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Adolfo Muñoz MD – José Conde BESS PhD
Medical Director -- Rehabilitation Coordinator
@dradolfomunoz
Session 5. Treatment/Rehabilitation
REHABILITATION OF RECTUS FEMORIS INJURIES
Experience at SEVILLA FC
Introduction Anatomy
Epidemiology
Injury
Mechanism
Diagnosis
Treatment /
Rehabilitation
RTP
Surgical
Treatment
Introduction Anatomy
Epidemiology
Injury
Mechanism
Diagnosis
Treatment /
Rehabilitation
RTP
Surgical
Treatment
Treatment / Rehabilitation
Medical Physiotherapy Rehabilitation
MULTIDISCIPLINAR
CLINICAL SESSIONS
CONTINUOS FAST TRACKING
Workgroup
• Multidisciplinary Focus
Footbal
Player
Physician
Physiotherapist
Phisical Coach
Nutritionist
Psychologist
Podiatrist
Rectus Femoris Injuries. Experience at Sevilla FC
He broke the direct and
réflex tendón
Dr. Orava made surgery to
him. 5 months after he
returned to play until today
Rectus Femoris Injuries. Experience at Sevilla FC
AVALIABLE
AVALIABLE IN MONITORING
NO AVALIABLE
EVOLUTION PENDING
1 2 3 4 5 6 7
1 2 3 4 5 6 7
1 2 3 4 5 6 7
1 2 3 4 5 6 7
1 2 3 4 5 6 7
Medical – PRIMUM NON NOCERE
• RESPECT THE BIOLOGICAL TIMING FOR HEALING
• RICE
• Crutches
• Compression
• Ergogenic supplementation: Arginin / Curcumin / Vitamin C
• No AINES
• Acupuncture
• Mecanotrasduction
• Taut bands
• Microdrops PRGF
• Revision everyday: Clinicial / Ultrasound / MRI
Rectus Femoris Injuries. Experience at Sevilla FC
Rectus Femoris Injuries. Experience at Sevilla FC
Rectus Femoris Injuries. Experience at Sevilla FC
Acupuncture
Importance of Injuries
Health, Performance,
Career of the player
Avaliability for
Technical Staff
Revaluation
Human Asset
My Deontologic Concerns
WE NEED
- PREVENT BETTER THAN TREAT
- SHORTEN DEADLINES
- AVOID RECURRENCES
The final results of the teams depend on:
- Total number of injuries
- Total timing of injuries
- Injuries in your best players
Direct Mechanism
Direct Mechanism
He played 47´ day 27/09 Tuesday
After 4 days
He played 90´ day 1/10 Saturday
Indirect Mechanism
Casos: rectos Femorales.
Jugador 2: Recidiva durante periodo de readaptación. Tras vuelta se infiltró 1 vez y se dio alta a
las 4 semanas. Única recidiva de lesión muscular en la temporada.
Casos: rectos Femorales.
Jugador 3: Infiltrado a los 8 días de la lesión.
Physiotherapy
• Hands on process
• Lymphatic drenaje
• Massage in aproximation
• Electroestimulation
• Isometric exercises in diferent angles
• Deep termotherapy TECAR
• High power Laser
• Double session
More intense day by day from the
RICE the first 24-48h and the soft
treatment to the intense
treatment and stress in the zone
of injury until the next steps
coordinating actions in the
multidisciplinary group
Rectus Femoris Injuries. Experience at Sevilla FC
Rehabilitation
• Work all the physical contents until the player can Return To Play
• Flexibility
• Force
• Speed
• Endurance
Rectus Femoris Injuries. Experience at Sevilla FC
The 2 days STEP Rule - SFC
We have to repeat the same contents 2 sessions and see that the
clinical evolution is right before changing the step.
• We check that the player doesn´t have pain or negative symptoms
• When doing the session
• Inmediately after the session
• 2h after finishing the session
• The day after the session.
