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Anterior pelvic tilt assessment

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Nick van der Horst behaalde zijn diploma fysiotherapie in 2007 aan de Hogeschool Utrecht. Hij werkte 10 jaar lang als sportfysiotherapeut/echografist/docent bij het Academie Instituut te Utrecht. Daarna heeft hij de overstap gemaakt naar waar zijn hart ligt, het professionele voetbal. Hij heeft twee jaar als sportfysiotherapeut en hoofd van de medische staf bij Go Ahead Eagles in Deventer gewerkt. Momenteel is is Nick werkzaam bij de KNVB. Zijn onderzoeks-activiteiten zijn gefocust op de voetbal-medische zorg. In 2017 behaalde hij zijn doctoraal na het verdedigen van zijn proefschrift ‘Prevention of hamstring injuries in male soccer’.

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Correct pelvic alignment – Posture assessment
Although there is controversy regarding the analysis of static posture and its relationship with injuries during sports movements, certain postural patterns can provide valuable information about certain players’ predispositions to injury.

Recent studies have highlighted the role of excessive anterior pelvic tilt (APT) in increasing the risk of hamstring (Mendiguchia, et al., 2021) and hip injuries (Suits, 2021) and low back pain (Das, et al., 2017). However, the field is still evolving, and there are no cut-off values for the degree of pelvic tilt and its relationship to the most common injuries in football.

Suits (2021) defined pelvic tilt as the angle formed by a horizontal line and a line that separates the anterior superior iliac spine and the posterior superior iliac spine in the sagittal plane (see Image 1). He also presented in his article the findings of several articles that measured the pelvic tilt angle in healthy subjects, showing results ranging from 8º to 13º APT. This indicates that APT is a natural anatomical position and not inherently harmful. However, problems can arise when excessive APT occurs, particularly during high-intensity running.

^{Image 1. Pelvic tilt}

Falk et al. (2020) set a cut-off value of 8° for APT, considering a higher degree excessive. However, the previous review by Suits (2021) suggests that this
cut-off value may be too low. Additionally, in healthy populations, women may exhibit a higher degree of APT than men (11.7° vs. 9.6°) (McKeon & Hertel, 2009).

In a 2013 study, Barbosa et al. compared the impact of a treatment involving manipulation of the sacroiliac joint and strength training of knee flexors and extensors on the degree of APT and subjective pain in 7 patients with low back pain. The results demonstrated a reduction of more than 5 degrees in APT (from 20.38 degrees to 14.63 degrees), which also led to a significant decrease in pain as indicated by subjective pain scale measurements (from 5.83 to 1.29).

Can we classify an APT greater than 13 degrees as a faulty postural pattern that increases the risk of injury in soccer players?
We can only make assumptions at this point, as no articles have studied the degree of APT and its association with injuries in football.

Range of motion

If the hip flexors are excessively tight and not adequately stabilized, they can cause the pelvis to rotate forward (Neumann, 2010). Table 1 lists the muscles that can potentially function as hip flexors and consequently increase APT.

^{Table 1. Musculature involved in hip flexion (Neumann, 2010)}

Modified Thomas Test

The procedure starts with the individual sitting at the edge of the table and lying back. Then, they should flex both hips as much as possible and hold their legs behind the knees in the popliteal area. Finally, they need to relax and extend one leg while still holding the other firmly in the fully flexed position (see Image 2).

^{Image 2. Modified Thomas Test}

The inability to maintain a neutral back position, arching the lower back, often indicates excessive shortening of the Psoas major.
This shortening can also result in an inability to fully extend the hip (Image 3).

^{Image 3. Hip extension restriction}

If the inability to fully extend the hip is accompanied by external rotation of the knee (Image 4, right), our biggest suspect will be the TFL. We can check this by passively adducting the extended leg (Image 4, left). An increase in external rotation of the knee will indicate excessive tension of the TFL and the iliotibial band (Neumann, 2010).

^{Image 4. Modified Thomas Test – Knee external rotation. (Sahrmann, 2002)}

Another very common pattern is a lack of knee flexion (Image 5). Due to its biarticular nature, the rectus femoris can limit hip extension and knee flexion. Excessive tension of this muscle will cause the knee to extend, which, with correct mobility, should be perpendicular to the ground (Image 2).

