FMPA Publication - Issue 46 - Spring 2024

football medicine & performance

In this issue

Anterior Cruciate Ligament (ACL) Surgery - Part 2: An Interview with surgeon, Mr Andy Williams

Coping with the Heat while Playing Football: Challenges and Potential Solutions

George Nassis

Surface Electromyography

Implementation in Football Players Rehabiliation After Lower Limb Injury

Maxime Gaspar & Florian Forelli

The Role of the Physiotherapist in Serie A: Is Rehabilitation for Elite Athletes Always as Simple as it Appears?

Leonardo Bellotti

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CEO MESSAGE

“Though it is now 2 years since the pandemic the repercussions of COVID still resonate today.” While this might now sound like a bit of a cliché there are in fact consequences of that era that still affect each and every one of us. For the FMPA, the main concern during COVID was the lack of direct contact with clubs, our members, and commercial partners. The lockdown effectively meant less emails, less dialogue, less connectivity, loss of communication and a sense of isolation for all concerned. Add to this, the inordinate number of changes in personnel both during this time and subsequently; we emerged to a very different and challenging landscape.

With this in mind, and since I believe there is still a need to re-establish that connectivity, I have embarked on a plan to visit as many clubs as possible across the four leagues. A quarter of the way in, the meetings have been both rewarding, and productive for members and the association. What seemed like an onerous task has been enjoyable and engaging and the personal contact demonstrates that we as an association are in touch with and supportive of our members.

Aside from these positive outcomes one of the by-products of the meetings is that we are re-establishing a senior point of contact at each club (usually one of the Department Heads), who will then keep us engaged and in the loop with changes and developments within our sector.

And of course, I hope to see many of you at our Conference in May!

“Coming together is a beginning. Keeping together is progress. Working together is success.” - Henry Ford

Salmon Eamonn

Chief Executive Officer

Football Medicine & Performance Association

What makes ProMOTION EV1 different?

With many different cold compression devices on the market, what makes EV1 different?

ProMOTION EV1 makes a unique and versatile addition to the typical tool kit used by clubs, clinics and players alike. It provides targeted cryotherapy, contrast therapy, heat and compression therapy all in one device. EV1 can be used to quickly and accurately control the specific skin temperatures needed to deliver effective therapy, all without the need for any ICE, WATER or Mains ELECTRIC. With its compact and portable nature, its versatility and ease of use is unparalleled, supporting applications for targeted warm-ups, cooldowns, recovery and rehabilitation, all in one portable device (see fig. 2).

Use ProMOTION EV1 throughout the Rehabilitation Journey

Offering cryotherapy, contrast therapy and heat therapy, with or without compression, ProMOTION EV1 can be used throughout the stages of rehabilitation to support athlete recovery from injury and back into training.

Clinical injury management guidelines have evolved over many years (RICE > PRICE > POLICE), and new research suggests PEACE & LOVE, which recommends greater consideration to the therapy needs at the different stages of tissue healing; acute, subacute and chronic. Read more or listen to the FMPA Podcast “TO ICE OR NOT TO ICE”

ProMOTION EV1 has been developed through scientific research to support all three rehabilitation stages (see fig. 1).

Versatility of Application

Due to its small and targeted nature, and the range of compression wraps and straps supplied with the Elite Package as standard, EV1 can be used across the body at ease.

Its range of temperature settings make it highly versatile for use across the injury rehabilitation journey. Additional applications of targeted warm-up, targeted cool-down and

Fig. 1: Stages

Fig. 2:

FROM THE EDITORS

As the season draws to an end, the focus of medical and performance practitioners shifts to reflecting on the season, preseason preparation and the challenges that it brings. The end of the season also signifies that the FMPA conference is on the horizon, an event that combines excellence in educational content and superb networking opportunities for members. Throughout this edition, one can find more information about this year’s event.

As different challenges arise in different leagues and countries in elite football, Leonardo Belotti discusses the role of the physiotherapist in the Italian Serie A. Returning to the hot topic of hamstring injuries, Martin McIntyre’s delves deeper in part 2 of ‘Unravelling the Hamstring Quandary’. Orthopaedic surgeon Mr Andy Williams transcribed podcast continues to discuss management options for ACL injuries in this second part segment. Another important ligamentous injury commonly seen in elite football is ankle syndesmosis injuries. In this two-part series, Everton’s first team physiotherapist Adam Johnson discusses the diagnosis and classification of this injury.

With planning for preseason tours and trips overseas for many, George Nassis reflects on the challenges and potential solutions when playing in warm weather. On the other hand, Juan de la Torre explains the importance of thermography to mitigate injuries in football.

We hope you find this edition interesting and useful for your everyday practice and that we will be able to discuss these topics in further detail during the FMPA Conference in May.

Dr. Fadi Hassan Editor, FMP Magazine

Dr. Andrew Shafik Editor, FMP Magazine

Fadi Hassan Andrew Shafik

Dr. Daniela Mifsud Editor, FMP Magazine

Daniela Mifsud

ASSOCIATE EDITORS

Ian Horsley Lead Physiotherapist

Dr. Jon Power Director of Sport & Exercise Medicine

REVIEWERS

Matthew Brown Academy Sports Scientist

Lisa Edwards Sports Therapist

Dr. Danyaal Khan Academy Doctor

Mike Brown Head of Physical Performance

Jake Heath Elite Sports Specialist Podiatrist

Dr. Dáire Rooney Doctor

Dr. Manroy Sahni Medical Doctor

Dr. Andrew Butterworth Senior Lecturer

Frankie Hunter Lead Sports Scientist

Dr. Jose Padilla MD Sports Medicine Specialist

Eleanor Trezise Medical Student

Dr. Avinash Chandran Director

Callum Innes Medical Doctor

Kevin Paxton Strength & Conditioning Coach

Football Medicine & Performance Association

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Cover Image Performance Coach, Bram Geers, instructs Burnley players during the warm-up before the Premier League match at Turf Moor, Burnley, Saturday March 16, 2024.

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Identify the Problem !

An eccentrically lengthening brake driven model of hamstring function is widely accepted while it is also suggested a quasi-isometric contraction exists in which it is the ability to maintain isometric function that predisposes the hamstrings to injury (Yu et al 2017; Van Hooren and Bosch (2017). There is a debate surrounding both theories but what we do know is that late swing and early stance phase are the most hazardous for hamstring injury, where the hamstrings are most vulnerable and under the greatest stress (Liu et al., 2017). The strength of the muscle and its ability to withstand be it eccentric/isometric force in the late swing and the transition to early stance is surely the critical factor in protecting players.

08 Anterior Cruciate Ligament (ACL) Surgery

Interview with Mr Andy Williams - Part 2

12 Unravelling the Hamstring Quandary

“Elementary my Dear Watson”

Dr Martin McIntyre

SPECIFICITY & LOADING IN LATE SWING/EARLY STANCE!

17 Thermography: A Game-Changer for Injury Prevention and Performance in Football

Juan de la Torre

23 FMPA Conference & Networking Event

2024

Hamstring Injuries in the first half of the 23/24 season accounted for 2,319 days lost in the premier league, the greatest of all injuries (Sky sports 2023) and 13% of all players are reported to experience a hamstring issue (Maniar et al., 2023). The research indicates that issue is getting worse with hamstring injury occurrence doubling from 12% to 24% (Ekstrand et al., 2022). It is widely debated that increases in sprinting speeds and match exposure are contributing factors. With the great advances in performance and conditioning propelling our players to record speeds what are we missing from a performance context that is predisposing our players to hamstring risk ? Advances in screening, technology and sports science have led to the introduction of pre session screening, monitoring fatigue and recovery, but what are we missing ? We know that there are a large number of risk factors associated with hamstring injury however previous injury is still the strongest risk factor and with a relatively high reoccurrence rate what are we missing when this is the case ? Subsequently, with this is mind, one would think we need to re-examine our approach and the spirit of one great English detective, examine the “Elemenatry” “Basic” and “Fundamental” clues to solving this case.

39 Coping with the Heat while Playing Football: Challenges and Potential Solutions

George Nassis

44 Don’t Forget to Look Up High! Assessment of Ankle Syndesmosis Injuries

Adam Johnson

49 The Role of the Physiotherapist in Serie A: Is Rehabilitation for Elite Athletes Always as Simple as it Appears?

52

Does our current exercise prescription simulate these joint positions and what time is spent loading specifically at 30 degrees of knee flexion/time under load ? The Roman Chair Hold, Single-Leg RDL, Roman Chair Hamstring Curl are widely used to strengthen at longer muscle lengths (McAllister 2014), but do they truly simulate the biomechanical hamstring function in late swing/early stance and how effective are they when loading in the vulnerable phase of circa 30 degrees of knee flexion. Dr Martin McIntyre’s research over the last number of years has focused on spending time under load in a more specific manner, simulating running posture to either swing or early stance. Very rarely is the position of the contralateral hip considered and it is important to do so as it better simulates posture (200 of hip extension) while running where the contralateral or non-weight bearing limb during late swing/early stance in 15-250 of hip extension (Kenneally-Dabrowski et al., 2019). Previous researchers have attempted to investigate this either in a and Mc Call et al. (2015). This is an important consideration to testing as this would alter the centre of gravity of the subject and create an extension moment around the hip more similar to running. Introducing extension (200) into the contralateral hip, the kinaesthetic feedback of subject’s is that the hamstring became “tighter” and ‘longer”, even t hough the knee angle (300 of knee flexion) of the testing limb did not change. We can speculate that this maybe reflective of an increase in the intrinsic muscle tendon unit length change similar to that noted (112%) during the running cycle. Interestingly Dr McIntyre’s research has led him to develop the HRIG which simulates these positions and now has the capacity to load and train the muscle over time, isometrically, specifically in these positions (Figure 1.1).

• Mechanism of injury

Leonardo Bellotti

Surface Electromyography Implementation in Football Players Rehabiliation After Lower Limb Injury

Maxime Gaspar & Florian Forelli

Hamstring injury in field sports are either sprint or stretch b occur during linear acceleration or in high speed running, where stretch related injuries are seen in deceleration, lunging, landing, jumping or kicking (Gronwald et al., 2022). Running is main mechanism of injury and accounts for 48% injuries (Roe et al., 2018; Wilson et al., 2007; Askling et al., 2013) ( . If the greater number of injuries occur inn sprinting let s examine when they occur.

Implementing load in Late swing/Early stance !

HRIG isometric rehabilitation is described as a pushing isometric action (PIMA) isometric action which if moved would elicit a concentric contraction. There are two types of (PIMA) a) isometric actions maintaining average force/torque for a specified period of time expressed as a % of max force and b) quasi isometric actio isometric muscle actions requiring rapid isometric stabilisation with a gradual control/reduction in muscle force over a period of time.

• PIMA Isometrics

Time spent under load can vary between 5 isometric contractions into the program submaximal in the early stages of rehabilitation and progress to maximal repetitions. Biceps Femoris (BF) has also been shown to be maximally acti and 300 whereas the semi-membranous are maximally activated at the shorter muscle lengths with knee flexion angles of 90 stimulation of the BF as the lateral hamstrings contribute a significantly greater percent

Figure 1.1. HRIG loading similar to late swing/early stance.

Figure 1.1. HRIG loading similar to late swing/early stance.

ANTERIOR CRUCIATE LIGAMENT (ACL) SURGERY: AN INTERVIEW WITH SURGEON, ANDY WILLIAMS - PART 2

FEATURE / MR ANDY WILLIAMS INTERVIEW BY DR ELLE TREZISE

This is part 2 of 2 of a transcript of the FMPA Podcast episode that was released in March 2024. It has been edited to improve readability.

If you’d prefer to listen, episodes can be found on the FMPA website, Apple Podcasts, SoundCloud and Spotify.

In this podcast episode host Dr Elle Trezise, a medical doctor working in London and a member of the FMPA Education Team, interviews Consultant Orthopaedic Surgeon Mr Andy Williams.

Elle Trezise

It’s key to have a graft to reconstruct the ACL and it can be sourced from multiple places such as the hamstring tendon, quadricep tendon and patella tendon. Where do you personally prefer grafts to be sourced from and why?

Andy Williams

I’ve got very strong preference for the patient’s own tissue (autograft), certainly. Some surgeons are using allograft, i. e. donated tendon from cadavers just in the same way you can donate a kidney or other organ, tendon can be harvested for the purpose of reconstruction. However, the re-rupture rates are very much higher and in young patients probably around 5-7 times higher than autograft.

Synthetic ligaments were tried in the past and they did not do well within the knee joint, although they definitely have a place in extra articular ligaments, such as the medial collateral ligament. I am about to publish very good results on using synthetics there, but my strong preference for the ACL is to use autograft and I vary my graft according to the person’s sport and their lifestyle, et cetera.

For the general population, hamstring grafts work extremely well. The patients recover very easily from the harvest of the hamstring and have very good results, but the truth is that the rerupture rate is a little higher than for patella tendon, in particular. Certainly, I

saw this higher re-rupture rate in data that we published a couple of years ago.

In professional football, a hamstring graft placed in the right position has a re-rupture rate of 10% with hamstring and around 7% with patella tendon. As I mentioned earlier, if you add a tenodesis, this lateral procedure which tightens the IT band up, leaving it attached to tibia and attached to the distal femur. If you add that, it brings the re-rupture rate down to 2% if you’re using patella tendon graft.

In professional football, for some reason, patella tendon has a significantly lower re-rupture rate, and it is very obviously the best graft. It has a bit of bone at each end. It has a natural connection of soft tissue to the bone, and it will heal extremely rapidly. But you could argue the price of it is a little more; in that it’s more painful for the patient, and the rehab is a little more difficult. Obviously with pro athletes, I’m blessed to operate on really tough, really hard people because they play sports and are used to pain. They also have great physio at the clubs, and great rehab and direction from their medical teams. So, I’m blessed that I can get away with doing big operations that hurt on these people. But for my standard patients, I’ve used hamstrings.