• If all is ok we increase 1 step of difficulty
• Always increase the volume before than the intensity
Rectus Femoris Injuries. Experience at Sevilla FC
REHABILITATION OF INJURIES
KEY POINTS
1- EMPTY TRAINING (Gerad Moras)
2- TRAINING TO SPECIFICITY
3- TRAINING ACTIONS TOWARD HIGH INTENSITY
(Alberto Méndez Villanueva)
4- RESPECT THE ANATOMY
5- APPROACH TO THE INJURY MECHANISM
1- EMPTY TRAINING (Gerad Moras)
Stimuli that apply must be justified and be useful
2- TRAINING TO SPECIFICITY
3- TRAINING ACTIONS TOWARD HIGH INTENSITY
(Alberto Méndez Villanueva)
Putting the focus on high-intensity actions
In elite rugby league, players who performed greater amounts (>9 m) of very high-speed (>7
m/s) running per session were 2.7 times more likely to sustain a non-contact, soft-tissue
injury than players who performed less very high-speed running per session
Rectus Femoris Injuries. Experience at Sevilla FC
RF is a fusiform and biarticular long muscle designed to execute movements
that requiere significant length change or high shortening velocity (Mendiguchía, et al. 2013)
Its functions are extends the knee, flexes the hip
and stabilises the pelvis on the femur in weight-
bearing (Bordalo-Rodriguez, et al. 2005; Shu, et al. 2011)
RF has a high demand for eccentric muscle contraction and has a high
percentage of type II fibres (Johnson, et al. 1973 en Mendiguchía et al. 2013; Soterios, et al. 2008)
4- RESPECT THE ANATOMY
MOST COMMON INJURIES
The proximal tendon is composed of a superficial, anterior portion from the
direct head (yellow) that originates from the anterior-inferior iliac spine, and a
deep intramuscular portion from the indirect head (red) emerging from the
posterior-superior acetabular ridge. (Mendiguchía, et al. 2013)
The most common site of rectus femurs injury
in soccer is at the deep myotendinous
junction of the indirect head, referred to as the
central part of the tendon. (Mendiguchía, et al. 2013; Balius, et
al. 2009; Bordalo-Rodriguez, et al. 2005; Shu, et al. 2011)
5- APPROACH TO THE INJURY MECHANISM
Usually occur during eccentric muscle actions, such as sprinting y kicking.
5- APPROACH TO THE INJURY MECHANISM
Usually occur during eccentric muscle actions, such as sprinting y kicking.
ACCELERATION
Early Swing Phase
Hip-flexor muscles generate force at the same time as the knee-extensor muscles absorbed energy through an eccentric muscle action
ACCELERATION
-PRACTICAL APPLICATION-
IMPORTANT.
EXERCISES WITH HIP EXTENSION AND KNEE FLEXION
(Absorb eccentric energy)
Introduce
disturbing
element (specificity)
MECHANISM OF INJURIES
DECELERATION
Football players repeatedly change in direction, decelerate or stop suddenly.
This results in additional
horizontal braking forces and
consequently more eccentric
force imposed on the
quadriceps. (Mendiguchía, et
al. 2013)
MECHANISM OF INJURIES
KICKING
The most common mechanism of rectus femoris muscle injury in soccer is kicking. (Woods, et al. 2002)
MECHANISM OF INJURIES
This part of the kicking action may be related to rectus femoris injury.
This specific action
has to appear in the
readaptation / RTP
process
- Practical Application -
ROTATIONAL VECTORS
MECHANISM OF INJURIES
ENTRENAR LOS MUSCULOS RESPETANDO SU
ANATOMIA y FUNCIÓN TRIDIMENSIONAL
- Practical Application -
MECHANISM OF INJURIES
“…These findings support our hypothesis that
divergent regions of muscle fibers within RF have
different functions for determining the force direction”
- Practical Application -
MECHANISM OF INJURIES
Foot to ball contact is much lower than ground reaction forces in the deceleration
at the final step of the kicking leg.
“Deceleration during a kicking motion causes the body to lean backwards and the leg to move farther
behind the body than normal, which places extra stress and strain on the rectus femoris".
(Mendiguchía, et al. 2013)
KICKING
HIP FLEXORS
It is very important the function of hip flexors for running
(aceleration/deceleration/direction changes)and for kicking to avoid fatigue and
overuse in Rectus Femoris.
