Wangensteen, Nicol van Dyk and Ricard Pruna

108 RTP from MAKING AN ACCURATE affected. In football players, the majority PHYSICAL EXAMINATION 109

DIAGNOSIS of hamstring injuries occur during high-
speed running when the player is running
As with other muscle injuries, the physical
examination should include observation
Making an accurate diagnosis is at maximal or close to maximal speed,5–7