Interestingly in professional rugby, I’ve tended to use hamstring. The reason for that is cultural, really. I went to Australia and was taught how to do hamstring ACL reconstruction, and the Australian rugby players tend to get hamstring grafts. In New Zealand, they get patella tendon. Again,

Mr Andy Williams

Dr Elle Trezise

that’s cultural because of the big-name surgeon there, Barry Tietjens, who did all the All Blacks, the best team in the world. So, you can’t knock a patella tendon graft in rugby in that setting.

You’d think the re-rupture rate in rugby would be greater in such a violent sport, but actually it’s greater in football. So, hamstring re-rupture rates are a low in rugby, particularly when a tenodesis is added.

Now, the new kid on the block, if you like, is quad tendon. Quadriceps tendon grafts are really gaining popularity, particularly in North America and in Victoria, Australia. Yet what I would say is we don’t yet have concrete data showing efficacy and satisfactory re-rupture rates. We have to watch that space carefully. I think that my ideal patient for a quad tendon graft is a person who kneels. So maybe a floor worker, carpet layer, that sort of person, or a judo fighter who has to be on their knees and has to maintain hamstring power, also dancers. I’ve routinely been using them in dancers for some time and certainly results have been very good. I believe the recovery is easier than with a patella tendon to some degree. But of course, I should say with patella tendon graft harvest, it is getting better and better, and the operation today is so much less traumatic than it was when I learned it 30 years ago.

Elle

Thank you for explaining that. It’s so interesting how the source of the tendon depends a lot on the patient. You’re tailoring it to the patient.

Andy

Yeah, I think customising surgery is really the way to go. To get great results from an operation, you have to fine tune and you don’t just do the same operation every time. You’ve really got to think. I know orthopaedic surgeons have a reputation for often not thinking. I was taught that you had to have “the strength of an ox and half the brain”, but I promise you that’s not true, and I promise you I think a lot before I operate on people. I have a ritual. The night before every surgery, I go through all the notes, all the imaging, and really think about that case.

The fine tuning is what makes the difference. You don’t win a football match or a rugby match without doing tactics and thinking about the opposition and nailing it. You also don’t just turn up and do surgery. You shouldn’t. Occasionally I think some people might do that, but it’s all about planning and there’s no excuse in orthopaedic surgery and certainly not in knee surgery to have a surprise. There are

The

key is that surgery is not undertaken until the knee is quiet.

one or two things that do happen, such as chondral lesions, which aren’t always visible on MRI. But you should know that in an ACL reconstruction case that there’s the possibility of a peripheral meniscus lesion or there’s a root lesion of the lateral meniscus even if not evident on the MRI because you’ve done the due diligence and you’ve got a surgical plan to fix all the lesions found at arthroscopy. If you don’t do that, the ACL graft takes more stress and it’s more likely to fail. So, I think we’re in an era now where we’ve worked out where to put the graft. There’s been huge debate over a long period and there was a period where understandably there was popularity for placing the graft in the centre of the so-called footprint on the femur of the ACL insertion, but actually the results were not good and my re-rupture rates in professional football doubled. That was a bad period for me. I went back to the original anteromedial bundle position on the femur. So, I think we know where to put the graft now.

We have to accept there are some limitations with grafts, but we’ve learned that we also need to deal with the peripheral lesions, the collateral damage e.g. if you leave a loose MCL, or if you leave a loose LCL, or an unstable meniscus tear, that ACL will have to work harder and is more likely to fail. So, we’re in an era now of fine tuning and that demands extra bits to the operation. My ACLs now take a lot longer than they used to. My poor anaesthetists have to suffer that, but my results are so much better.

Elle

That’s brilliant.

Andy

You did ask me a question earlier on about when to do ACL surgery and I forgot to answer it. The timing of an ACL reconstruction is important, and the terrible error is to do it too soon, and if you add

surgical trauma, and surgery is an injury, to the original injury trauma, the knee is at great risk of being excessively inflamed and scarring up and losing range of motion.

The most common complication of ACL reconstruction is loss of terminal extension, and if you operate on an angry knee as a surgeon, you’re asking for trouble. So, there are very few indications for early surgery. The only one really is in the context of an isolated ACL rupture which is a locked bucket handle tear of a meniscus. You want to get in and deal with that meniscus as soon as possible. Usually, I would then delay the ACL reconstruction for a month or two until the knee was quiet, but the key is that surgery is not undertaken until the knee is quiet. Obviously in professional sport, particularly professional football, a footballer may be earning an immense amount of money every week. The pressure from everybody to get on and do the operation is massive. But I think I’ve been around the business long enough. Most clubs listen to me and also the players. Sometimes it’s best to wait a few weeks until the knee is settled.

There are other needs though. In fact, today I operated on a guy who got injured at the weekend. So, it’s Wednesday and he did this four days ago, but his knee is quiet. He walked in without crutches. He’s got full active and passive extension and a small effusion. His knee was ready so we could crack on, but there are other guys I’ll make wait 12 weeks sometimes. Though that’s rare. We used to always wait a minimum of three weeks, but that’s not necessarily necessary. With many players we can get on with it earlier. My average time is about two weeks which is earlier than it used to be. But particularly with the general population, there is no rush. When I see somebody with a fixed flexion deformity and a surgeon asking me to sort it out, I look back at the history and the problem is almost always that the operation was done too soon.

Elle

Tell us a bit about the importance of post op physiotherapy and how you work with team physios, doctors, and other club staff to optimize outcomes for your patients.

Andy

Well, the first thing is that this is a team game and all of us in our various specialities bring something different to the table. To get a really good result from an operation, I need the help of a number of people who basically make me look good. Over the decades of me doing surgery on professional athletes, 25 years now, I’ve been blessed to have some amazing people - doctors and physios - who’ve really made me look alright, which is why I’m still in business, I think! One or two make me look bad and it’s not universally good, but in professional sport, usually I’m blessed to have expertise that not everybody has access to. So, it’s very important that I communicate properly, and we understand what’s going on and all of us have questions answered and we optimise treatments.

Now, the smart-arse answer about rehab is that it starts before the operation. For me to do an ACL reconstruction, I want the knee to have full active as well as passive extension. We used to think of passive being good enough. It’s not. You really want a good quad contraction and I want the knee quiet. In other words, little swelling. They need to be bending to at least 100 degrees or so comfortably and the knee isn’t as angry as it was. That’s when I will do the surgery and then immediately post operatively the absolute drive is twofold. One, to get the knee quiet again after the surgical trauma using various icing devices (we tend to use something called a Game Ready a lot). Also, to get the swelling down and that allows the quadriceps to start firing again and get extensions. The second thing, which is equally important, is to get

full extension as soon as possible. If you don’t get extension as soon as possible, scar builds up on the anterior surface of the ACL graft, and then you’ll never get straight. Then, the only answer would be a surgical solution which is regrettable.

If the knee won’t bend, usually all I need to do is manipulate it under anaesthetic. However, if it won’t come straight and manipulation doesn’t work, the only answer is to clear out the scar at the front of the knee, usually in the fat pad, and on the anterior graft, which is a so-called cyclops lesion. So, I clear that out and sometimes do a posterior capsule release. I used to do that through a posteromedial incision going right across the back of the knee, stripping the capsule off the bone. These days, quite frequently, I’m able to do that arthroscopically.

So, I want the physiotherapy and the rehab team to first of all understand the importance of those various goals, but then to execute the treatment that’s required. Passive stretches such as so-called prone hangs where the knee is on the edge of a couch with the leg below and foot hanging off it – are good ways of using gravity. The problem with a heel prop, where we put your heel up on something watching TV, is that within two seconds the knee tends to, or the limb tends to, externally rotate and you lose the gravitational effect. If you want to do a heel prop then you need to get the foot vertical, pointing upwards.

But all of the passive methods really are very much less important than active extension. You need to get the quad firing ASAP and the quads are grossly inhibited by swelling and pain. So, pain control is really important, and we need to nail that. Also, to reduce swelling. If you’ve got a big effusion, you can’t contract your quad. Then you have a weak quad, which means when you

If you don’t get extension as soon as possible, scar builds up on the anterior surface of the ACL graft.

walk, you have less shock absorbency, and you don’t drive the knee straight. All these things come together and work together. So, I want to get the quadriceps working.

One of the tricks is when you ask patients to straighten their knee, you’ll see them lift their buttock off the bed. What they’re doing is extending the hip with gluteal contraction. They’re using the bed to passively extend the knee. That’s not good enough. Sometimes the brain is brilliant at compromise. So, if you see that happening, I actually want the patient to lift the heel off the bed with a straight leg lift. Very slowly elevate the foot into dorsiflexion, try to get the quad to contract. If it doesn’t happen to contract, ask the patient to slowly lift the heel off the bed. That will stop the glutes working and extending of the hip because you want to flex the hip a bit. The only way of doing that is get your quad to work. So, sometimes an old-fashioned straight leg lift is actually quite important.

The other aspect to reduce the fat pad contribution to stiffness is mobility, and so patellar mobilisations are very important as well.

Elle

Based on your experience, how important is psychology and communication for improving patient outcomes?

Andy

Psychology, I suspect is 95% of my business. I’m a bit of an amateur psychologist, I guess, but showing empathy when you first meet a patient is critical. If they’re a professional athlete, they need to know that you get it, and you need to demonstrate that you realize how important this is for them and understand how devastating it is for them because they go through a classic grief type psychological reaction. You have to take them through that journey and if an athlete loses hope early on, it’s a disaster and it’s essential that I communicate in a very positive way, even if the injury is awful. There are ACLs and there are ACLs, but if you’ve got a big chunk out of your joint surface, that may be a career ending injury.

Whilst I will never lie and I always get that truth out in the first consultation, I will also explain what we’re going to do about this bad injury. I’ll say, “look, this could be career ending. However, there is treatment for this problem. I’ve had this experience many times before, and we’ve been totally successful in returning athletes to the highest levels of play despite this.”

Being positive is very important. You mustn’t lie, of course, and the player needs to know the situation in full. But the truth

is, we get people back, particularly with excellent physio and amazing people, i. e. the athletes themselves, that as a surgeon, you’re astonished they got back from. So, you shouldn’t be giving up just now. It’s not time to chuck the towel in. So, I hope I generate a very positive atmosphere, but also a very honest one and a very empathic one. That’s the beginning.

Then through the journey, the players will have issues. I think about 10 % of my ACLs have a snag along the way that needs an arthroscopy, and you need to explain what’s going on and convey confidence that all will be well. Obviously, if it’s a very serious problem and you know that they can’t recover, you’ve got to cut your losses and say it. Over the years I’ve encountered all sorts of problems. Usually, it’s pain from the fat pad or limited motion as you mentioned, and over the years you learn the solutions to these.

There are moments when I convey my confidence, although inside I’m thinking, “Christ, I’m not sure I’m going to fix this one.” But you have to have a plan and you have to be brave and you have to address the problem, take it seriously and fix it. With the athletes help, and they are amazing people, the physios help and the team physicians help, we usually get the result.

Elle

Lastly, please talk us through your approach to the following scenario. An athlete comes to you and they’ve had an ACL

reconstruction, but they’ve now suffered a re injury.

Andy

It would be a lie to say I’ve never had this scenario from my own surgery. I’m delighted, obviously, to tell you that the majority of such cases have had surgery with other people, but it’s a devastating situation for the poor athlete because they’ve been through the rehab program. They’ve worked like hell. Usually when there’s a re rupture, it occurs in the first 6 - 12 months after return to play. So, they almost get back-to-back injuries. It’s awful and they may be out of contract this time around, which is really difficult. So, as I mentioned earlier, you’ve got to show absolute empathy and you’ve got to explain what has happened, perhaps why it’s happened.

Unfortunately, we do see cases that where the initial operation wasn’t a good operation and the technical error from the surgery has led to the re-rupture. But it’s very bad to dwell on that. It creates a lot of negative psychology, but I’ll explain what’s happened why it’s happened, if I know. Often there is also bad luck, which is a commodity in professional sport that doesn’t seem to exist in most people’s opinions, but I promise you there is bad luck, and you have to offer a solution. Because the devastation of the re injury is real and big, and the athlete needs to know what you’re going to do to get them back into what they love doing, and ideally at the level that they’re happy with.

Thankfully modern surgery is very good. I’ve published data on revision ACL reconstructions in professional athletes with very high return to play rates. In fact, 90% with a primary ACL reconstruction. The return to play rate overall is just over 90%. Although in young athletes, it’s as high as 98%.

You wouldn’t get odds at the bookies that good for revisions. So, although it’s a devastating blow, thanks to modern revision surgery, most of my players will get back to the same level. So, it’s not all over and you have to encourage the right psychologies, as mentioned earlier, to get the athlete through that difficult time.

Elle

Well, that’s brilliant. Thank you. Unfortunately, we need to end there, but I found that really interesting. I’m sure the listeners have got a lot out of it as well. Thank you so much for giving up your time and for sharing your expertise with us.

Andy

Absolute pleasure. Thank you.

If you enjoyed this transcript, please subscribe to the FMPA podcast on Spotify, Apple Podcasts or SoundCloud. Alternatively, please check out the podcast section of the FMPA website. Links to any research papers or resources mentioned will be provided in the description of this podcast episode.

LOADING & PROTECTING PLAYERS –THE FUNDAMENTALS OF SPECIFICITY!

Dr Martin Mc Intyre M.MedSci., BSc., H.Dip

Identify the Problem !

An eccentrically lengthening brake driven model of hamstring function is widely accepted while it is also suggested a quasi-isometric contraction exists in which it is the ability to maintain isometric function that predisposes the hamstrings to injury (Yu et al 2017; Van Hooren and Bosch (2017). There is a debate surrounding both theories but what we do know is that late swing and early stance phase are the most hazardous for hamstring injury, where the hamstrings are most vulnerable and under the greatest stress (Liu et al., 2017). The strength of the muscle and its ability to withstand be it eccentric/isometric force in the late swing and the transition to early stance is surely the critical factor in protecting players.