HIP FLEXORS
Psoas Iliaco, TFL, Sartorio, Recto Femoral, Aductor Largo
OPTIMA RELACIÓN EN:
Force – Flexibility – Motor Sinergy
INTRINSIC RISK FACTORS
STRENGTH
FLEXIBILITY
CORE
STABILITY
FATIGUE
RECTUS
FEMORIS
INJURY
FLEXIBILITY
/ KNEE EXTENSORS
The logistic regression analysis identified
decreased flexibility of the quadriceps muscle as
almost an intrinsic risk factor for the development
of a quadriceps muscle injury (P 􏰂 0.063).
Quadriceps muscle flexibility (>128°) should be a cornerstone of any prevention programme targeted to reduce rectus femoris
injury, at least in soccer. (Mendiguchía, et al. 2013)
“Regarding quadriceps, a trend was documented for …, as well as for players with
eccentric strength (OR=5.01; 95% CI 0.92 to 27.14, p=0.06) and flexibility (OR=4.98;
95% CI 0.78 to 31.80, p=0.08) asymmetries in the quadriceps to be at greater risk for
a strain in this muscle group. This trend was not significant at the 0.05 level, probably
owing to the small number of players (seven) having this injury”
FLEXIBILITY
/ KNEE EXTENSORS
OPTIMA RELACIÓN EN:
FUERZA - FLEXIBILIDAD/ELASTICIDAD - SINERGIA MOTORA
Disponer de unos flexores superficiales de
cadera con el stifness optimo (elasticidad), pero
sin una limitación en el ROM de extensión de
cadera (ADM)
Correcta utilización del ciclo
estiramiento/acortamiento para ser más
eficaz en la realización del posterior momento
de fuerza en la flexión de cadera. Evitando
que el RF (u otras estructuras) necesiten
generar más fuerza para producir dicha
flexión (predispone a la fatiga y sobrecarga)
FLEXIBILITY / HIP FLEXORS
Una limitación en el ROM de la extensión de la cadera, el RF va a necesitar
generar más fuerza para producir la flexión de cadera
TEST:
1- Test de Thomas Modificado
(Observar si hay abducción, rotación interna de
cadera, rotación externa de cadera, rotación de rodilla,
>90º de flexión de la pierna extendida y distancia entre
la cara posterior del muslo de la pierna extendida y la
camilla)
En estos casos normalmente el PI está
debilitado (testear la fuerza del PI)
(RFA-TFL-Sart. ver si están rígidos y acortados)
FLEXIBILITY / HIP FLEXORS
FLEXIBILITY / HIP FLEXORS
TENSOR FASCIAE LATAE
STRENGTH / HIP FLEXORS
MUSCLE ACTION VS MUSCLE
TORQUE
STRENGTH / HIP FLEXORS
MUSCLE ACTION VS MUSCLE
TORQUE
“With the hip in full extension, this deflection
raises the tendon’s angle-of-insertion
relative to the femoral head, thereby
increasing the muscle’s leverage for hip
flexion”
PSOAS ILÍACO
STRENGTH
HIP FLEXORS
PSOAS ILÍACO
“As the maximum iliopsoas force value decreased, the model increased the PForce of
the TFL, the sartorius, and the adductor longus (Table 2). The majority of the increase
in the maximum anterior hip joint force was due to the adductor longus muscle (an
increase of 66.6 N between Conditions 1 and 4)”
STRENGTH / HIP FLEXORS
Sahrmann has also reported that in patients with
anterior hip pain, the hip medially rotates during
supine hip flexion suggesting that the action of the
TFL is dominant over the iliopsoas muscle
(Sahrmann, 2002). When simulating supine hip
flexion, the model predicts that the TFL, along with
the sartorius and adductor longus muscles,
increases its force contribution when the force
contribution from the iliopsoas muscle was
decreased. The TFL and sartorius act to flex the hip
while the adductor longus counteracts the
excessive hip abduction torque generated by the
TFL and sartorius.