^{Image 5. Knee extension restriction}

Jurdan Test

This test was first used in injury risk research in 2022 by Lahti et al. The test aims to assess the influence of the muscles of the lumbopelvic region on hamstring flexibility. The Jurdan test can be considered a combination of the active knee extension test and the modified Thomas test (Lahti, et al., 2022). The result of this test is defined as the difference between the shin angle of the actively lengthened leg and the thigh angle of the opposite leg (Image 6).

^{Image 6. Jurdan Test (Lahti, et al., 2022)}

Although both the modified Thomas Test and the Jurdan test can provide a lot of information about hip range of motion, more research is still needed to determine cutoff values and their relation with lower limb injuries.

Strength
The abdominal muscles must generate a strong stabilizing force to counteract the strong APT caused by the hip flexors. This stabilizes the lumboabdominal region by increasing intra-abdominal pressure and thoracolumbar fascia tension (Neumann, 2010).

To assess the strength of the abdominal musculature against APT, Haladay et al. (2014) studied the results of the Double Limb Lowering Test* (DLLT) (Image 7) and Lower Abdominal Muscle Progression* (LAMP) (Image 8) after an abdominal stabilization exercise program. They found that the LAMP test is more sensitive to change after abdominal stabilization programs. However, no subject was able to reach the “normal” range of motion in the DLLT test as it was found to be too demanding. It is important to note that this study had some limitations, including a small number of participants (only 11), the inclusion of subjects of different genders, and varying levels of physical activity. In sports with physically demanding requirements such as football, athletes should be able to perform either of these tests with maximum results.

^{Image 7. DLLT. The subject lays supine and raises their legs to a position of 90º of hip flexion with the knees extended. They are then instructed to maintain their pelvis in a posterior pelvic tilt by contracting the abdominals while slowly lowering the legs to the supporting surface. Strength is graded, from 5/10 to 10/10, by identifying the point at which the subject was last able to keep the pelvis stable, as assessed by an anterior tilt of the pelvis and arching of the back (Haladay, et al., 2014).}

^{Image 8. The subject lays supine and performs a series of 9 progressively more challenging lower extremity combinations of movements, assessing their ability to stabilize the pelvis. During this test, the subject is instructed to contract their abdominal muscles by pulling their navel toward their spine. They are assigned a grade (0.10 through 5.00/5.00) for the most challenging lower extremity movement they are able to complete without motion on their pelvis or lower back (Haladay, et al., 2014).}

^{* More information about these tests can be found in the following references: (Haladay, et al., 2014); (Sahrmann, 2002)}

In a previous blog, we discussed the importance of the gluteus maximus (GM) muscle in correcting APT. According to Buckthorpe et al. (2019), there are various ways to assess GM strength. They affirm the prone hip extension task with the knee flexed at 90º as the most commonly used assessment and suggest using a dynamometer to measure it. Other assessment methods include isometric or isokinetic assessment. Electromyography is the most commonly used method to measure muscle activation.

Although all of these methods provide objective and reliable data, many teams may not have the necessary equipment or time to perform them.
The Single-Leg Glute Bridge Test (Image 9) offers an alternative that requires no equipment and can be done with the entire team at the same time in just a few minutes.

^{Image 9. Single-leg glute bridge}

During this test, footballers are asked to perform as many repetitions as possible in the single-leg glute bridge exercise. After the test, the following data is recorded:

Maximum number of repetitions per leg – This will indicate whether there is an imbalance in the strength of the lower limb in unilateral hip extension.

Muscle that has suffered the greatest fatigue during the test – This test will determine if the muscle activation pattern of hip extension is functionally efficient. At the end of the test, it is normal to feel that fatigue in the GM has been the limiting factor of the exercise. I can assure you that you will strongly feel a “burning” sensation in that muscle if the test is carried out to failure. If other muscles, such as the quadriceps or hamstrings, are limiting the test result, this will indicate that the GM is not functioning correctly, and other muscles may be compensating for its weakness, known as synergistic dominance.

Muscle cramps or pain that may have limited the test result – Cramps in the hamstrings or back pain may indicate again weakness in the gluteus maximus and provide insight into other overloaded muscle groups due to lack of glute activation.