SPECIFICITY & LOADING IN LATE SWING/EARLY STANCE!

Hamstring Injuries in the first half of the 23/24 season accounted for 2,319 days lost in the premier league, the greatest of all injuries (Sky sports 2023) and 13% of all players are reported to experience a hamstring issue (Maniar et al., 2023). The research indicates that the issue is getting worse with hamstring injury occurrence doubling from 12% to 24% (Ekstrand et al., 2022). It is widely debated that increases in sprinting speeds and match exposure are contributing factors. With the great advances in performance and conditioning in propelling our players to record speeds what are we missing from a performance context that is predisposing our players to hamstring risk ? Advances in screening, technology and sports science have led to the introduction of pre session screening, monitoring fatigue and recovery, but what are we missing ? We know that there are a large number of risk factors associated with hamstring injury however previous injury is still the strongest risk factor and with a relatively high reoccurrence rate what are we missing when this is the case ? Subsequently, with this is mind, one would think we need to re-examine our approach and in the spirit of one great English detective, examine the “Elemenatry” “Basic” and “Fundamental” clues to solving this case.

The Clues !

Does our current exercise prescription simulate these joint positions and what time is spent loading specifically at 30 degrees of knee flexion/time under load ? The Roman Chair Hold, Single-Leg RDL, Roman Chair Hamstring Curl are widely used to strengthen at longer muscle lengths (McAllister 2014), but do they truly simulate the biomechanical hamstring function in late swing/early stance and how effective are they when loading in the vulnerable phase of circa 30 degrees of knee flexion. Dr Martin McIntyre’s research over the last number of years has focused on spending time under load in a more specific manner, simulating running posture to either late swing or early stance. Very rarely is the position of the contralateral hip considered and it is important to do so as it better simulates the posture (200 of hip extension) while running where the contralateral or non-weight bearing limb during late swing/early stance is in 15-250 of hip extension (Kenneally-Dabrowski et al., 2019). Previous researchers have attempted to investigate this either in a

• Mechanism of injury

and Mc Call et al. (2015). This is an important consideration to testing as this would alter centre of gravity of the subject and create an extension moment around the hip more similar to running. Introducing extension (200) into the contralateral hip, the kinaesthetic feedback of subject ’s is that the hamstring became “tighter” and ‘longer”, even t hough knee angle (300 of knee flexion) of the testing limb did not change. We can speculate this maybe reflective of an increase in the intrinsic muscle tendon unit length change to that noted (112%) during the running cycle. Interestingly Dr McIntyre’s research has him to develop the HRIG which simulates these positions and now has the capacity to and train the muscle over time, isometrically, specifically in these positions (Figure 1.1)

Hamstring injury in field sports are either sprint or stretch b occur during linear acceleration or in high speed running, where stretch related injuries are seen in deceleration, lunging, landing, jumping or kicking (Gronwald et al., 2022). Running is the main mechanism of injury and accounts for 48% injuries (Roe et al., 2018; Wilson et al., 2007; Askling et al., 2013) ( . If the greater number of injuries occur inn sprinting let s examine when they occur.

Figure 1.1. HRIG loading similar to late swing/early stance.

Figure 1.1. HRIG loading similar to late swing/early stance.

greater percent (63.4%) of the total EMG than the medial hamstrings at this length (p<0.0001) (Fiebert et al., 2001).

Figure 1.2 PIMA Isometrics (63.4%) of the total EMG than the medial hamstrings at this length (p<0.0001) (Fiebert 2001).

1.2: Late Swing and Early Stance phase (Kenneally-Dabrowski et al., 2019).

• QUASI Isometrics

• QUASI Isometrics

specified period of time expressed as a % of max force and b) quasi isometric actions which are dynamic isometric muscle actions requiring rapid isometric stabilisation with a gradual control/ reduction in muscle force over a period of time.

PIMA Isometrics

• QUASI Isometrics

Time spent under load can vary between 5-40 seconds dependant on the programming of isometric contractions into the program (Figure 1.2). These contractions can be controlled submaximal in the early stages of rehabilitation and progress to maximal repetitions. The Biceps Femoris (BF) has also been shown to be maximally

Figure 1.2 PIMA Isometrics

activated in outer ranges at 15 0 and 30 0 whereas the semi-membranous are maximally activated at the shorter muscle lengths with knee flexion angles of 90 0 and 105 0 (Onishi et al., 2002). Particularly useful for stimulation of the BF as the lateral hamstrings contribute a significantly greater percent (63.4%) of the total EMG than the medial hamstrings at this length (p<0.0001) (Fiebert et al., 2001).

QUASI Isometrics

Quasi isometrics are undertaken where a maximal isometric contraction is initiated and held for a period of 3-20secs followed by, a submaximal contraction controlled over a specific period of time

(Figure 1.3). This Quasi isometric training is relatively un-researched however training the hamstrings to generate and attenuate forces has obvious benefits, particularly from a MTU perspective given the incidence of both proximal and distal intramuscular tendon issues. Furthermore Dr McIntyre has previously reported that BF fascicle length is strongly related to performance during their bilateral (r=0.442, P<0.086) and unilateral (r=0.389, P<0.136) isometric methodologies and not Nordic strength (r=0.389, P<0.136). Players producing large forces during these contractions are highly correlated with long muscle fascicles, “long and strong muscle fascicles” (Mc Intyre et al., 2023).

Quasi isometrics are undertaken where a maximal isometric contraction is initiated and held for a period of 3-20secs followed by, a submaximal contraction controlled over a specific period of time (Figure 1.3). This Quasi isometric training is relatively un-researched however training the hamstrings to generate and attenuate forces has obvious benefits, particularly from a MTU perspective given the incidence of both proximal and distal intramuscular tendon issues. Furthermore Dr McIntyre has previously reported that BF fascicle length is strongly related to performance during their bilateral (r=0.442, P<0.086) and unilateral (r=0.389, P<0.136) isometric methodologies and not Nordic strength (r=0.389, P<0.136). Players producing large forces during these contractions are highly correlated with long muscle fascicles, “long and strong muscle fascicles” (Mc Intyre et al., 2023).

Quasi isometrics are undertaken where a maximal isometric contraction is initiated for a period of 3-20secs followed by, a submaximal contraction controlled over a specific period of time (Figure 1.3). This Quasi isometric training is relatively un-researched however training the hamstrings to generate and attenuate forces has obvious benefits , particularly from a MTU perspective given the incidence of both proximal and distal intramuscular tendon issues. Furthermore Dr McIntyre has pre viously reported that BF fascicle length strongly related to performance during their bilateral (r=0.442, P<0.086) and unilateral (r=0.389, P<0.136) isometric methodologies and not Nordic strength (r=0.389, P<0.136) Players producing large forces durin g these contractions are highly correlated with long muscle fascicles, “long and strong muscle fascicles” (Mc Intyre et al., 2023).

Quasi isometrics are undertaken where a maximal isometric contraction is initiated for a period of 3-20secs followed by, a submaximal contraction controlled over a period of time (Figure 1.3). This Quasi isometric training is relatively un-researched training the hamstrings to generate and attenuate forces has obvious benefits , particularly from a MTU perspective given the incidence of both proximal and distal intramuscular tendon issues. Furthermore Dr McIntyre has pre viously reported that BF fascicle strongly related to performance during their bilateral (r=0.442, P<0.086) and unilateral (r=0.389, P<0.136) isometric methodologies and not Nordic strength (r=0.389, P<0.136) Players producing large forces durin highly correlated with muscle fascicles

• Ballistic Quasi

• Ballistic Quasi

Figure

1.3 Quasi Isometrics

These contractions are undertaken where maximal muscle contraction is achieved and held for approximately 1-2 seconds, the contraction released to approximately 50% of a maximal voluntary isometric contraction

These contractions are undertaken where maximal muscle contraction is achieved for approximately 1 -2 seconds, the contraction released to approximately 50% of voluntary isometric contraction (0.5 secs), this process is then repeated for a numb repetitions (Figure 1.4). It has been debated whether isometric contractions exist macroscopic level where muscle tendon units can shorten by up to 28% in “isometric contractions (Griffiths 1991; Rogers and Cavanagh 2005; Mademli et al 2005). This

Figure

Figure 1.3: Quasi Isometrics

Figure 1.3 Quasi Isometrics

Figure 1.2 PIMA Isometrics

isometric contractions exist at all, as at macroscopic level where muscle tendon units can shorten by up to 28% in “isometric muscle contractions (Griffiths 1991; Rogers and Cavanagh 2005; Mademli et al 2005). This HRIG Ballistic Quasi isometric function certainly supports that theory.

Ballistic Quasi Isometrics

Ballistic Quasi

These contractions are undertaken where maximal muscle contraction is achieved and held for approximately 1-2 seconds, the contraction released to approximately 50% of a maximal voluntary isometric contraction (0.5 secs), this process is then repeated for a number of repetitions (Figure 1.4). It has been debated whether isometric contractions exist at all, as at macroscopic level where muscle tendon units can shorten by up to 28% in “isometric muscle contractions (Griffiths 1991; Rogers and Cavanagh 2005; Mademli et al 2005). This HRIG Ballistic Quasi isometric function certainly supports that theory.

How does th ese fundamentals of specificity compare to running ?

• Be specific – maximise time under load at 30 0 of knee flexion and attempt to place the contralateral hip into extension.

• PIMA isometric exercises can be effective in dosing players in early stages of rehabilitation

• PIMA and Ballistic Quasi’s can be

References

effective from a performance point of view in protecting players.

• These methodologies have high levels of reliability, quick to administer, are highly correlated with muscle fascicle length and elicit EMG activity in the BF similar to running at 1.7 m/s.

Dr Mc Intyre has studied EMG levels of the HRIG and compared this to running at This testing position is biased towards the lateral hamstrings (91-100%) versus the hamstrings (76-81%) when normalising EMG levels to 1.7 m/s. He has also compared selected isometric body weight exercises and the above PIMA exercises in which hamstring activity is similar to running at this par ticular velocity (Figure 1.5).

Fiebert, I., Spielholz, N., Applegate, E., Fox, C., Jaro, J., Joel, L., Raper, L. 2001. Comparison of Emg activity of medial and lateral hamstrings during isometric contractions at various cuff weight loads. Knee, 8, 145-50.

Kenneally-Dabrowski, C., Brown, N., Lai, A., Perriman, D., Spratford, W.,Serpell, B. 2019. Late swing or early stance? A narrative review of hamstring injury Liu, Y., Sun, Y., Zhu, W., Yu, J. 2017. The late swing and early stance of sprinting are most hazardous for hamstring injuries. Journal Of Sport And Health Science, 6, 133-136

Implementing load in Late swing/ Early stance!

Dr Mc Intyre has studied EMG levels of the HRIG and compared this to running at 1.7 m/s. This testing position is biased towards the lateral hamstrings (91-100%) versus the medial hamstrings (76-81%) when normalising EMG levels to 1.7 m/s. He has also compared some selected isometric body weight exercises and the above PIMA exercises in which isometric hamstring activity is similar to running at this particular velocity (Figure 1.5).

Conclusions

• Isometric contractions are not technically “Isometric”

Mc Call A., Carling, C., Davison, M., Nedelec, M., Le Gall, F., Berthoin, S., Dupont, G. 2015. Reliability and sensitivity of a simple isometric posterior lower limb muscle test in professional football players. Journal of Sport Science, 33, 1298-304.

Onishi, H., Yagi, R., Oyama, M., Akasaka, K., Ihashi, K., Handa, Y. 2002. Emg-angle relationship of the hamstring muscles during maximum knee flexion. Journal Of Electromyography And Kinesiology, 12, 399-406

Van Hooren, B., Bosch, F. 2017. Is there really an eccentric action of the hamstrings during the swing phase of high-speed running? Part I: A critical review of the literature. Journal of Sports Science, 35, 2313-2321

Wollin, M., Purdam, C. & Drew, M. K. 2016. Reliability of externally fixed dynamometry hamstring strength testing in elite youth football players. Journal of Science and Medicine in Sport.19, 93-6

Yu, B., Queen, R., Abbey, A., Liu,, Moorman, C., Garrett, W. 2008. Hamstring muscle kinematics and activation during overground sprinting. Journal of Biomechanics. 41, 3121-6

Figure 1.4 Ballistic Quasi Isometrics

Figure 1.4

Figure 1.4: Ballistic Quasi Isometrics

How does these fundamentals of specificity compare to running ?

Dr Mc Intyre has studied EMG levels of the HRIG and compared this to running at 1.7 m/s. This testing position is biased towards the latWrings (91-100%) versus the medial hamstrings (76-81%) when normalising EMG levels to 1.7 m/s. He has also compared some selected isometric body weight exercises and the above PIMA exercises in which isometric hamstring activity is similar to running at this particular velocity (Figure 1.5).

Figure 1.5 EMG activity and HRIG specificity.

Figure 1.5 EMG activity and HRIG specificity.

Figure 1.5: EMG activity and HRIG specificity.

THERMOGRAPHY: A GAMECHANGER FOR INJURY

PREVENTION & PERFORMANCE IN FOOTBALL

FEATURE / JUAN DE LA TORRE

Introduction

Football is a dynamic sport distinguished by electrifying sprints, impactful tackles, and dynamic aerial duels. As a result, it inherently predisposes athletes to be susceptible to injuries. These injuries, characterized by their potentially debilitating effects, deal pain, compromise athletic performance and consequentially can lead to benching of players during crucial matches.

Thermography has emerged as a pioneering tool revolutionizing the landscape of football. This non-invasive modality uses infrared cameras to capture fluctuations in skin temperature, thereby unveiling physiological insights hidden under the surface.