STRENGTH / HIP FLEXORS
STRENGTH / HIP FLEXORS
“ … a reduction in the strength and/or activation of the iliopsoas
muscle may result in rectus femoris compensation to generate
more hip flexion force”
STRENGTH / HIP FLEXORS
It could drive to
fatigue and
overtraining
CORE STABILITY
If the pelvis is inadequately stabilized by
other muscles, a sufficiently strong force
from the rectus femoris (or any other hip
flexor muscle) could rotate or tilt the pelvis
anteriorly. In this case, the arrowhead of the
rectus femoris would logically be pointed
down- ward toward the relatively fixed
femur.
Rectus Femoris Injuries. Experience at Sevilla FC
Thanks!
Dr. Adolfo Muñoz
Medical Director Sevilla FC SAD
dradolfomunoz@sevillafc.es
@dradolfomunoz

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Rectus Femoris Injuries. Experience at Sevilla FC

  • 1. Adolfo Muñoz MD – José Conde BESS PhD Medical Director -- Rehabilitation Coordinator @dradolfomunoz Session 5. Treatment/Rehabilitation REHABILITATION OF RECTUS FEMORIS INJURIES Experience at SEVILLA FC
  • 4. Treatment / Rehabilitation Medical Physiotherapy Rehabilitation MULTIDISCIPLINAR CLINICAL SESSIONS CONTINUOS FAST TRACKING
  • 7. He broke the direct and réflex tendón Dr. Orava made surgery to him. 5 months after he returned to play until today
  • 9. AVALIABLE AVALIABLE IN MONITORING NO AVALIABLE EVOLUTION PENDING
  • 10. 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7
  • 11. Medical – PRIMUM NON NOCERE • RESPECT THE BIOLOGICAL TIMING FOR HEALING • RICE • Crutches • Compression • Ergogenic supplementation: Arginin / Curcumin / Vitamin C • No AINES • Acupuncture • Mecanotrasduction • Taut bands • Microdrops PRGF • Revision everyday: Clinicial / Ultrasound / MRI
  • 16. Importance of Injuries Health, Performance, Career of the player Avaliability for Technical Staff Revaluation Human Asset My Deontologic Concerns
  • 17. WE NEED - PREVENT BETTER THAN TREAT - SHORTEN DEADLINES - AVOID RECURRENCES The final results of the teams depend on: - Total number of injuries - Total timing of injuries - Injuries in your best players
  • 18. Direct Mechanism Direct Mechanism He played 47´ day 27/09 Tuesday After 4 days He played 90´ day 1/10 Saturday
  • 20. Casos: rectos Femorales. Jugador 2: Recidiva durante periodo de readaptación. Tras vuelta se infiltró 1 vez y se dio alta a las 4 semanas. Única recidiva de lesión muscular en la temporada.
  • 21. Casos: rectos Femorales. Jugador 3: Infiltrado a los 8 días de la lesión.
  • 22. Physiotherapy • Hands on process • Lymphatic drenaje • Massage in aproximation • Electroestimulation • Isometric exercises in diferent angles • Deep termotherapy TECAR • High power Laser • Double session More intense day by day from the RICE the first 24-48h and the soft treatment to the intense treatment and stress in the zone of injury until the next steps coordinating actions in the multidisciplinary group
  • 24. Rehabilitation • Work all the physical contents until the player can Return To Play • Flexibility • Force • Speed • Endurance
  • 26. The 2 days STEP Rule - SFC We have to repeat the same contents 2 sessions and see that the clinical evolution is right before changing the step. • We check that the player doesn´t have pain or negative symptoms • When doing the session • Inmediately after the session • 2h after finishing the session • The day after the session. • If all is ok we increase 1 step of difficulty • Always increase the volume before than the intensity
  • 28. REHABILITATION OF INJURIES KEY POINTS 1- EMPTY TRAINING (Gerad Moras) 2- TRAINING TO SPECIFICITY 3- TRAINING ACTIONS TOWARD HIGH INTENSITY (Alberto Méndez Villanueva) 4- RESPECT THE ANATOMY 5- APPROACH TO THE INJURY MECHANISM