Motor control

Hip flexion-extension pattern

This is especially important in young players. Correctly teaching lumbopelvic dissociation is crucial, assuring that the footballer has perfect control over the motion of his/her hip without any compensation at the lumbar level. In a previous blog post, “Hamstring injuries – Post injury evaluation”, you can find several examples for the evaluation of lumbopelvic motor control.

Link: Hamstring injuries – Post injury assessment

Sprint technique

Excessive APT during sprinting increases the risk of hamstring injuries. Correcting this movement pattern is crucial. This year, the reliability of the Sprint Mechanics Assessment Score (S-MAS) was evaluated, showing it to be a reliable tool for assessing sprint mechanics in football players (Bramah et al., 2024). I recommend reading the full assessment. In this post, we will only describe the most important points for footballers who present excessive APT.

^{Image 10. Phases of sprint cycle. MVP – Maximal vertical projection (Bramah, et al., 2024)}

^{Table 2. Phases of sprint cycle (Bramah, et al., 2024)}

Although injury prevention is multifactorial in nature, correct and efficient movement plays a key role. Human movement is highly complex, but mastering specific motor patterns can substantially lower the risk of injury. We will soon delve into training these patterns and achieving a proper balance of muscular forces in the lumbopelvic area.

References

Barbosa, A., Martins, F., Barbosa, M. & Dos Santos, R., 2013. Manipulation and selective exercises decrease pelvic anteversion and low-back pain: A pilot study. Journal of Back and Musculoskeletal Rehabilitation, Volumen 26, pp. 33-36.

Bramah, C. y otros, 2024. The Sprint Mechanics Assessment Score – A Qualitative Screening Tool for the In-field Assessment of Sprint Running Mechanics. The American Journal of Sports Medicine, 20(10), pp. 1-9.

Buckthorpe, M., Stride, M. & Della Villa, F., 2019. Assessing and treating gluteus maximus weakness – A clinical commentary. The International Journal of Sports Physical Therapy, pp. 655-670.

Das, S. y otros, 2017. Prevalence of lower crossed syndrome in young adults: a cross sectional study. International Journal of Advanced Research, 5(6), pp. 2217-2228.

Falk, A., Overgaard, S., Hróbjartsson, A. Holsgaard, A., 2020. Non-surgical interventions for excessive anterior pelvic tilt in synptomatic and non-symptomatic adults: A systematic review. Efort Open Reviews, Volumen 5.

Haladay, D., Miller, S., Challis, J. & Denegar, C., 2014. Responsiveness of the double limb lowering test and lower abdominal muscle progression to core stabilization exercise programs in healthy adults: A pilot study. The Journal of Strength and Conditioning Research, 28(7), pp. 1920-1927.

Lahti, J., Mendiguchia, J., Edouard, P. & Morin, J.-B., 2022. A novel multifactorial hamstring screening protocol: association with hamstring muscle injuries in professional football (soccer) – a prospective cohort study. Biology of sport, 39(4), pp. 1021-2031.

McKeon, J. Hertel, J., 2009. Sex differences and representative values for six lower extremity alignment measures. Journal of Athletic Training, 44(3), pp. 249-255.

Mendiguchia, J. y otros, 2021. Can we modify maximal speed running posture? Implications for performance and hamstring injury management. International Journal of Sports Physiology and Performance.

Neumann, D., 2010. Kinesiology of the hip: A focus on muscular actions. Journal of orthopaedic & sports physical therapy, 40(2), pp. 82-94.

Neumann, D., 2010. Kinesiology of the musculoskeletal system. 2nd ed. Missouri: Mosby.

Sahrmann, S., 2002. Diagnosis and Treatment of Movement Impairment Syndromes. 1st ed. Missouri: Mosby.

Task design in football and training load

VOETBAL MEDISCH SYMPOSIUM 2020

DE BEHANDELING VAN VOETBALBLESSURES

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OP DE KNVB CAMPUS IN ZEIST VINDT KOMEND JAAR OPNIEUW HET VOETBALMEDISCH SYMPOSIUM PLAATS.

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(VELD)REVALIDATIE NA EEN VOETBALBLESSURE

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These guys are the best when it comes to style and have great attention to detail.