In contrast to conventional imaging modalities that show anatomical structures, thermography highlights the physiological context of underlying tissues. Heightened temperatures mean higher blood circulation and metabolic activity which is often indicative of inflammatory processes. Conversely, regions showing lower temperatures hint at compromised blood perfusion, potentially signalling muscular dysfunction or neural impairment.

Understanding Thermography

Thermography, often associated with thermal imaging, constitutes a methodological approach grounded in infrared technology for detecting and visualizing temperature variations. This technique operates on the foundational premise that all targets emit thermal radiation, which can be captured and represented as a thermal image.

Applied to humans, skin temperature reflects the state of the underlying tissue. These images reveal temperature variations in the skin, which may indicate physiopathological conditions.

For instance, muscles under overload tend to have higher skin temperatures than muscles at rest. Conversely, when a muscle is injured, it shows a consistent drop in skin temperature for at least 15 days (Fernandez Cuevas et al., 2022).

AI: The Superpower for Personalised Insights

The integration of AI with thermography enhances its efficacy in several ways:

• Automated Image segmentation: AI algorithms proffer the capability to meticulously analyse thermal images, discern

anatomical regions and segment them in accordance with predefined areas of interest for comprehensive evaluation.

• Building Your Unique Thermal Fingerprint: By learning from existing data, AI allows the construction of individualized thermal profiles. These profiles enable the assessment of athletes’ physiological states and the tracking of their progression during the season. This facilitates targeted interventions and optimization of performance strategies.

Artificial intelligence alarm system: It can also detect patterns indicative of potential injuries or muscular overload. This approach not only results in significant time savings by reducing the assessment duration to a mere 30 seconds per player but also obviates human subjectivity, ensures heightened diagnostic precision and facilitates prompt interventions where necessary.

Applications in Football Thermography plays various roles in football, including:

• Injury Prevention: Early detection of non-contact injuries before symptoms arise allows teams to take preventive measures and avoid aggravation. Thermography helps evaluate player workload and identify areas showing thermal imbalances.

Overload not only increases injury risk but also hinders performance. Recognizing such areas allows coaches to design personalized training programs that minimize injury risk and optimise player performance.

Example 1: A football team scans its roster with thermography before the match (MD-1) to ascertain the players´s condition to compete.

Example 2: The team performs a thermographic evaluation on match day +1 or +2 to assess objectively the assimilation of loads (internal load).

If players are detected with a significant temperature difference in an area, the coaching staff can make an adaptation to reduce the workload in that area, or even to drive a more individualised treatment or recovery strategy.

• Injury follow-up: Thermography helps assess the healing process of injuries. Comparing the skin temperature of the injured area against that of a healthy contralateral area allows medical professionals to determine the progress of recovery and treatment needs.

Example: A player with an ACL injury could undergo weekly thermographic scans to monitor their progress. A gradual decrease in knee skin temperature indicates healing, while a persistent or rising temperature might suggest delayed healing or worsening of the injury. In addition to that, thermography can also provide relevant information about other areas (for instance, quadriceps, hamstrings or ankles) that might suffer because of compensation, or even lack of activity and resulting atrophy, which is also relevant information regarding the rehabilitation process.

• Fatigue identification: Robin Thorpe (director of sports performance, science, research & innovation at Red Bull Athlete Performance Center), has described the most common types of fatigue after competing: structural damage and metabolic fatigue. Both of them are recognised as fatigue, but the physiological reasons behind them are totally different (and therefore, they should be treated with different recovery strategies).

When performing a thermographic evaluation MD+1 or MD+2, it is common to find players whose bodies are warmer or cooler than his or her historical data.

Taking this information into account, it would be interesting to individualise recovery strategies according to how cold or warm the athletes are. Cold interventions should be beneficial for warmer players and warm interventions for those players who are colder.

In a Spanish LaLiga first division team, images were taken in a MD+2. It was observed, as can be seen in the image opposite, that two players who had played the same minutes and covered similar distances presented temperatures far from normal (one with a general cooling of the body and the other with a general warming up), indicating two types of fatigue with different origins.

The player with a temperature much greater than normal had played a high number of games in recent weeks and therefore his fatigue was structural (increased inflammation, overload). The player who had cooled down had travelled a few days earlier from South America (jet lag, lack of sleep) and was therefore suffering from metabolic or internal fatigue.

The recommendation for the recovery strategy of each player is different, a cooling strategy (for example cryotherapy or cold tub) would be recommended for the first player while the second player would be directed towards sauna, hot baths and diathermia.

Beyond the Benefits: Addressing the Limitations

It’s important to acknowledge the limitations of thermography to ensure its responsible and effective use. Factors like ambient temperature, clothing, and recent physical activity can influence skin temperature readings. Nevertheless, it is very important to mention that most of those factors affect our body symmetrically, so the best way to mitigate for these influences is to look for thermal asymmetries.

For example, warmer ambient temperature might raise the skin temperature, but in the same proportion on my left and right side and that is why it is more advisable to note asymmetries instead of absolute temperatures.

That being said, we strongly recommend following standardised protocols, as per the thermographic imaging in sports and exercise medicine (TISEM) consensus, to minimise the influence of external factors.

At the end of the day, we should understand infrared thermography as an excellent way of measuring the internal load. However, it is not the final solution for preventing all injuries or identifying perfectly all types of fatigue. Therefore, it is strongly recommended to start using this technology, but always combining its results and alarms with the information provided

by other technologies, such as GPS, heart rate, ERP, CK, force plates and blood analysis.

Conclusion

Thermography presents a promising future for football, offering an objective, non-invasive, data-driven approach to injury prevention, follow-up, and fatigue identification. While limitations exist,

ongoing research and technological advancements are paving the way for even greater accuracy and efficacy. As thermography continues to gain traction in the world of professional football, its potential to revolutionise injury management and enhance player performance promises to benefit not only the beautiful game but also athletes across various disciplines.

Take home messages:

• Thermography is a useful and validated tool to assess the condition of athletes.

• Well-structured data collection is essential to build a reliable thermal profile of the player.

• New technologies allow rapid and objective analysis of thermograms and these help football teams to have a detailed report on the condition of their roster.

Juan de la Torre is working as a physical therapist expert in thermography at ThermoHuman. He has worked for several years in different clinics as a sports physical therapist performing treatments for athletes of different disciplines. He is very interested in the study of the thermal behaviour of musculoskeletal pathologies. Juan graduated in physical therapy from Gimbernat-Cantabria University.

Questions or comments? Email juan.delatorre@thermohuman.com or follow him on LinkedIn, where he regularly shares thermography infographics and case studies. thermohuman.com

References

Sillero-Quintana, M., Fernández-Jaén, T., Fernández-Cuevas, I., Gómez-Carmona, P. M., Arnaiz-Lastras, J., Pérez, M. D., & Guillén, P. (2015). Infrared thermography as a support tool for screening and early diagnosis in emergencies. Journal of Medical Imaging and Health Informatics, 5(6), 1223-1228.

Côrte, A. C., Pedrinelli, A., Marttos, A., Souza, I. F. G., Grava, J., & José Hernandez, A. (2019). Infrared thermography study as a complementary method of screening and prevention of muscle injuries: pilot study. BMJ Open Sport & Exercise Medicine, 5(1), e000431. doi: 10.1136/bmjsem-2018-000431

Gómez-Carmona, P. M., Fernández-Cuevas, I., Sillero-Quintana, M., Arnáiz-Lastras, J., & Navandar, A. (2020). Infrared Thermography Protocol on Reducing the Incidence of Football Injuries. Journal of Sport Rehabilitation. doi: 10.1123/jsr.2019-0056

Thorpe RT (2021) Post-exercise Recovery: Cooling and Heating, a Periodized Approach. Front. Sports Act. Living 3:707503. doi: 10.3389/fspor.2021.707503

Cano, S. (2016). Use of infrared thermography as a tool to monitor skin temperature along the recovery process of an anterior cruciate ligament surgery. https://doi.org/10.20868/upm.thesis.41041

Fernández-Cuevas et al. (2022). Hamstring injuries in professional football players get colder. Infrared Thermography as an additional technology for return to play decisions. Conference: 27th Annual Congress of the European College of Sport Sciences ECSS. Sevilla, Spain

Haluzan D, Davila S, Antabak A, Dobric I, Stipic J, Augustin G, Ehrenfreund T, Prlic I. Thermal changes during healing of distal radius fractures-Preliminary findings. Injury. 2015 Nov;46 Suppl 6:S103-6.

We are delighted that England Men’s U21 Physiotherapist, Dave Galley will be heading up #fmpa2024 educational content.

As many of you will remember this is a fantastic venue which has hosted all but one of the FMPA Conferences over the last 10 years.

The FMPA Conference is THE medicine and performance event in the professional football calendar, combining excellence in educational content and superb networking opportunities for members and business partners alike.

The Conference this year is aimed at a wide variety of subjects to give practitioners an idea of the medical and performance aspects of our game. We will be looking at the high end performance strategies, through to how managerial changes affect us all on the Medicine and Performance side. We aim to encompass the world of the Men’s and Women’s game, Academies and also how external practitioners are currently working alongside medical departments to better serve our players. We will also cover how the world of nutrition works and how this has changed dramatically over the last few years.

We are lucky to have so many highly qualified, experienced and knowledgeable speakers and they will all come together at the end of the day as a round table to answer any of your questions

We are looking forward to, what we are sure, will be an excellent event. Join us!

THE SPEAKERS

CONFERENCE LEADS

DAVE GALLEY

England Mens U21s Physiotherapist & FMPA Conference Co-ordinator

Dave is a highly Skilled Physiotherapist with a wealth of knowledge and experience gained from working with a range of worldclass footballers and teams including a number of Premiership teams, The England National Squad and a range of International football clubs.

KEVIN PAXTON

High Performance Manager

Kevin has worked in professional sports for nearly 25 years and is a BASES High Performance Sport Accredited Practitioner, Supervisor and Reviewer with chartered scientist status and UKSCA Accredited Strength & Conditioning Coach.

Chair, Medical Advisory Group, Lord’s Ground

Simon Shepard has worked at Lord’s cricket ground for the past 30 years, firstly as a physiotherapist, then head of player health, wellbeing and sports science, before overseeing organisation development and culture.

Alongside this work he has used data (heart rate variability) to unlock a greater understanding of the way individuals are dealing with the demands of daily life.

More recently, he has turned his attention to the brain; and he has started to look at how data can lead practitioners to glean a better understanding in the event of a concussion. This has also lead to some frank personal reflection, and a commitment to what can be done to help players not just get better but return to the performance levels required for success.

Senior Physiotherapist, Women’s Super League

Ally is a senior physiotherapist currently working within the Women’s Super League. She has over 7 years experience working across men’s and women’s professional football. Her special interests are optimising female health for performance. She is currently an expert panel member with UEFA writing a consensus piece on menstrual cycle tracking in female footballers.

SIMON SHEPARD

ALLY BARLOW

CALLUM WALSH

Elite Performance Management Specialist

With over 15 years of experience in elite performance management, I have worked in several leagues and competitions across different cultures and continents, including the Premier League, Euro 2016 Championship, Championship, League 2, Turkish Super Lig, and Brazilian Serie A. I have collaborated with various coaches and stakeholders at multiple levels, from international senior and junior teams to world-leading performance institutes such as EXOS and Aspire Academy. My mission is to apply my scientific knowledge, practical skills, and cultural awareness to help athletes and teams of staff achieve their full potential.

PHIL HAYWARD

Head of High Performance, Wolverhampton Wanderers FC

Phil has vast experience as a leader in elite sport having spent 19 years in football, tennis and rugby. He started his career at Bradford Bulls before transitioning into football, initially at Bolton Wanderers before moving to Wolverhampton Wanderers in 2008. Phil progressed from Head of Academy Medical to become Head of Medical Services in 2012.

After 8 years as Head of Medical Services, Phil made the switch to the USA and Major League Soccer, becoming Director of High Performance at the most successful club in US soccer history, LA Galaxy. During this time he oversaw dramatic change across the performance and medical areas and sat on the MLS working group as the league became the first in professional sport to return to competition during the Covid pandemic, helping develop protocols for the MLS Is Back ‘bubble’ – a 6 week long residential tournament held in Orlando, FL.

After 2 years stateside, Phil returned to the UK and took up a role on the ATP Tour as performance physio for Sir Andy Murray, the greatest British tennis player of all time.

In January 2023, Phil returned to Wolves as Head of High Performance where he currently oversees all aspects of performance across Men’s, Women’s and Academy programmes.

Sponsored by

MATT KONOPINSKI

Director of Physiotherapy & Performance

Matt has extensive experience at the highest level of Mens’ Professional Football. Previous roles include Head of Physiotherapy at Liverpool, Rangers and Barnsley FC and Mens’ Team Physiotherapist at the FA. Specialising in lower limb rehabilitation Matt is passionate about human movement and it’s impact on injury and performance. His vision is to create an optimal team culture at R4P for staff and clients alike.

Sponsored by

THE SPEAKERS

PROFESSOR DON MACLAREN

Emeritus Professor of Sports Nutrition, Liverpool John Moores University

Don is an emeritus Professor of Sports Nutrition at Liverpool John Moores University (the first professor of sports nutrition in the UK), which is a testimony to his many publications on the subject in journals and books as well as his presentations at scientific and coaching conferences. He has been research active since 1980 in the fields of carbohydrate and fat metabolism, nutritional ergogenic aids, and applied aspects of sports nutrition. A consequence of the work undertaken has resulted in two prestigious fellowships being awarded i.e. FBASES and FECSS. Don has been responsible for the development of the NutritionX range of sports nutrition products. Although retired from full time duties at LJMU in 2010, Don has kept his links by lecturing to final year students and on the MSc programmes as well as helping with research ideas and projects.

JOHN LUCAS

Head of Physical Performance, Preston North End FC

John Lucas joined Preston North End in May 2022 as Head of Physical Performance.. John has previously worked at Bury FC and Plymouth Argyle enjoying promotion with both clubs. Early in his career, John spent time at Rochdale and Salford City. He also has a background of lecturing at the University of Bolton, and he has also worked with the Rugby Football Union.