  • 29. 1- EMPTY TRAINING (Gerad Moras) Stimuli that apply must be justified and be useful
  • 30. 2- TRAINING TO SPECIFICITY
  • 31. 3- TRAINING ACTIONS TOWARD HIGH INTENSITY (Alberto Méndez Villanueva) Putting the focus on high-intensity actions
  • 32. In elite rugby league, players who performed greater amounts (>9 m) of very high-speed (>7 m/s) running per session were 2.7 times more likely to sustain a non-contact, soft-tissue injury than players who performed less very high-speed running per session
  • 34. RF is a fusiform and biarticular long muscle designed to execute movements that requiere significant length change or high shortening velocity (Mendiguchía, et al. 2013) Its functions are extends the knee, flexes the hip and stabilises the pelvis on the femur in weight- bearing (Bordalo-Rodriguez, et al. 2005; Shu, et al. 2011) RF has a high demand for eccentric muscle contraction and has a high percentage of type II fibres (Johnson, et al. 1973 en Mendiguchía et al. 2013; Soterios, et al. 2008) 4- RESPECT THE ANATOMY
  • 35. MOST COMMON INJURIES The proximal tendon is composed of a superficial, anterior portion from the direct head (yellow) that originates from the anterior-inferior iliac spine, and a deep intramuscular portion from the indirect head (red) emerging from the posterior-superior acetabular ridge. (Mendiguchía, et al. 2013) The most common site of rectus femurs injury in soccer is at the deep myotendinous junction of the indirect head, referred to as the central part of the tendon. (Mendiguchía, et al. 2013; Balius, et al. 2009; Bordalo-Rodriguez, et al. 2005; Shu, et al. 2011)
  • 36. 5- APPROACH TO THE INJURY MECHANISM Usually occur during eccentric muscle actions, such as sprinting y kicking.
  • 37. 5- APPROACH TO THE INJURY MECHANISM Usually occur during eccentric muscle actions, such as sprinting y kicking.
  • 38. ACCELERATION Early Swing Phase Hip-flexor muscles generate force at the same time as the knee-extensor muscles absorbed energy through an eccentric muscle action
  • 39. ACCELERATION -PRACTICAL APPLICATION- IMPORTANT. EXERCISES WITH HIP EXTENSION AND KNEE FLEXION (Absorb eccentric energy) Introduce disturbing element (specificity)
  • 40. MECHANISM OF INJURIES DECELERATION Football players repeatedly change in direction, decelerate or stop suddenly. This results in additional horizontal braking forces and consequently more eccentric force imposed on the quadriceps. (Mendiguchía, et al. 2013)
  • 41. MECHANISM OF INJURIES KICKING The most common mechanism of rectus femoris muscle injury in soccer is kicking. (Woods, et al. 2002)
  • 42. MECHANISM OF INJURIES This part of the kicking action may be related to rectus femoris injury. This specific action has to appear in the readaptation / RTP process - Practical Application -
  • 43. ROTATIONAL VECTORS MECHANISM OF INJURIES ENTRENAR LOS MUSCULOS RESPETANDO SU ANATOMIA y FUNCIÓN TRIDIMENSIONAL - Practical Application -
  • 44. MECHANISM OF INJURIES “…These findings support our hypothesis that divergent regions of muscle fibers within RF have different functions for determining the force direction” - Practical Application -
  • 45. MECHANISM OF INJURIES Foot to ball contact is much lower than ground reaction forces in the deceleration at the final step of the kicking leg. “Deceleration during a kicking motion causes the body to lean backwards and the leg to move farther behind the body than normal, which places extra stress and strain on the rectus femoris". (Mendiguchía, et al. 2013) KICKING
  • 46. HIP FLEXORS It is very important the function of hip flexors for running (aceleration/deceleration/direction changes)and for kicking to avoid fatigue and overuse in Rectus Femoris.