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MODEL, FRANCE

These guys are the best when it comes to style and have great attention to detail.

Issac Newton

MODEL, FRANCE

Nick van der Horst

Meet the soccerdoc

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“These players are not fit. They need to run more during training.” How many times have we heard this after witnessing a soccer team lose a game? Although soccer is very physically demanding, the idea that running more solves all problems is far from the truth. Football primarily depends on technical and tactical skills, with decision-making playing a crucial role.

I believe that the primary goal of training is to enhance the team’s game model, which encompasses tactical, technical, and physical aspects that are inseparable due to the nature of the game. This involves developing collective behaviors that enable the team to surpass the opposition when attacking and withstand them when defending.

Is it possible to achieve comparable improvements through training based on the team’s game model instead of isolated running training?

Bucheit et al. (2024), in their article “The 11 evidence-informed and inferred principles of microcycle periodization in football”, state the following:

“While metrics such as High-Speed Running distance and maximal speed exposures provide insights into performance and injury risks, they should not detract from the primary goal of football training: to enhance player interactions and the development of dynamic in-game scenarios through ball play.[…] It advocates for the crafting of training sessions that organically incorporate locomotor “targets” within a football-specific framework (as running is an integral part of football by definition), eliminating the necessity for isolated running drills.”

The belief that the game itself is not a valid tool to improve footballers’ physical capacity is a misconception inherited from traditional forms of periodization in other disciplines. Although certain forms of training contribute to maximizing footballers’ performance, we must not lose sight of the essence of the game.

In 2019, Kunz et al. compared the effects of high-intensity interval training (HIIT) with those of Small-Sided Games (SSG) on physical parameters in young soccer players. They concluded that SSG and HIIT result in similar improvements in several variables related to running performance. This conclusion aligns with the results of a systematic review by Hill-Haas et al. in 2011, supporting this notion.

The results regarding the improvement of neuromuscular parameters are contradictory. Some authors, such as Kunz et al. (2019) and Clemente et al. (2021), did not find effective SSGs for improving RSA, sprint, or jump.

However, others, such as Eniseler et al. (2017), did show significant improvements in RSA after an SSG-based training program. The variability of the game, the heterogeneity in the study populations, and the differences in the design of the training programs could be the causes of these differences. With an adequate design, improvements in these physical qualities can also be achieved.

Maximum speed training with SSG seems more complex due to the unpredictable and uncontrolled nature of the game. This can lead to some soccer players overtraining while others may undertrain (Gualtieri et al., 2023).

It’s important to remember that the amount of time a player spends with the ball is crucial. In a study by Eniseler et al. (2017), one group of young football players focused their training on small-sided games (SSG), while the other group trained with linear sprints and changes of direction.

The SSG group completed a total of 5111 actions with the ball, while the other group DID NOT PERFORM ANY actions with the ball during that part of the training. As a result, the SSG group showed twice as much improvement in a short-pass test compared to the other group.

When appropriately designed, SSG are an effective tool for enhancing cardiovascular and neuromuscular fitness in football players while improving their technical and tactical skills specific to the team’s game model. However, it is important to note that other alternative methods may be more effective for improving maximum speed actions (Zhi Yong et al., 2023), as they offer simpler control and quantification.

How do different variables in task design impact the internal and external training load?

Pitch size and number of players are the variables that have the most significant impact on the physical, physiological, and technical-tactical demands (Castellano & Casamichana, 2019).

Castellano and Casamichana (2019) propose a model that focuses on the primary actions within the game based on the interaction between players and pitch size. They introduce the concept of relative area per player (RAPP), calculated as the pitch size (in m²) divided by the number of players. The model is divided into three conditional qualities:

Strength: Tasks involving a high number of accelerations, decelerations, and changes of direction with a small number of players and a small RAPP.

Endurance: High-intensity tasks at a cardiovascular level. A high RAPP and a small number of players are used.

Speed: Tasks focused on high-speed running actions. This requires sufficient space and time. Therefore, these exercises will involve a high number of players and a high RAPP.

