Rehabilitation of rectus Femoris Injuries. Experience at Sevilla FC
José Conde And Adolfo Muñoz
8th MuscleTech Network Workshop
Tuesday 4th October, 2016
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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
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
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.
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
23.
24. Rehabilitation
• Work all the physical contents until the player can Return To Play
• Flexibility
• Force
• Speed
• Endurance
25.
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
27.
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
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
33.
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.
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)
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
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
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.