  • 47. HIP FLEXORS Psoas Iliaco, TFL, Sartorio, Recto Femoral, Aductor Largo OPTIMA RELACIÓN EN: Force – Flexibility – Motor Sinergy
  • 49. FLEXIBILITY / KNEE EXTENSORS The logistic regression analysis identified decreased flexibility of the quadriceps muscle as almost an intrinsic risk factor for the development of a quadriceps muscle injury (P 􏰂 0.063). Quadriceps muscle flexibility (>128°) should be a cornerstone of any prevention programme targeted to reduce rectus femoris injury, at least in soccer. (Mendiguchía, et al. 2013)
  • 50. “Regarding quadriceps, a trend was documented for …, as well as for players with eccentric strength (OR=5.01; 95% CI 0.92 to 27.14, p=0.06) and flexibility (OR=4.98; 95% CI 0.78 to 31.80, p=0.08) asymmetries in the quadriceps to be at greater risk for a strain in this muscle group. This trend was not significant at the 0.05 level, probably owing to the small number of players (seven) having this injury” FLEXIBILITY / KNEE EXTENSORS
  • 51. OPTIMA RELACIÓN EN: FUERZA - FLEXIBILIDAD/ELASTICIDAD - SINERGIA MOTORA Disponer de unos flexores superficiales de cadera con el stifness optimo (elasticidad), pero sin una limitación en el ROM de extensión de cadera (ADM) Correcta utilización del ciclo estiramiento/acortamiento para ser más eficaz en la realización del posterior momento de fuerza en la flexión de cadera. Evitando que el RF (u otras estructuras) necesiten generar más fuerza para producir dicha flexión (predispone a la fatiga y sobrecarga) FLEXIBILITY / HIP FLEXORS
  • 52. Una limitación en el ROM de la extensión de la cadera, el RF va a necesitar generar más fuerza para producir la flexión de cadera TEST: 1- Test de Thomas Modificado (Observar si hay abducción, rotación interna de cadera, rotación externa de cadera, rotación de rodilla, >90º de flexión de la pierna extendida y distancia entre la cara posterior del muslo de la pierna extendida y la camilla) En estos casos normalmente el PI está debilitado (testear la fuerza del PI) (RFA-TFL-Sart. ver si están rígidos y acortados) FLEXIBILITY / HIP FLEXORS
  • 53. FLEXIBILITY / HIP FLEXORS TENSOR FASCIAE LATAE
  • 54. STRENGTH / HIP FLEXORS MUSCLE ACTION VS MUSCLE TORQUE
  • 55. STRENGTH / HIP FLEXORS MUSCLE ACTION VS MUSCLE TORQUE “With the hip in full extension, this deflection raises the tendon’s angle-of-insertion relative to the femoral head, thereby increasing the muscle’s leverage for hip flexion” PSOAS ILÍACO
  • 57. “As the maximum iliopsoas force value decreased, the model increased the PForce of the TFL, the sartorius, and the adductor longus (Table 2). The majority of the increase in the maximum anterior hip joint force was due to the adductor longus muscle (an increase of 66.6 N between Conditions 1 and 4)” STRENGTH / HIP FLEXORS
  • 58. Sahrmann has also reported that in patients with anterior hip pain, the hip medially rotates during supine hip flexion suggesting that the action of the TFL is dominant over the iliopsoas muscle (Sahrmann, 2002). When simulating supine hip flexion, the model predicts that the TFL, along with the sartorius and adductor longus muscles, increases its force contribution when the force contribution from the iliopsoas muscle was decreased. The TFL and sartorius act to flex the hip while the adductor longus counteracts the excessive hip abduction torque generated by the TFL and sartorius. STRENGTH / HIP FLEXORS
  • 59. STRENGTH / HIP FLEXORS
  • 60. “ … a reduction in the strength and/or activation of the iliopsoas muscle may result in rectus femoris compensation to generate more hip flexion force” STRENGTH / HIP FLEXORS It could drive to fatigue and overtraining
  • 61. CORE STABILITY If the pelvis is inadequately stabilized by other muscles, a sufficiently strong force from the rectus femoris (or any other hip flexor muscle) could rotate or tilt the pelvis anteriorly. In this case, the arrowhead of the rectus femoris would logically be pointed down- ward toward the relatively fixed femur.
  • 63. Thanks! Dr. Adolfo Muñoz Medical Director Sevilla FC SAD dradolfomunoz@sevillafc.es @dradolfomunoz