^{Tabel 1. Different game formats according to space and number of players (Castellano & Casamichana, 2019)}

Depending on the session’s objective and the task, these two variables can be combined, as shown in Table 1, to have a more significant impact on certain specific qualities. Castellano and Casamichana (2019) not only recommend using SSG, but also Medium and Large-Sided Games. In smaller spaces, the number of accelerations and decelerations will increase, while the distance covered at high speed will decrease (Clemente et al., 2022). As the RAPP increases, the players’ physical and physiological load and perceived effort (RPE) also increase (Casamichana & Castellano, 2010). Depending on our objective, there are also several variables that we can modify and will influence the actions during the game.

Game format
Coaches often use situations of numerical advantage or disadvantage to achieve specific tactical goals. In 2010, Hill-Haas et al. studied the impact of using teams with an equal number of players (3 vs 3 and 5 vs 5) compared to teams with an unequal number of players (3 vs 4 and 5 vs 6). They found that the total distance covered by the equal teams was greater than that of the teams with the higher number of players. The players in the outnumbered teams reported higher RPE compared to the teams with more players.

Inclusion of floaters
Hill-Haas et al. (2010) found that in smaller spaces, the floaters covered a greater total distance, whereas in larger spaces, they completed a greater number of high-intensity runs (>18 km/h).

Asian et al. (2022) conducted a study to investigate the correlation between the position of the floaters (Figure 1) and the internal and external training load in a 4 vs 4 + 2 task among semi-professional soccer players. The study found that regular players experienced higher internal and external loads in all formats. Additionally, floaters in the inside and outside positions had higher internal and external loads compared to those in the zone and square positions, with the inside position being the most demanding. The authors concluded that adding floaters to the task could be an effective strategy for reducing the training load on these players, and it may be used as an active recovery or with players in the process of returning to play.

^{Image 1. SSG Design by Asian et al. (2022)}

In match simulation tasks, the inclusion of floaters can mean a greater reduction in intensity than in tasks with the objective of maintaining possession of the ball (Lacome, et al., 2017).

Inclusion of goalkeepers
It’s quite surprising that there’s very little research evaluating the impact of including goalkeepers on the internal and external training load in soccer.
The only study directly investigating this found that including goalkeepers reduces the intensity of the physiological responses and the distances covered at high intensity. The authors suggest that this might be because including goalkeepers leads to more passes and shots on goal, which can slow down the pace of the task and increase the time the ball is out of play (Koklu, et al., 2015).

Training regime
Casamichana et al. (2013) studied the difference between interval and continuous training regimes. They found that both formats are effective for achieving high intensity in the task. However, the total distance covered was greater in the intermittent game formats, as were the distances covered at speeds greater than 13km/h. On the other hand, RPE and maximum heart rate (HR) may be higher in the continuous format (Hill-Haas et al., 2011).

If the primary goal of training is to elicit greater cardiovascular responses, longer game formats should be utilized, whereas, if the primary goal is to promote high-intensity actions, game formats should be shorter (Casamichana et al., 2014).

Rest duration
In a recent study by de Dios et al. (2024), it was found that short rests (1-2 minutes) increased the RPE of soccer players, while long rests (4 minutes) led to an increase in the number of accelerations and decelerations. Another study by Branquinho et al. (2021) observed that long rests increased actions at maximum speed, while short rests tended to promote greater physical demands, both internal and external.

Short rest periods usually result in higher internal demands and a higher RPE, whereas longer rest periods tend to favor an increase in high-intensity and speed actions. However, the effect of rest on the training load is largely determined by the duration of each repetition and the design of the task. The use of the work:rest ratio can be helpful in quantifying this variable.

Rules modification
The modification of certain rules during tasks is a common practice aimed at influencing team behavior. Offside is a frequently modified rule, but it appears to have no effect on the HR of footballers during SSG (Custódio, et al., 2022).

Halouani et al. (2017) investigated the effect of different ways of scoring goals in SSG on young football players. The study’s findings indicated that using an area at the end of each half of the field where players had to control and stop the ball in order to score resulted in greater physiological responses (HR, RPE, and lactate levels) compared to using small goals. Including the rule that all players must be in the opponent’s half for the goal to count has been shown to increase maximum HR and blood lactate levels (Hill-Haas, et al., 2010).