DI RYDING

Former Head of Foundation and Youth Development, Manchester United FC

Diane Ryding joins us following 18 years at Manchester United FC where she was Head Physio for the Foundation and Youth Development phases.

She also worked within the NHS for 10 years specialising in Musculoskeletal physiotherapy at the Royal Bolton Hospital and is therefore experienced in managing both adult and paediatric musculoskeletal conditions.

12.35 LUNCH BREAK / EXHIBITOR DEMOS Sponsored by

FMPA CONFERENCE PROGRAMME 2024

8.30 – 10.00 REGISTRATION OPEN

9.00 MEET & GREET BREAKFAST

Network with colleagues and exhibitors. Tea/Coffee & breakfast served.

10.15 Concussion: The Role of Rehabilitation and The Importance of Responsibility

The role of rehabilitation in the management of concussion is gathering pace. No longer simply a matter of counting to ‘x’ many days and adding in some exercise, this session will look at how multimodal assessment, clinical reasoning and a targeted approach to rehabilitation may be key for both the short term and longterm health of a player and their performance. It will be frank and challenge people to consider how proactive they are in dealing with the condition.

10:50 Lessons learned from The ATP Tour

Lessons learned from the ATP Tour: A talk providing insight into life as a physio on the ATP tour with some detailed reflections and learnings from my time working with Andy Murray. How my 16 years of previous work in football helped me give a different perspective to Andy and how now, on returning to football, my work and approach has evolved as a result of experiences at the cutting edge of elite Tennis.

11.35 The applied recovery day

• The demands of a championship season

• Periodising the weekly schedule

• Incorporating recovery into what we do and how we do it.

• Are recovery protocols transferable across different clubs

• Lessons learned over a period of time and what are the key fundamentals

12.00 Why Gender Matters - Disparity Between ACL Injuries in Males and Females

Are ACL injuries an epidemic in the women’s game or are we just taking note of them now. Professionalisation and media attention surrounding women’s football is rapidly growing. The burden of injury is more important than ever to clubs and national teams. This talk will discuss the sex and gender differences between males and females particularly relating to injury and ACL injury. Specific focus will be given to the menstrual cycle and its impact on female footballers performance

Simon Shepard Chair, Medical Advisory Group, Lord’s Ground Session sponsored by:

Phil Hayward Head of High Performance

Wolverhampton Wanderers

Session sponsored by:

John Lucas Head of Physical Performance

Preston North End FC

Session sponsored by:

Ally Barlow

Women’s Team Physiotherapist

Chelsea FC

Session sponsored by:

Sponsored by

• Ballistic Quasi

Figure 1.3 Quasi Isometrics

THURSDAY 23 RD MAY

• Ballistic Quasi

13.45

These contractions are undertaken for approximately 1 -2 seconds, voluntary isometric contraction repetitions (Figure 1.4). It macroscopic level where contractions (Griffiths 1991; Ballistic Quasi isometric function

FMPA CONFERENCE PROGRAMME 2024

These contractions are undertaken where maximal 1-2 seconds, the contraction released to approximately (0.5 secs), this process is then repeated for isometric contractions exist at all, as at macroscopic 28% in “isometric muscle contractions (Griffiths This HRIG Ballistic Quasi isometric function

Tackling Academy Physiotherapy

We all know the old adage that ‘children are not mini adults’, but what does this really mean to the medical and performance team working with the youth academy player? Practical aspects of growth and maturation will be discussed along with a child-centred approach and paediatric pathology. We will consider how we optimise Academy physiotherapy over and above the standard rehab pathway, considering how we create ownership and engagement in our youth athletes. Finally, we will discuss how we can also develop our Academy therapy staff as well as our players.

14.40 Impacts of managerial change on performance support staff

– The New Manager Cycle (NMC)

– The Managers Position

– Our Position – Impact of External and Internal threat on High Performance.

– How do training and game models impact support staff and their service provision and requirements?

– Do injuries follow managers?

– How can we learn from I’m a Celebrity Get Me Out of Here?

– Why would a manager trust you

– Strategies around increasing trust and supporting transition day to day.

15.25 My Guy

There is a changing landscape in professional football. Players are seeking external service providers on a more regular basis. What are the challenges for club Medical and Performance staff? How can these be overcome? This presentation will discuss and contrast perspectives of ‘in-house’ staff versus ‘externals’. Case examples will be used to outline processes utilised at R4P to address the challenges for club staff.

16.00 Football and Nutrition: reflections on 25 years working with professional clubs

The last 25 years or so have seen some significant changes in the professional football scene within the UK.Mirroring some of these changes has been the revolution in nutrition advice to football players based on developing science. This presentation explores the adaptations that have taken place in the role of the nutrition advisor (not least the relationships between nutrition and the managerial, fitness and medical staff), significant enhancements in the so-called canteen facilities and meals presented to players, as well as the explosion of sports nutrition companies and supplements available. Some key aspects of the developing science related to football performance and recovery is also examined.

How does these fundamentals

Matt Konopinski

Director of physiotherapy & Performance, Rehab 4 Performance

Dr Mc Intyre has studied This testing position is biased hamstrings (76-81%) when selected isometric body hamstring activity is similar

Professor Don Maclaren

Professor of Sports Nutrition

Liverpool John Moores University

Session sponsored by:

16.35

THE PANEL!

All the speakers will come together to discuss points raised during the day. All Speakers

17:00 CLOSING ADDRESS

Thank you to all our trade exhibitors and sponsors.

Eamonn Salmon CEO, FMPA

Callum Walsh Elite Performance Management Specialist Session sponsored by:

Figure 1.4 Ballistic Quasi Isometrics

BREAKING BOUNDARIES IN TRAINING: OBJECTIVE MUSCLE FATIGUE MEASUREMENT FOR ATHLETE

ADVERTORIAL / MYOCENE

All physical activities lead to more or less fatigue depending on the intensity of the physical effort and its duration. This fatigue reduces the subject’s physical performance, especially when the degree of fatigue is important. Since physical fatigue is secondary to muscular exertion, it is generally called muscle fatigue.This muscle fatigue can be reflected in a decrease in physical performance. Any reduction in maximal muscle force or power output due to exercise is defined as fatigue. In research, measurement of the maximal force of a muscle is used to investigate the physiology of muscle fatigue, what leads to define muscle fatigue as a loss of maximal force generating capacity (1-2)

Central and peripheral fatigue

Physiologists describe nowadays two main kinds of fatigue (Figure 1): the central (or nervous) fatigue and the peripheral (or muscle fibre) fatigue.

The central fatigue is a diminution in the nerve impulses firing on motor-units, leading to the recruitment of less motor-units and/or at a lower frequency and consequently less muscle force generation (3)

The peripheral fatigue is a diminution of force of the muscle fibres in response to nerve impulses i.e., for a same nervous system impulses firing, the muscle produces less force output. The peripheral fatigue has two components: a short-lasting component and a long-lasting component. Short lasting fatigue is related to metabolic factors and is thus named as well metabolic fatigue. The metabolic changes during muscle exertion are

indeed important: depletion of adenosine triphosphate, phosphocreatine, or glucose/ glycogen and accumulation of metabolic products in the fibres cytoplasm can affect the function of the contractile elements.

Long-lasting fatigue

To understand the long-lasting peripheral muscle fatigue, we need to consider the force-frequency relationship, that is, the force generated by a muscle in terms of the frequency of nerve impulses. The muscle force-frequency relationship draws a sigmoid curve. At very low frequency (roughly less than 10 impulses per second) the strength developed by a muscle does not increase.

Then, at low frequency (above 10 Hz) there is a tetanus and the strength rises sharply with the frequency to reach its maximum force and a fused tetanus at high frequency (roughly above 80 Hz).

The long-lasting fatigue affects the muscle force-frequency relationship (Figure 2). The sigmoid curve moves to the right and the slope at the low frequency (roughly between 10 and 50 Hz) is significantly less sharp while at high frequencies (above 80 Hz) the force is just a little affected (4)

Therefore, the long-lasting fatigue is markedly measurable at low frequency and less at high frequency firing of nerve impulses. This is the reason why long-lasting fatigue is as well called “low frequency fatigue”.

The origin of the long-lasting fatigue or low frequency fatigue has been investigated in details. It is now well established that it is due to a reduction of Ca2+ ions released by the reticulum sarcoplasmic (RS). When an action potential is transmitted from motoneuron to muscle fibres, it propagates along the fibres membrane and the t-tubule, inducing the release from the RS of Ca2+ ions that trigger the actine-myosin cross-bridges mechanical response. As the amount of Ca2+ released from the SR into the cytosol decreases, this attenuates the binding of Ca2+ to troponin C. Fewer cross-bridges are formed between actin and myosin and consequently less force is produced by the contraction (5-6). As a matter of fact, the long-lasting fatigue is of primary importance for sport exercises.

Figure 1: The different types of muscle fatigue

Figure 2: The long-lasting fatigue is more pronounced at low frequency that at high frequency

Firstly, because it lasts for several hours or days after the muscle exertion. But as well because it moves the steep part of the force-frequency curve to the right causing a significant reduction in the force of contraction and needing the central nervous system to compensate partly by increasing the firing frequency of the motoneurons. Therefore, it is a fundamental parameter closely linked to sports performance and it needs to be precisely monitored.

Monitoring of muscle fatigue in athletes

Up until this point, conditioning teams have had to assess the internal load, i.e. how the athlete body reacts physiologically to the workload of competitions and trainings, either based on subjective perception of fatigue expressed by the athlete on an analog scale, or based on performance tests which depend on the commitment and voluntary movements of the athlete.

On the other hand, wearable technologies like GPS in collective sport or power meters in cycling allow to accurately measure the external load, i.e. the amount of work performed, which can be evaluated with the total distance run, number of meters at max speed, number of accelerations and decelerations of the player during the game or the watts developed by the cyclist. However, Strength and Conditioning coaches miss objective data to monitor the internal load.

On-field measurement of long-lasting fatigue

The Myocene has been developed and designed to be an on-field device to objectively measure the long-lasting fatigue of the quadriceps. The device combines a neurostimulator that allows to produce perfectly quantified muscle contractions on the quads of both legs of the athlete and a sensor specifically developed to register very accurately the force variations of the quadriceps in response to these contractions. The fatigue index is then calculated by a specific algorithm using the forces values recorded by the sensor. The Myocene device has been scientifically validated by renowned universities to confirm reproducibility, repeatability and sensitivity of the measurement, as well as correlation

medicine & performance football

CASE STUDY: MATCHDAY + 1 RECOVERY ASSESSMENT

Post-game fatigue measurement to individually adapt the recovery period and related recovery modalities allows to ensure full recovery before resuming the training. This image shows matchday + 1 fatigue index values (right leg in orange and left leg in blue). For the first two matches, the player fully recovered. After the third match, the fatigue index is decreased: the player did not fully recover from the game. The recovery modalities were enhanced and the player did not train on the pitch with the team on that day.

with traditional laboratory techniques used to evaluate the muscle fatigue (7)

The game changer aspect of Myocene is the objectivity of the measurements it creates. The portability of the technology and how quickly data is generated are great assets for performance team. It is a unique technology which allows to realistically check and monitor muscle fatigue without having to use physical movement of the athlete.

The fatigue index is instantly available, allowing the performance team to see the true individual picture of how that athlete is recovering from muscle fatigue. In football for instance, by comparing the fatigue index taken in a post training or game condition to a rest condition index, the fatigue can be quantified and monitored till the player has fully recovered. In congested period for instance, several consecutive decreased fatigue indexes are a sign of an accumulated fatigue and incomplete recovery, which can lead to overtraining syndrome and increased risk of injuries.

In conclusion, the Myocene is a portable datagenerating device which allows conditioning coaches to be able to very quickly assess the muscle readiness. This unique technology removes the subjective perception or voluntary action element of the measurement of the internal load.

With manageable test times and instant access to performance data, coaches can make quick decisions based on accurate and objective data to reduce muscle fatigue as a factor in future games and trainings.

References

1. Merton, P.A. (1954) Voluntary strength and fatigue, J. Physiol. Lond., 123: 553–564.

2. Ciba Foundation symposium 82, Human muscle fatigue: physiological mechanisms, Pitman Medical Ltd 1981 ISBN 0 272-79618-2

3. WNLöscher,AGCresswell,AThorstensson(1996) Central fatigue during a long-lasting submaximal contraction of the triceps surae. Exp Brain Res(1996) Mar;108(2):305-14

4. S A Binder-Macleod, L R McDermond (1992) Changes in the force-frequency relationship of the human quadriceps femoris muscle following electrically and voluntarily induced fatigue. Phys Ther 1992 Feb;72(2):95-104.

5. Simeon P Cairns, Luke A G Inman, Caroline P MacManus (2017) Central activation, metabolites, and calcium handling during fatigue with repeated maximal isometric contractions in human muscle. Eur J Appl Physiol 2017 Aug;117(8):1557-1571.

6. ChristopherA.Hill,MartinW.Thompson,PatriciaA. Ruell, Jeanette M. Thom, Michael J. White (2001) Sarcoplasmic reticulum function and muscle contractile character following fatiguing exercise in humans. Journal of Physiol (2001), 531.3, pp.871–878

7. Ridard J, Rozand V, Millet GY and Lapole T (2022), On-field low- frequency fatigue measurement after repeated drop jumps. Front. Physiol. 13:1039616. doi: 10.3389/fphys.2022.1039616

COPING WITH THE HEAT WHILE PLAYING FOOTBALL: CHALLENGES AND POTENTIAL SOLUTIONS

FEATURE / GEORGE NASSIS, PHD, MBA

Introduction

Playing football in the heat can be a challenge for the players’ health and performance, and this is due to the rise in internal body temperature (Nybo et al., 2017). It seems that more matches will be played in the heat in the future, including the 2026 FIFA World Cup (Gouttebarge et al., 2023; Nybo et al., 2021) and this calls for searching for potential solutions to mitigate the effects of heat on players’ health and performance. This article focuses on the cooling techniques that can be applied before and during the match with the aim to provide practical solutions.

