Standardized Criteria-based rehabilitation for Rectus Femoris Injuries Experiencies from Aspetar Sports Medicine Hospital. Andreas Serner 8th MuscleTech Network Workshop Tuesday 4th October, 2016

1. Rehabilitation of acute rectus femoris injuries
Andreas Serner
Physiotherapist, PhD candidate
@aserner

2. Clinical examination of proximal rectus femoris injuries
@aserner
Hip flexor injuries 1/3 of acute groin injuries
- Rectus femoris & iliopsoas
High discrepancy between clinical diagnosis & imaging
- 35-46% different location
(Serner et al, BJSM, 2016)
Chance of positive MRI if positive test
(Positive predictive value - PPV)
• 62% Palpation of the Rectus femoris (CI 32-85%)
• 47% Stretch of the Rectus femoris (CI 22-73%)
• 42% Resisted knee extension (CI 20-64%)
(Serner et al, AJSM, 2015)

3. MRI of proximal rectus femoris injuries
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(Serner et al, submitted)
Often include tendon injury
• Insertion or intramuscular
• Indirect tendon > direct tendon

4. Rehabilitation of acute rectus femoris injuries
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Context will often influence outcome
Standardized criteria to inform the shared decision-making
Multi-disciplinary team
Physiotherapists, S&C coaches, Sports rehabilitators, Massage therapists,
Sports physicians, Orthopedic surgeons, Radiologists, Club Medical staff.

5. Our biggest competition
Time
What do we think we can change?
Duration
(tissue healing)
Re-injury risk
(capacity & function)
Performance
(general fitness)
Symptoms
(pain/tightness)
@aserner

6. 1 player – 2 rec fem injuries
• Insert Julio Cesar – Kicking injury
1 player
2 rec fem inj.

7. Similar injury • Indirect tendon
2013 – Left 2016 – Right

8. @aserner
Structure AND function
Kicking & Sprinting
Maximal hip extension occurs before max knee flexion
(Nunome, MSSE, 2002)
(Brophy et al, JOSPT, 2007)
(Charnock et al, SB, 2009)

9. Kicking and ball impact
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(Shinkai et al, MSSE, 2009)
• Peak ball reaction force at max deformation:
2926 ± 509N
• Short duration: 8-9 ms. Foot angular velocity
6.2 ± 0.6 cm
Even submaximal kicks will include
high load at ball impact!
Potential to play with ball pressure
as part of rehab program

10. Two-part rehabilitation program
Basic exercise progression
• 5 phases
• Focus: Tissue load & synergists
Functional running progression
• 4 phases
• Focus: Running speed & agility
Progression independently
Criteria passed for both before pitch training

11. When to start your exercises?
(Balius et al, 2009)
@aserner
Allowing healing vs. improving healing
(Cross et al, 2004)
1 week? 48 hours?
Or does it depend on the individual?

12. The MTJ & exercise
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Exercise groupNon-exercise group
(Kojima et al, JOS, 2008)
(Curzi et al, EJH, 2008)

13. MRI fibrosis & re-injury
Quality of the new junctions?
Patients without re-injury = More fibrosis on MRI

14. So we start as soon as possible!
• Usually day 2 or 3 regardless of imaging findings
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Criteria to start loading
NRS ≤2/10
• Walking
• Max active hip extension & knee flexion
Plus all other non-
provocative training allowed

15. Basic exercise program
1 key exercise from beginning to end
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Standing hip flexion with elastic bands around the ankle
• Close to injury position
• Crosses hip & knee
• Highly load adjustable

16. Basic exercise program
1 key exercise from beginning to end
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Standing hip flexion with elastic bands around the ankle
1-4 elastic bands • 3m long
Distance 4-9 m. • 20 cm. increments

17. So what about intensity?
• Load usually determined using “Repetition Maximum”
– e.g. % of 1RM or 10RM
– Not possible with pain!
@aserner
Training to fatigue may be more important for
exercise adaptations
(Morton et al, JAP, 2016, Ogasawara, IJCM, 2013,
Schoenfield et al, SCR, 2015, Mitchell et al, JAP, 2012)

18. PRM - “Pain-controlled repetition maximum”
Maximum number of repetitions repeated to failure with maximum pain 2/10 accepted.
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Maximal load every session!
Pain
0 1 2 3 4 5 6 7 8 9 10
Reduce loadIncrease
load!
Try to
increase load
“Perform this exercise as many times as you can or until you experience pain 3 out of 10”

19. Intensity
• Phase 2
– 2 sets of 20-50 PRM
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• Phase 3
– 3 sets of 15-20 PRM
• Phase 4
– 4 sets of 10-15 PRM
Velocity
Concentric : Eccentric
3s : 3s
20 PRM
10 RM
15 PRM

20. Intensity
• Phase 2
– 2 sets of 20-50 PRM
@aserner
• Phase 3
– 3 sets of 15-20 PRM
• Phase 4
– 4 sets of 10-15 PRM
Velocity
Concentric : Eccentric
3s : 3s
20 PRM
10 PRM
15 PRM
“The whip”
Ballistic stretch

21. Intensity
• Phase 2
– 2 sets of 20-50 PRM
@aserner
• Phase 3
– 3 sets of 15-20 PRM
• Phase 4
– 4 sets of 10-15 PRM
Velocity
<1s : 3s
Concentric : Eccentric
Concentric : Eccentric
3s : 3s
20 PRM
10 PRM
15 PRM
“The whip”
Ballistic stretch

22. Intensity
• Phase 2
– 2 sets of 20-50 PRM
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• Phase 3
– 3 sets of 15-20 PRM
• Phase 4
– 4 sets of 10-15 PRM
20 PRM
10 PRM
15 PRM
Base exercises – Synergists
Hip flexion - Ankle Hip flexion - Knee Hip adduction Abdominal twist

23. Intensity
• Phase 2
– 2 sets of 20-50 PRM
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• Phase 3
– 3 sets of 15-20 PRM
• Phase 4
– 4 sets of 10-15 PRM
20 PRM
10 PRM
15 PRM
Base exercises – Synergists
Hip flexion - Ankle Hip flexion - Knee Hip adduction Abdominal twist
Reverse Nordic
“Tension Arc”
Kicking exercise

24. Basic exercises on alternate days
Net synthesis of collagen >36 hours after exercise
(Magnusson et al, 2010)
High load of injured structure every second day
Posterior chain and other individual deficiencies on alternate days

25. Completion criteria
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Running
• 10 x 30m sprints at 100%
• T-Test at 100%
Sports-specific training
• 3 completed on field sessions pain free
• Speed with and without ball • Spider test
• Agility • Illinois test
• Kicking • Passes/set plays/running /corner/goal kicks/shots
Clinically pain free
• Outer-range resistance
• Palpation
• Maximal passive stretching
• Hip flexion exercise • 10RM
• Reverse Nordic • 1x10
(Ardern et al, BSJM, 2016)

26. Aspetar Rectus Femoris Protocol
• Early movement is key
– Basic exercises and progressive running
• Training to failure
– Train with pain ≤2/10
– Pain-controlled repetition maximum (PRM)
• Resistance training in injured structure every 2nd day
• Hard kicking after completed clinical & running criteria
@aserner

27. Thank you!
Aspetar Rehab team
NSMP club staff
Sports Groin Pain Centre
andreas.serner@aspetar.com
@aserner