Number of ball touches
Casamichana et al. (2014) discussed the results of several studies showing an increase in intensity in several physical parameters when the allowed number of touches was reduced. However, their study yielded different results. By allowing only two touches in a possession game (12-min; 6 vs. 6; RAPP of 245 m2), in the first 6 minutes, it was observed that players spent more time at an intensity level below 80% of their maximum HR. In the second 6 minutes of the game, there was a significant decline in running performance in the group without a limit on ball touches, while in the group with a limit, an increase was observed in the amount of time that players spent in the high-intensity zone (>90% of their maximum HR). Fatigue and the technical-tactical skills of the players can greatly influence this variable.

Type of marking
Research has shown that man-marking leads to increased distance covered at moderate and high intensity, as well as a higher number of high-intensity accelerations. However, it does not appear to significantly affect the physiological demands (Casamichana, et al., 2015).

Conclusion
If the tasks are designed correctly, football players can achieve optimal fitness with a training program based on the collective game model. However, special attention should be paid to maximum-speed running, which is crucial for performance and injury prevention but very difficult to control due to the unpredictable nature of the game. In this case, other additional forms of training might be beneficial.

One of the key attributes that distinguishes great football players is their capacity to make correct decisions incredibly fast. It is impossible to develop this capacity if, during training, we simply hand everything to the players without requiring them to make any decisions. Even though sports sciences attempt to control every aspect, football will always retain that uncontrollable element that makes it ‘the beautiful game’.

References

Asian, J. et al., 2022. The influence of floater position on the load of soccer players during a 4 vs 4 +2 game. Kinesiology, 54(1), pp. 82-91.

Branquinho, L. et al., 2021. Effects of different recovery times on internal and external load during Small-Sided Games in soccer. Sports Health, 13(4), pp. 321-324.

Casamichana, D. & Castellano, J., 2010. Time–motion, heart rate, perceptual and motor behaviour demands in small-sides soccer games: Effects of pitch size. Journal of Sports Sciences, p. 1615–1623.

Casamichana, D., Castellano, J. & Dellal, A., 2013. Influence of different training regimes on physical and physiological demands during small-sided soccer games: Continuous vs intermittent format. Journal of Strength and Conditioning Research, 27(3), pp. 690-697.

Casamichana, D., San Román, J., Castellano, J. & Calleja, J., 2015. Influence of the Type of Marking and the Number of Players on Physiological and Physical Demands During Sided Games in Soccer. Journal of Human Kinetics, Volume 47, pp. 259-268.

Casamichana, D., Suarez, L., Castellano, J. & San Román, J., 2014. Effect of Number of Touches and Exercise Duration on the Kinematic Profile and Heart Rate Response During Small-Sided Games in Soccer. Journal of Human Kinetics volume, Volume 41, pp. 113-123.

Castellano, J. & Casamichana, D., 2019. El arte de planificar en fútbol. s.l.:Futboldelibro.

Clemente, F. M. et al., 2021. A Meta-Analytical Comparison of the Effects of Small-Sided Games vs. Running-Based High-Intensity Interval Training on Soccer Players’ Repeated-Sprint Ability. International Journal of Enviromental Research and Public Health.

Clemente, F. M. et al., 2022. Physiological and locomotor demands during small‑sided games are related to match demands and physical fitness? A study conducted on youth soccer players. BMC Sports Science, Medicine and Rehabilitation.

Custódio, I. et al., 2022. Effect of Small-Sided Games with and without the Offside Rule on Young Soccer Players: Reliability of Physiological Demands. International Journal of Enviromental Research and Public Health, Volume 19.

de Dios, V., Padrón, A., Miguel Lorenzo, M. & Rey, E., 2024. Effects of Different Recovery Duration on External and Internal Load Measures during Bouts of Small-Sided Games. Journal of Human Kinetics, Volume 90, pp. 151-159.

Eniseler, N., Şahan, Ç., Özcan, I. & Dinler, K., 2017. High-Intensity Small-Sided Games versus Repeated Sprint Training in Junior Soccer Players. Journal of Human Kinetics.

Fradua, L. et al., 2013. Designing small-sided games for training tactical aspects in soccer: Extrapolating pitch sizes from full-size professional matches. Journal of Sports Sciences, p. 573–581.