Why playing football in the heat is a challenge

Playing football in the heat will raise the internal body temperature at a higher rate compared with when playing in a thermoneutral environment and this

may compromise the players’ health by elevating the risk of heat illness and affect their performance in a negative manner (Brito et al., 2014; Nybo et al., 2017). Ozgunen et al. (2010) reported an internal body temperature of 39.6 oC with individual values around 40.2 oC while playing football matches at temperatures between 34 oC and 36 oC. Likewise, Mohr et al. (2012) reported internal body temperatures of 39.6 oC when playing football at an air temperature of 42 oC. The detrimental effects of heat on health and performance will be greater in the presence of significant fluid loss due to sweating (Periard et al., 2021). The degree of the potential negative effect of heat on performance could vary depending on the level of football players. For example, elite football players seem to cope with the heat by adjusting their running pace in order to maintain some key performance

indicators (Nassis et al., 2015). We speculate that this may not be the case with less experienced players and with young players.

How to combat the heat when playing football

The top two priorities to effectively prepare players for playing matches and training in the heat are acclimatisation and hydration (Adams et al., 2016; Racinais et al., 2015). Precooling and midcooling strategies can also help in reducing the rate of internal body temperature rise (Nassis et al., 2024). In football, there are three windows for cooling during the game; the two cooling breaks around the 30th and 75th min of each half and the halftime. The cooling breaks last three minutes each whereas the effective time for cooling during the halftime is between 5 and 10 min. This

timeframe limits the available solutions that can be used to effectively lower the internal temperature.

The strategies that can help players cope with the heat are presented below in their order of effectiveness in lowering the internal body temperature:

• Heat acclimatisation (training outdoors) and heat acclimation (training in an artificial environment). The goal is to maintain the internal body temperature in the range 38.5 to 39.8 oC for at least 60 min of training. To maximize the benefits the teams should perform 10-14 sessions in the heat (Sekiguchi et al., 2021).

• Hydration. Fluid losses beyond 2% of body mass may have detrimental effects on performance (Periard et al., 2012) and should be avoided. Players should ingest enough fluids (water or sports drinks) before and during competition. To educate the players on the proper hydration before competition, practitioners can regularly check their body weight and/or the urine specifc gravity and colour and make them aware about the results (Sekiguchi et al., 2019).

• Application of precooling and midcooling techniques. In an ideal scenario, the cooling strategy can include a combination of precooling and midcooling techniques. Cooling before exercise will decrease the internal body temperature at the beginning of exercise and will result in a greater temperature gradient before performance is negatively affected. Evidence shows that partial-body and whole-body cold-water immersion is the most effective method in reducing internal body temperature (Adams et al., 2016; Table 1). Consideration should be given not to decrease the internal temperature too much as this may have a negative impact on performance. When cold-water immersion is impractical, the combination of head and hand cooling with the application of an ice towel to

cover the head and neck and the hands immersed up to the wrist in containers of cold water may help in reducing the internal body temperature (Minnet et al., 2011). This strategy may be more effective when applied both before the match and during halftime (Minnet et al., 2011).

Potential solutions during halftime

• Cold-water immersion is the most effective strategy in combination with hydration. Cold-water immersion can result in a decline of internal body temperature in the range of 0.25-0.35 °C per minute (Adams et al., 2016). However, this technique may be impractical in some cases and it is also associated with cost. Proper rehydration is also a key strategy for halftime cooling (Table 2). The ingestion of ice-slushy drinks can help too (Adams et al., 2016).

• The application of ice towels to cover a large body surface is the next most effective option and it may result in a decline of internal body temperature at a rate of 0.1°C per minute (Adams et al., 2016).

Potential solutions during the 3 min cooling breaks

During these breaks, which are called when Wet Bulb Globe Temperature (WBGT) reaches 32 oC, the practitioners should focus on:

• Hydration and cooling: provide players with enough chilled water either alone or in combination with the application of ice towels applied around the neck (Chalmers et al., 2019) or on a large body surface.

• Reducing the players thermal sensation and discomfort due to heat: various techniques such as ice towel application around the neck and on large body surface, head and hand cooling (Zhang et al., 2014), skin wetting and fan use can help in reducing the players skin temperature and this will make them feel better for the next few minutes of the match.

• Fan and wet sponge use: When the above techniques are impractical, pracitioners could consider the use of fan and wet sponges applied to the skin of face, neck, arms and thighs in 1 min intervals for the 10 min of the 15 min of halftime (Osakabe et al., 2021). These techniques may improve the perception of feeling cool but have poor cooling rate.

Table 1: Advantages and disadvantages of the precooling techniques suggested for football players. The techniques are presented in the order of their potential capacity to lower the internal body temperature.

Technique

Partial-body or whole-body cold water immersion

Cold water consumption

Wearing ice/cooling vest

Advantages

Effective in lowering internal body temperature

Practical, effective in lowering internal body temperature, low cost

Practical

Disadvantages

Low practicality, relatively high cost

Some players may not like drinking high volume of cold water

Contradictory evidence regarding its cooling efficacy, high cost

Table 2: Advantages and disadvantages of the midcooling methods (applied during halftime and the 3 min cooling breaks) suggested for football players. The techniques are presented in the order of their potential capacity to lower the internal body temperature.

Method

Partial-body or whole-body cold water immersion

Hydration

Application of cold or ice towels to cover a large body surface

Ingestion of ice-slushy drinks

Various strategies to reduce thermal sensation during the 3 min break (i.e. application of wet towels, hand/forearm cooling, fan use and application of wet sponges on the body)

Conclusions and the solution framework

Based on the available evidence, below is a summary of the main points the practitioners and coaches could consider while preparing their players for playing matches in the heat:

• Estimate the heat stress index in advance. This will help in building the best-fit strategy for cooling. To approximate the heat stress index, one can use the weather forecasts. For a long-term evaluation of weather conditions, practitioners may check the historical data for the match location (Nassis and Geladas, 2002).

• Keep humidity levels low in the dressing room before the game and during the halftime. This will ensure a large internal to skin temperature difference which is essential for heat dissipation. To create an atmosphere with low relative humidity in the room, you can use ceiling fans and dehumidifiers. Avoid the use of hot baths which can elevate the relative humidity in the dressing room.

• Consider combining precooling and midcooling techniques as this may be more effective.

• The decision on what specific cooling techniques to use depends on the timing, the practicality of the technique, the physical space and the manpower available to support.

• Safety of players is key. Consideration should be given to the techniques that improve the perception of feeling cool while they have no effect on internal body temperature. Players who underestimate their heat stress level or fail to recognize the early signs of heat illness

Advantages

Effective in lowering internal body temperature

Practical, effective in lowering internal body temperature, low cost, can be applied both during halftime and 3 min cooling breaks

Practical, effective in lowering internal body temperature, low cost, can be applied both during halftime and 3 min cooling breaks

Practical, effective in lowering internal body temperature, low cost

Low cost

may be at a higher risk of experiencing heat illness (Adams et al., 2016).

• Engage players and coaches. Ask players about their preferences and work with them in finding the best-fit solutions. You may also need to work with the coaches and engage them with the strategy (Nassis et al., 2023; Nassis, 2017).

Disadvantages

Low practicality, relatively high cost, can only be applied during halftime

Limited amount of fluids can be consumed before some players experience gastrointestinal discomfort

Relatively limited evidence

Some players may not like ice ingestion

Poor cooling rate

• Test your strategy beforehand. Apply your strategy during training before executing it in the game.

• For youth matches, the organizers should consider lowering the WBGT threshold for the implementation of the cooling breaks and provide more frequent rehydration opportunities.

Dr. George Nassis is the Chair at the Physical Education Department at the United Arab Emirates University. Previously, he was the International Director of the High-Performance Support Team with the Chinese Olympic Committee and the Chinese Institute of Sport Science. He has extensive experience in football as an applied sport scientist and manager of projects. He was the director of sport science lab at Panathinaikos FC for a number of years. George has published more that 100 articles and has been included in the Stanford University list of top 2% most cited scientists. He is also ranked 8th in the list of experts in football (soccer) worldwide. In addition to his MSc and PhD degrees, George holds an MBA. His MBA and his extensive experience in the industry have shaped his approach towards seeking practical solutions for everyday life problems in football. Contact: georgenassis@gmail.com

References

Adams WM, Hosokawa Y, Casa DJ (2016). Body-cooling paradigm in sport: maximizing safety and performance during competition. J Sport Rehabil 25:382-394. doi: 10.1123/jsr.2015-0008

Brito J, Racinais S, Nassis GP (2014). The second Summer Youth Olympic Games in Nanjing, People’s Republic of China: preparing youth athletes to compete in the heat. Open Access J Sports Med 5:205-207. https://doi.org/10.2147/OAJSM.S70278.

Chalmers S, Siegler J, Lovell R, et al. (2019). Brief in-play cooling breaks reduce thermal strain during football in hot conditions. J Sci Med Sport 22(8):912917. doi: 10.1016/j.jsams.2019.04.009

Gouttebarge V, Duffield R, den Hollander S, et al. (2023). Protective guidelines and mitigation strategies for hot conditions in professional football: starting 11 Hot Tips for consideration. BMJ Open Sport Exerc Med 21;9(3):e001608. doi: 10.1136/bmjsem-2023-001608.

Minett GM, Duffield R, Marino FE, et al. (2011). Volume-dependent response of precooling for intermittent-sprint exercise in the heat. Med Sci Sports Exerc 43(9):1760-1769. doi: 10.1249/MSS.0b013e318211be3e

Mohr M, Nybo L, Grantham J, Racinais S (2012). Physiological Responses and Physical Performance during Football in the Heat. PLoS One 7:e39202. https://doi.org/10.1371/journal.pone.0039202

Mohr M, Krustrup P, Nybo L, Nielsen JJ, Bangsbo J (2004). Muscle temperature and sprint performance during soccer matches-beneficial effect of rewarm-up at half-time. Scand J Med Sci Sports 14:156-162. https://doi.org/10.1111/j.1600-0838.2004.00349.x

Nassis GP, Girard O, Chiampas G, Krustrup P, Racinais S (2024). In-match strategies to mitigate the effect of heat on football (soccer) players’ health and performance. Br J Sports Med Online First: 08 March 2024. doi: 10.1136/bjsports-2023-107907

Nassis GP, Verhagen E, Busch H, Krustrup P (2023). Looking for better science communication? Do it like the Harvard Business Review. BMJ Open Sport Exerc Med 13:9(2):e001611. https://doi.org/10.1136/bmjsem-2023-001611.

Nassis GP (2017). Leadership in science and medicine in football: can you see the gap? Sci Med Footb 1(3):195-196. https://doi.org/10.1080/24733938.2 017.1377845

Nassis GP, Brito J, Dvorak J, Chalabi H, Racinais S (2015). The association of environmental heat stress with performance: analysis of the 2014 FIFA World Cup Brazil. Br J Sports Med 49: 609-613. https://doi.org/ 10.1136/bjsports-2014-094449

Nassis GP, Geladas ND (2002). Potential stress due to environmental conditions in the 2004 summer olympic games. J Hum Environ 6(1):39-45. https://doi.org/10.1618/jhes.6.39

Nybo L, Flouris AD, Racinais S, Mohr M (2021). Football facing a future with global warming: perspectives for players health and performance. Br J Sports Med 55(6):297-298. https://doi.org/10.1136/bjsports-2020-102193.

Nybo L, Nassis GP, Racinais S (2017). Soccer in the heat – impact on physiological responses, match-play characteristics and recovery. In: Bangsbo J, Krustrup P, Hansen PR, Ottesen L, Pfister G, Elbe AM (editors) Science and Football VIII: The Proceedings of the Eighth World Congress on Science and Football, Routledge, London, pp. 94-104.

Osakabe J, Yamamoto M, Matsumoto T, et al. (2022). Addition of In-Play Cooling Breaks During Intermittent Exercise While Wearing Lacrosse Uniforms in The Heat Attenuates Increases in Rectal Temperature. J Hum Kinet 26;82:111-121. doi:10.2478/hukin-2022-0037

Ozgunen KT, Kurdak SS, Maughan RJ, Zeren C, Korkmaz S, Yazici Z, Ersoz G, Shirreffs SM, Binnet MS, Dvorak J (2010). Effect of hot environmental conditions on physical activity patterns and temperature response of football players. Scand J Med Sci Sports 20 (Suppl 3):140-147. https://doi. org/10.1111/j.1600-0838.2010.01219.x.

Périard JD, Eijsvogels TMH, Daanen HAM (2021). Exercise under heat stress: thermoregulation, hydration, performance implications, and mitigation strategies. Physiol Rev 101(4):1873-1979. https://doi.org/10.1152/physrev.00038.2020.

Racinais S, Alonso JM, Coutts AJ, Flouris AD, Girard O, Gonzalez-Alonso J, Hausswirth C, Jay O, Lee JKW, Mitchell N, Nassis GP, Nybo L, Pluim BM, Roelands B, Sawka MN, Wingo JE, Périard JD (2015). Consensus recommendations on training and competing in the heat. Scand J Med Sci Sports 25 (Suppl 1):6-19. https://doi.org/10.1111/sms.12467

Sekiguchi Y, Benjamin CL, Giersch GEW, et al. (2021). Practical implementation strategies for heat acclimatization and acclimation programming to optimize performance. Athletic Training & Sports Health Care13(4):e238-e246

Sekiguchi Y, Adams WM, Curtis RM, Benjamin CL, Casa DJ. (2019). Factors influencing hydration status during a National Collegiate Athletics Association division 1 soccer preseason. J Sci Med Sport 22(6):624-628. doi: 10.1016/j.jsams.2018.12.005.