Gualtieri, A., Rampinini, E., Dello Iacono, A. & Beato, M., 2023. High-speed running and sprinting in professional adult soccer: Current thresholds definition, match demands and trainingstrategies. A systematic review. Frontiers in Sports and Active Living.

Halouani, J. et al., 2017. Soccer small-sided games in young players: Rule modification to induce higher physiological responses. Biology of Sport, 2(2).

Hill-Haas, S., Coutts, A., Dawson, B. & Rowsell, G., 2010. Time motion characteristics and physiological responses of small sided games in elite youth players: The influence of player number and rule changes. Journal of Strength and Conditioning Research, 24(8), p. 2149–2156.

Hill-Haas, S., Dawson, B., Impellizzeri, F. & Coutts, A., 2011. Physiology of Small-Sided Games Training in Football. Sports Medicine, pp. 199-220.

Koklu, Y., Sert, O., Alemdaroglu, U. & Arslan, Y., 2015. Comparison of the physiological responses and time motion characteristics of young soccer players in Small-Sided Games: The effect of goalkeeper. Journal of Strength and Conditioning Research, 29(4), pp. 964-971.

Kunz, P., Engel, F. A., Holmberg, H.-C. & Sperlich, B., 2019. A Meta-Comparison of the Effects of High-Intensity Interval Training to Those of Small-Sided Games and Other Training Protocols on Parameters Related to the Physiology and Performance of Youth Soccer Players. Sports Medicine.

Lacome, M., Simpson, B., Cholley, Y. & Buchheit, M., 2017. Locomotor and Heart Rate Responses of Floaters During Small-Sided Games in Elite Soccer Players: Effect of Pitch Size and Inclusion of Goal Keepers. International Journal of Sports Physiology and Performance, 13(5), pp. 1-13.

Zhi Yong, Z. et al., 2023. A Meta-analysis of the Effects of High-Intensity Interval Training and Small-Sided Games on Sprint Performance in Adolescents. Strength and Conditioning Journal, pp. 587-597.

The lower crossed syndrome

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Have you heard of this syndrome before? Even if you’ve never heard of it, you probably see it every day without realizing that many of the players on your team or in your clinic develop this postural disorder. In this post, we will define what this syndrome is, why it occurs, what the risks are, and how it is related to our greatest enemy, the hamstring injury.

What is Lower Crossed Syndrome?
Lower Crossed Syndrome is a pattern of muscle imbalance involving the lumbar spine, pelvis, and hip. According to Das et al. (2017), this syndrome involves excessive tension in the hip flexors and lumbar extensors, along with weakness in the abdominal muscles and hip extensors. This pattern of movement primarily affects the L4-L5 and L5-S1 vertebral segments, the sacroiliac joint, and the hip joint.

The change in muscle activation of the lumbopelvic-hip complex will lead to postural disorders that may increase the risk of injury and low back pain. The main change is an increase in anterior pelvic tilt, which causes hip flexion and increased lumbar lordosis, resulting in an excessive curve in the lower back (Kritz & Cronin, 2008). Other postural changes that may occur include lateral alterations of the pelvis, lateral rotation of the leg, or hyperextension of the knees.

^{Image 1. Anterior pelvic tilt (Neumann, 2010)}

More common than we think in football players

^{Image 2. Rating scale: 5, ideal posture; 4, minor deviation; 3, significant deviation; 2, marked deviation; 1, severe deviation. (Kritz & Cronin, 2008)}

Image 2 presents a study from 2008 by Kritz & Cronin, which demonstrated a tendency towards increased lumbar lordosis in athletes engaged in high-intensity running sports, such as football.
The study, involving 98 athletes, found that 33% of them exhibited marked or severe lumbar deviation during a static posture analysis. Authors like Das et al. (2017) have linked this type of postural imbalance to low back pain, while others, such as Mendiguchia et al. (2024),
have associated an increase in anterior pelvic tilt with greater elongation and strain in the hamstring muscle complex, leading to a higher risk of injury.

Football involves multiple explosive hip flexion movements, such as shooting the ball or passing, as well as short-duration, high-intensity actions like accelerations, decelerations, jumps, or changes of direction. These movements primarily stimulate the hip flexor and knee extensor muscles, leading to increased tension and overactivation of these muscle groups.