Zhang Y, Nepocatych S, Katica CP, Collins AB, Casaru C, Balilionis G, Sjökvist J, Bishop PA (2014). Effect of Half Time Cooling on Thermoregulatory Responses and Soccer-Specific Performance Tests. Monten. J Sports Sci Med 3(1):17-22.

DON’T FORGET TO LOOK UP HIGH! ASSESSMENT OF ANKLE SYNDESMOSIS INJURIES

FEATURE / ADAM JOHNSON

Introduction

Syndesmosis injuries represent one of the most challenging rehabilitation cases that present within the ankle complex. Early recognition and correct management of these injuries is vital if a positive rehabilitation outcome is to be achieved. This initial article will look to review all elements of the ankle syndesmosis injury, from anatomy and diagnosis to classification of injury.

Anatomy

The distal ankle syndesmosis is comprised of three major ligamentous structures which provide approximately 90% of the total resistance to lateral fibular displacement1;

• Anterior Inferior Tibiofibular Ligament (AITFL)- The AITFL is a trapezoidal ligament comprised of three bundles2 which runs from it’s thickest point on the tibia to approximately 3cm above the lateral malleolus of the fibula.

• Posterior Inferior Tibiofibular Ligament (PITFL)- As with the AITFL, the PITFL is also trapezoidal in shape, with the thickest part of the ligament originating at the tibia and also attaching approximately 3cm above the lateral malleolus, but as suggested by the name, the ligament runs from the posterior aspect tibia to the fibula. The PITFL is a slightly thicker ligament than the AITFL2

• Tibiofibular Interosseous Ligament (TFIL)- The TFIL is a much shorter ligament than the other two ligaments, and being pyramidal is also different in shape. It originates on the medial aspect of the distal fibular shaft and inserts on the lateral surface of the distal tibia. It’s different shape and structure is likely due to its role as a “spring” which allows for slight separation of the medial and lateral malleolus during ankle dorsiflexion1

Although these are the three primary ligaments of the syndesmosis it is important to understand that there are other ligamentous structures contributing to stability of the syndesmosis. The true contribution and reasoning behind that will be discussed later in the article, but for now it is important to be aware of basic deltoid ligament anatomy (Figure 2);

• Superficial Deltoid- Comprised of four distinct bands- Tibionavicular, Tibiospring, Tibiocalcaneal & Superficial Posterior Tibiotalar Ligaments. Primarily responsible for resisting eversion of the hindfoot.

• Deep Deltoid- Formed of the deep anterior and deep posterior tibiotalar ligaments. These structures are perhaps more relevant to the syndesmosis, as their primary functional role is to provide primary resistance to external rotation of the talus.

Figure 1: Ligamentous anatomy of the distal tibiofibular joint. Taken from Norkus & Floyd (2001)

Mechanism of Injury

The literature would suggest that there is a primary mechanism of injury which should heighten the index of suspicion around potential syndesmosis injuries1;

• Dorsiflexion and External RotationThis combination of movements is achieved when a player is tackled or fallen upon. As the ankle is taken into dorsiflexion the anterior portion of the talus is wedged between the medial and lateral malleoli. Since this anterior portion of the talus is wider than the posterior aspect there is an increase in the joint surface contact. This increase is absorbed by the spring like mechanism of the TFIL in normal conditions. However, with the addition of a forced external rotation mechanism, this wider anterior talus will laterally rotate and so result in a further widening of the ankle mortise, which if performed under great enough force will result in injury to the ligamentous structures of the syndesmosis.

Diagnosis- Objective Assessment

As explained above, the subjective assessment surrounding mechanism of these injuries will give some guidance towards the potentially injured structures as the mechanism will differ to the classic lateral ankle ligament injury which is sustained with an inversion mechanism. This section will look to outline the objective tests3 which are available to rule in/out a syndesmosis ankle injury;

• Palpable Tenderness- Systematic Review literature3 would suggest that palpable tenderness of the syndesmosis ligaments is the most sensitive diagnostic test in the identification of syndesmosis injury, meaning that if there is no palpable tenderness over the syndesmosis then it is unlikely there is an injury in the area. This achieved a sensitivity of over 75% and highlights the importance of a good understanding of the anatomy of the area if a correct diagnosis is to be achieved. It is also

suggested that the higher the palpable pain continues to be present, the more severe the injury, with greater interosseus membrane involvement4

• Squeeze Test- If palpable tenderness is the most sensitive diagnostic test, it is reported that the squeeze test is the most specific of the special tests for the ankle syndesmosis. The test is performed by applying compression to the proximal tibia and fibula. The aim being to induce separation of the two bones distally, which will in turn stress the ligaments of the syndesmosis whose role is to prevent this separation.

• Lunge & Compression Test - With the patient in a maximal lunge position on the injured side the therapist performs a manual compression of the distal tibia and fibula to attempt to recreate the support provided by an uninjured syndesmosis. A positive test is seen as either an increase in range of movement, or a decrease in pain when the manual compression is applied.

Figure 2: Illustration of the distinct bands of the deltoid ligament of the ankle. Taken From Campbell et al. (2014)

Table 1: Modified West Point Classification Criteria. Taken From Wever et al. (2022)

• Combined Dorsiflexion & External Rotation (Frick) Test - The patient’s leg is placed off the edge of the bed with the knee in ninety degrees of flexion before the therapist provides a combined forced dorsiflexion and external rotation stress. This test demonstrated the highest diagnostic accuracy with moderate to good sensitivity and specificity. Of the four clinical tests within this section, this was suggested to have the lowest diagnostic accuracy3

In summary there is not one objective diagnostic test that can be utilised to either confirm the presence or absence of a syndesmosis injury. For this reason, it is important for therapists to utilise all of the tests in combination to try

and support a diagnosis that may be suggested by the patient’s subjective diagnosis.

Diagnosis- Imaging

Due to the lack of high-quality objective assessment testing, it is important to utilise imaging in order to confirm a suspected syndesmosis injury. This section will look to discuss four different imaging modalities and the reasoning behind each choice.

• X-Ray- The initial reasoning behind utilisation of a standard X-Ray is that syndesmosis injuries are commonly associated with distal fibula fractures, and so this choice of imaging would allow for exclusion of this association injury. Secondly it is possible for radiologists to perform a weight-

bearing X-Ray which allows for analysis of the gapping of the distal tibia and fibula under stress. It is proposed that a tibiofibular clear space of greater than 6mm at 1cm proximal to the tibial plafond is suggestive of syndesmosis pathology2

• CT- Like X-Ray, it is suggested that CT imaging should be completed in a weight-bearing setting. This will allow for clear measurements of the tibiofibular gapping and translation of the fibula.

• Ultrasound - This imaging modality is sometimes more easily accessed and cheaper to perform which makes it a useful choice in other ankle ligament injury diagnoses, however within the imaging of the syndesmosis it is less useful. Visualisation of the AITFL is

Injury Grade Definition

I Isolated injuries to the AITFL

II Injury to the AITFL, interosseous ligament, and interossesous membrane

III Injury to the AITFL, interosseous ligament, and interossesous membrane and PITFL

IV Injury to the AITFL, interosseous ligament, and interossesous membrane, PITFL, and deltoid ligament

possible on the ultrasound, however it is not possible to visualise the PITFL or TIFL and so should not be the imaging of choice if suspecting an injury in this area2

• MRI - This is the imaging modality of choice when suspecting syndesmosis injury as it demonstrates good sensitivity and specificity for these injuries. MRI allows for visualisation of other structures and associated lesions in the area that may occur secondary to the high trauma mechanism on injury such as bone bruising or osteochondral lesions.

Classification of Injury

When looking to make the correct decisions surrounding management of these injuries it is important to correctly classify the injury, but this remains challenging as some classifications such as the Sikka classification rely solely on MRI imaging, which not all clinicians will have access to4. However, in the context of this article looking at the management of these injuries in elite football below is a summary of the two most commonly utilised classification systems;

References

• Modified West Point ClassificationThis is a three-point grading classification system which was recently modified5 (Table 1) to combine both radiological findings with objective assessment in order to more specifically categorise the challenging Grade II injuries into stable or unstable. This is an important distinction to make when moving forward with management decisions.

• Sikka Classification- This is a fourgrade classification system which relies wholly upon MRI imaging to make a diagnosis. This system (Table 2) grades the injury upon the exact structures involved, and so as the increased number of structures are involved, so is the proposed instability of the ankle.

Summary

• Ankle syndesmosis injuries pose a challenge to clinicians working within the elite football setting due to their potential to result in long term disability and substantial time loss.

• Due to inadequacies with objective tests for this injury it is vital that practitioners utilise a full battery of tests to either prove or disprove their initial suspicions surrounding diagnosis.

• In relation to current injury grading systems, it is important to try and obtain MRI imaging to understand the significance and exact structures involved before clinical management decisions can be made.

Adam Johnson is a Physiotherapist with 13 years of full time experience working within professional football. Throughout this time he has been heavily involved within short, to medium-term rehabilitation cases which has driven an interest in the literature surrounding muscle and ligamentous injuries. Alongside his day-to-day work Adam has also been able to get three articles published in peer-review journals.

1. Norkus, S.A. & Floyd, R.T. (2001). The Anatomy and Mechanisms of Syndesmotic Ankle Sprains. Journal of Athletic Training, 36(1), 68-73.

2. Tourne, Y., Molinier, F., Andrieu, M., Porta, J. & Barbier, G. (2019). Diagnosis and treatment of tibiofibular syndesmosis lesions. Orthopaedics & Traumatology: Surgery & Research, 105, S275-S286.

3. Sman, A.D., Hiller, C.E., Rae, K. et al. (2015). Diagnostic accuracy of clinical tests for ankle syndesmosis injury. British Journal of Sports Medicine, 49, 323-329.

4. van Dijk, C.N., Longo, U.G., Loppini, M. et al. (2016). Classification and diagnosis of acute isolated syndesmotic injuries: ESSKA-AFAS consensus and guidelines. Knee Surgery, Sports Traumology, Arthroscopy, 24, 1200-1216.

5. Calder, J.D., Bamford, R., Petrie, A. & McCollum, G.A. (2016). Stable Versus Unstable Grade II High Ankle Sprains: A Prospective Study Predicting the Need for Surgical Stabilization and Time to Return to Sports. Arthroscopy, 32(4), 634-642.

6. Wever, S., Schellinkhout, S., Workman, M. & McCollum, G.A. (2022). Syndesmosis injuries in professional rugby players: associated injuries and complications can lead to an unpredictable time to return to play. Journal of ISAKOS, 7(4), 66-71.

7. Sikka, R.S., Fetzer, G.B., Sugarman, E. et al. (2012). Correlating MRI Findings with Disability in Syndesmotic Sprains of NFL Players. Foot & Ankle International, 33(5), 371-378.

Table 2: Illustration of the distinct bands of the deltoid ligament of the ankle. Taken From Campbell et al. (2014)

THE ROLE OF THE PHYSIOTHERAPIST IN SERIE A: IS REHABILITATION FOR ELITE ATHLETES ALWAYS AS SIMPLE AS IT APPEARS?

FEATURE / LEONARDO BELOTTI

Modern football injuries, thanks to the help of social media and the media, are a highly debated and widely disseminated topic which attracts the interests of many health professionals: from sports doctors to physiotherapists, from surgeons to movement and body scientists rehabilitation, psychologists, nutritionists, mental coaches, personal trainers, podiatrists and all health assistants who in one way or another can contribute to the best 360° well-being of our athletes.

Those who observe this world from the outside, those who come from other sports, might think that football players, having everything at their disposal with an unlimited budget and staff, can have the best results following an injury and follow a linear rehabilitation path that is easier to manage compared to a non-footballer, but is it always that simple?

From my ten-year experience in Italian football as a physiotherapist, the management of a high-level athlete is not at all trivial or obvious. We must, first of all , analyse the figure of the player within this context from a psychological point of view. The footballer is a role that is subjected to many pressures inside and outside the club on a daily basis, a role in which every day they are required to always be in the best physical condition so as not to risk losing their place on the pitch to one of their teammates or in order not to compromise their performance level, a role in which external people try to give advice that is not always requested, often negatively influencing our athletes’ thinking.

On a daily basis I deal with the management of unlucky athletes

within my Club (first team in Serie A). My work team is made up of 3 other physiotherapist colleagues, one of whom has the role of Head of Physiotherapist, with the role of making decisions regarding physiotherapy treatments and the scheduling of home matches or away and to choose the rehabilitation program for each athlete together with the Medical Officer in Charge.

In addition to the group of my colleagues, there are 2 doctors specialised in Sports Medicine with many years of experience in the world of football and rehabilitation, an athlete trainer (graduated in motor sciences) who takes care of the work in the gym and on the field, a data analyst who monitors the workload with GPS systems to optimise the management of the RTP of our athletes every time they train

on the playing field, and finally a head of performance who takes care of the final and fundamental part of the RTP to ensure the player is ready to fully return to the demands of participation of professional football.

Information is exchanged between the multidisciplinary team and coaching staff to guide the structured rehabilitation programme for the individual players.

Return to training is managed with technical/tactical exercises with and without the ball, with high-speed runs or changes of direction to conclude with specific gestures and small sided games before returning to training with the group.

My role as a Physiotherapist becomes indispensable in the rehabilitation process of an athlete immediately post-injury. We spend most of the time, initially, with the injured player and can monitor physiological as well as psychological well being throughout the rehabilitation process. We then work with the coaching and conditioning staff to transition them from the physiotherapy room back out onto the pitch and returning to full training.

The fundamental points that a sports physiotherapist must have to work best in my opinion are:

• Respect the biological times of each injury, knowing in depth the anatomy, physiology, and psychology of each athlete.

• Respect the hierarchies, roles, tasks, and functions of each figure within the club.

• Monitor the objectives to be achieved, physical responses and progression criteria on a daily basis.

• Apply your knowledge and skills in agreement with the healthcare manager

Leonardo Belotti has been working as a physiotherapist in the world of football for 10 years. He obtained my Bachleor’s degree in physiotherapy in Pavia in 2013 and immediately started working in the third division of Lega Pro. Subsequently, he started working in one of the best youth football development sectors in Italy. 5 years ago Leonardo landed the role as first team physiotherapist with a Serie A club. He has also obtained a second degree in Motor Sciences to specialise more in the recovery of injured players. Finally, Leonardo believes that a physiotherapist in the world of football must be multifaceted and ready to adapt to dynamics that continually change during the sporting season.

Respect the biological times of each injury, knowing in depth the anatomy, physiology, and psychology of each athlete

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SURFACE ELECTROMYOGRAPHY IMPLEMENTATION IN FOOTBALL PLAYERS REHABILITATION AFTER LOWER LIMB INJURY

FEATURE / MAXIME GASPAR & FLORIAN FORELLI

Introduction

Surface electromyography (sEMG) is a commonly used tool in laboratory settings or scientific studies, but it is still under-utilised in everyday physiotherapy practice1,2. In a previous article, we highlighted the role of sEMG in athlete rehabilitation. sEMG is an interesting tool for studying muscle coordination, that is, the distribution of activation among different muscles to produce a specific combination of joint moments3 The signal’s amplitude is dependent, among other factors, on the number of motor units and their firing frequency. In our daily practice, the use of sEMG is particularly relevant in the rehabilitation of muscle injuries or anterior cruciate ligament (ACL) reconstruction surgery. ACL injuries are arguably the most attention-grabbing knee injuries due to the prolonged recovery period required4 ACL injuries are also associated with an increased risk of subsequent knee injuries,

particularly long-term osteoarthritis development, with a 4 to 6 times higher risk5. Achieving symmetrical muscle strength (>90%) is also a key criterion for return to sport.

Hamstring muscle injuries, on the other hand, are among the most common injuries in football, accounting for 20 to 37% of professional players’ time off the field6. According to Ekstrand et al., there seems to be no change in this trend in recent years7,8. One of the major issues with hamstring injuries is the risk of recurrence; 12 to 48% of players experience a relapse, which is twice as high as any other injury9. Both pathologies pose real challenges in athlete rehabilitation. During the rehabilitation journey, sEMG finds its place as both an evaluation tool and a feedback mechanism.

The objective of this article is to introduce

the concept of using sEMG during rehabilitation and athletic training of athletes following an ACL reconstruction or muscle injury.

Part 1: Anterior cruciate ligament reconstruction rehabilitation

Assessment

After an ACL rupture, it is widely acknowledged that deficits in quadriceps muscle strength persist in 20% of cases at the time of return to sport10,11. The origins of persistent quadriceps weakness after ACL reconstruction are not entirely clear, but literature consistently suggests that muscle activation inhibition is a contributing factor12

In this context, the use of sEMG proves valuable, both as an evaluation tool for this activation and as a means of rehabilitation through visual feedback.

Consider the patient who stagnates with strength recovery at 5- or 6-months postsurgery, despite adhering to prescribed muscle strengthening methods and progressions. In this case, the issue may not necessarily be related to pure strength. Instead, it could be caused by an activation deficit associated with muscle inhibition. The objective, to better target rehabilitation, is to determine whether the problem stems from central neurological origins (muscle inhibition) or peripheral muscular causes (strength deficit), as rehabilitation methods will differ in each case13,14

Evaluation through sEMG alone provides part of the answer; it needs to be correlated with other factors for precise interpretation. Analysing an isolated root mean square (RMS) curve with differing activation between two muscles does not conclusively indicate whether the difference is due to inhibition of the weaker muscle, or over-activation, which could be explained by the need to recruit a greater number of motor units for the same effort due to muscular weakness.

Figure 1a: Normalised sEMG evaluation of the VM during 3 repetitions of CMJ. Green: Curve of the Right VM (operated limb) Blue: Left VM (non-operated limb). Peaks correspond to push-off during takeoff, and the smaller subsequent peaks correspond to landing.

Ideally, functional MRI would provide insights into muscle architecture, but this is impractical in daily practice. Instead, initially comparing results with the patient’s history, pathology, and medical records provides guidance. Subsequently, conducting tests with tools allowing for objective quantification (such as isokinetic testing, force platforms, dynamometers) sheds light on sEMG results.

For example, consider a player who underwent ACL reconstruction surgery using the Mc Intosh Fascia Lata (Mac FL) technique four months ago. During the initial isokinetic test, a 27% deficit in force is noted in the quadriceps of the operated limb compared to the nonoperated limb. In the sEMG evaluation during a functional movement like Counter Movement Jump (CMJ) with both

legs followed by a single leg, a difference of over 40% is observed between the operated and non-operated legs in ground reaction forces (GRF) during push-off and landing. Finally, sEMG evaluation highlights differences in activation of the vastus medialis (VM) on the operated side (Figure 1a-b).

Certainly, it’s important to note that differences in activation alone may not explain everything, and as mentioned later, analysis of dynamic movements should be approached with caution. However, it cannot be denied that in this case, motor inhibition of the vastus medialis plays a role in these results and should be addressed in rehabilitation. Rehabilitative feedback is one of the preferred techniques in such circumstances.

Conversely, the following example involves a patient also undergoing ACL reconstruction surgery using hamstring graft with lateral reinforcement four months post-surgery. During a submaximal isometric test (80% of maximal voluntary isometric contraction, MVIC), a perfect balance of muscle activations between the muscles is observed. (Figure 2)

Figure 1b: sEMG evaluation of the VM during 3 repetitions of single leg CMJ.

Figure 2: Submaximal Isometric Evaluation (80% of MVIC) of the non-operated left leg (left graph) and the operated right leg (right graph).

Rehabilitation biofeedback

Visual biofeedback with sEMG involves converting the electrical signal into a visual signal, most commonly RMS which is the most easily understandable on-screen signal. It has been reported that visual biofeedback on activation levels with sEMG can improve strength by increasing motor unit recruitment and optimising discharge frequency through mechanisms generated by the cortex15. This has been demonstrated at the knee after meniscectomy, improving both strength and activation of the VM during submaximal tasks16–18

While this practice is well developed in perineology, it is still underutilised in the rehabilitation of sports trauma, despite the widespread use of “simple” electrostimulation. Several devices capable of working with biofeedback exist, with most sEMG devices allowing for it. Others, like the Neurotrac MyoPlus 4 Pro®, enable the association of sEMG with electrostimulation, for example. As mentioned earlier, biofeedback is valuable for stimulating activation and helping patients feel the correct movement during muscle contraction. Another benefit in the rehabilitation after ACL reconstruction ligaments is promoting muscle relaxation.

Post-operatively, arthrogenic muscle inhibition is often found, characterized by quadriceps inhibition (especially the VM) and hamstring hyperactivation due to a central origin phenomenon (19,20). As previously indicated, biofeedback may have value in stimulating quadriceps muscle activation, but it can also be used to promote hamstring relaxation (Figure 3), complementing the myotensive techniques described by Delaloye et al (20).

Figure 3: Example of hamstring relaxation exercise with biofeedback.

Figure 4: Conceptual framework of the proposed role of neuromuscular inhibition following hamstring injury in the development of several maladaptations associated with an increased risk of recurrence. Adapted from Fyfe et al., 2013.25

Part 2: Muscle injury rehabilitation

Muscle injuries pose a significant problem in the sports environment, with hamstring muscles being the most commonly affected group9,21,22. Despite a decrease in overall lower limb injuries and recurrences over the past 18 years, the prevalence of hamstring injuries continues to rise, despite increasingly stringent return to sport criteria7,8. It has been demonstrated that there is an inability to achieve optimal activation after hamstring injury, which can result in difficulty improving eccentric strength and fascicle length23–25. The latter has proven effective in hamstring injury prevention (Figure 4)26,27. To our knowledge, there are no studies in the literature that integrate muscle activation among the return to sport criteria. The idea is promising, but further studies are needed to determine if this could be an intrinsic factor in hamstring injury recurrence28

Let’s consider the case of a professional female player who has experienced recurrent injuries to the long head of the right biceps femoris. After passing through various clinical stages, we decide to conduct a muscle activation evaluation.

The first step is electrode placement. For practical purposes, we decide to consider both the Semi-Membranosus (SM) and the Semi-Tendinosus (ST) together. Since we cannot perform ultrasound-guided placement to differentiate between the two internal hamstring muscles, we follow SENIAM recommendations, which also do not differentiate the semi-membranosus29 Attempting to analyze all three muscles in this manner risks signal errors known as “cross-talk” between the ST and SM.

The second step, essential for any EMG evaluation, involves performing MVIC. Several modalities are described, but we opt for 2 repetitions of 5-second contractions while seated on a leg curl machine with a cushion under the leg to prevent electrode-chair contact, which could disrupt results due to friction. This step serves to normalise other results.

Finally, we conduct analytical and global tests such as knee flexion in prone position, Good Morning exercises, or treadmill running at 18 km/h to achieve submaximal hamstring contractions. It is known that at 14 km/h, hamstring muscles reach approximately 50% of MVIC contraction30

While results should be interpreted cautiously (see limitations of sEMG), Figure 5 demonstrates the outcome of the treadmill running test. This highlights the deficit in activation of the injured muscle, as widely described in the literature25,28,31

This assessment allows us to readjust our techniques. After objectively identifying this neuro-inhibition, we implemented techniques

to combat motor inhibitions, such as mental imagery, feedback, the Allyane® method, and others.

Part 3: Other injuries

While we have only presented cases of ACL rehabilitation and muscle injury here, the use of sEMG is not limited to these two pathologies. Depending on one’s patient population and the type of trauma involved, sEMG can be a useful evaluation and rehabilitation tool.

In the context of ankle sprain rehabilitation or patellofemoral pain syndrome (PFPS), for example, sEMG can also provide information on activation timing. It has been reported in

the literature that there is approximately a 20-millisecond delay of the vastus medialis compared to the vastus lateralis during walking and postural tasks in individuals with PFPS32–35. However, this should be interpreted with caution, as a systematic review has shown that while there may be a tendency for delayed activation of the vastus medialis compared to the vastus lateralis in individuals with PFPS, not all individuals exhibit this alteration36

The case of ankle sprains has been extensively studied, particularly regarding the phenomenon of pre-activation of the peroneal muscles prior to ground contact. A delay in activation of these muscles results in less optimal joint protection during weight-bearing37,38

Limitations

Although sEMG is a highly valuable tool in evaluation, like all techniques, it has its limitations. Firstly, there are technical limitations. The setup must be extremely rigorous (skin cleaning, electrode placement, etc.) to ensure the highest possible accuracy (Figure 6).

Even when all criteria are met, it is important to take a step back from the evaluations conducted. Indeed, muscle activation for the same effort between two muscles of the same function (e.g., BF and ST) can vary from one individual to another. Numerous studies report differences in activation of the rectus femoris or gastrocnemius muscles during walking among individuals39. The same observation applies to activation of the quadriceps after an analytical isometric knee extension exercise, where the average corresponds to a balance of activation between the two vasti (medialis and lateralis). In

Figure 5: sEMG evaluation of the biceps femoris during a treadmill running test at 18 km/h. Red: Right Biceps Femoris (injured); Blue: Left Biceps Femoris (healthy).

Figure 3: Example of a setup for quadriceps sEMG evaluation.

reality, half of the population activates the vastus medialis more, while the other half activates the vastus lateralis more.39 Muscle architecture is one of the factors that can contribute to this variability through the force-length relationship. Firstly, there is variability in muscle architecture among individuals, particularly depending on their sporting activities. Moreover, activation will also differ when comparing two muscles within the same muscle group. For example, a fusiform muscle and a bipennate muscle have different pennation angles and therefore different force-length relationships.

Secondly, dynamic evaluation must be interpreted with even more caution as it is subject to the force-velocity relationship and can thus influence the results28

Considering the impact of muscle architecture and individual responses. It is clear that a comprehensive understanding of individual muscle coordination strategies cannot rely solely on muscle activation. It requires an approach that combines neurophysiology to assess muscle activation and biomechanics to evaluate the mechanical effect of this activation39

References

Interpreting results should always be done after normalisation based on the Maximum Voluntary Contraction (MVC), which is typically performed isometrically, hence the term MVIC. Without normalization, there are too many confounding factors that can bias the results.

It is advisable to provide sufficient contraction time to reach a plateau. In the literature, contraction durations of generally between 3 and 5 seconds are recommended 40–43. We suggest conducting evaluations with 2 sets of 5-second contractions to achieve this plateau.

It is important not to establish a direct link between activation level and force output. For the same level of activation (expressed as a percentage of MVC), a muscle with a larger cross-sectional area will produce more force than a muscle with a smaller cross-sectional area. In an ideal scenario, for individuals monitoring athletes over the long term, having a “map” of the athlete’s muscle coordination pre-injury would be optimal to serve as a guide for rehabilitation and return to sport post-injury.

Conclusion

Surface electromyography has become an accessible technique for practitioners and can

be used for both evaluation and rehabilitation purposes. In our daily practice, muscle injury and anterior cruciate ligament reconstruction are two suitable indications. However, they are not the only ones, as both the lower and upper extremities can be investigated using sEMG.

It is important to keep in mind that while this technique has its strengths, it also has its weaknesses. Therefore, interpreting the results requires taking a step back to avoid erroneous conclusions. sEMG devices are now more readily available to practitioners and can be integrated into daily practice to optimise assessments and better guide treatments for our patients.

Maxime Gaspar, PT – MSc Student, Clairefontaine Medical Center, French Football Federation, France

Florian Forelli, PT – PhD Student, Orthosport Rehab Center, Domont, France; Orthopaedic Surgery Department Clinic of Domont, Ramsay Heathcare, @OrthoLab, Domont, France; SFMK Lab, Pierrefite sur seine, France

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