When one muscle contracts, the opposite or antagonist muscle relaxes. This is known as reciprocal inhibition. Excessively tight hip flexors will cause reciprocal inhibition of the gluteus maximus, the primary hip extensor (Buckthorpe, et al., 2019). This muscle activation pattern may cause excessive anterior pelvic tilt and, consequently, increase lumbar lordosis. In turn, the increase in lumbar lordosis will cause shortening and stiffness of the lower back muscles and reciprocal inhibition of the abdominal muscles (Image 3). Moreover, when the hip flexors become overactive, they start to take over functions that the abdominal muscles should perform. Again, this weakens the abdominal muscles and leads to the weakening and lengthening of the gluteus maximus due to their agonist-antagonist relationship (Das et al.,2017). Weakness in the gluteus maximus can lead to compensatory actions by secondary hip extensor muscles, such as the hamstrings and hip adductors, clinically known as “synergistic dominance” (Buckthorpe et al., 2019).

^{Image 3. Lower crossed syndrome (Source: www.erikdalton.com)}

How does this syndrome impact maximal speed running?

During maximum-speed running, athletes who present this motor pattern may increase hip and rear leg extension to compensate for the lower activation of the gluteus maximus (Image 4, left). Increasing hip extension during the final stance phase allows the athlete to apply force over a longer time, resulting in a greater impulse (Kritz & Cronin, 2008). Although this may seem positive, it’s actually an ineffective force production strategy used to compensate for the lack of force during the first half of the stance phase, where the peak of ground reaction forces should occur (Bramah et al., 2023). Excessive hip extension lengthens the stance phase and reduces the flight time and the time available to reposition the lower limb for the next foot contact, increasing the speed of the leg change and, consequently, the strain produced on the hamstrings (Bramah et al., 2023). Hip hyperextension may also cause excessive anterior pelvic tilt, which increases stress on the proximal hamstring region during high-intensity running (Mendiguchia et al., 2021).

^{Image 4. Trailing leg extension (Bramah, et al., 2023)}

Several authors, such as Schuermans et al. (2017), have shown how the increased activity of the hip flexors during sprinting increases the strain on the biceps femoris of the contralateral leg. This author also states that the activity of the abdominopelvic muscles, especially the gluteus maximus and abdominal obliques, reduces strain in the proximal region of this muscle. A proper balance of the lumbopelvic muscles, especially the relationship between iliopsoas-erector spinae and abdominal-gluteal muscles, is key to reducing strain on the biceps femoris (Mendiguchia et al., 2021).

This relationship once again highlights the importance of lumbopelvic control during maximum-intensity running. The increase in anterior pelvic tilt will cause a significant elongation of the hamstring muscles (Mendiguchia et al., 2024), which during high-intensity running increases the risk of suffering hamstring injuries (Mendiguchia et al., 2021).

Now that we understand the implications of this inefficient movement pattern, my next question is: How can we assess it and improve it?
We will address these questions in upcoming posts.

See you soon!

References

Bramah, C., Mendiguchia, J., Dos’Santos, T. & Morin, J., 2023. Exploring the role of sprint biomechanics in hamstring strain injuries: A current opinion on existing concepts and evidence. Sports Medicine, Volumen 54, pp. 783-793.

Buckthorpe, M., Stride, M. & Della Villa, F., 2019. Assessing and treating gluteus maximus weakness – A clinical commentary. The International Journal of Sports Physical Therapy, pp. 655-670.

Das, S. y otros, 2017. Prevalence of lower crossed syndrome in young adults: A cross sectional study. International Journal of Advanced Research, pp. 2217-2228.

Kritz, M. & Cronin, J., 2008. Static posture assessment screen of athletes: Benefits and considerations. Strength and Conditioning Journal, 30(5), pp. 18-27.

Mendiguchia, J. y otros, 2024. Anterior pelvic tilt increases hamstring strain and is a key factor to target for injury prevention and rehabilitation. Knee surgery, sports traumatology, arthroscopy , pp. 1-10.

Mendiguchia, J. y otros, 2021. Can we modify maximal speed running posture? Implications for performance and hamstring injury management. International Journal of Sports Physiology and Performance.

Neumann, D., 2010. Kinesiology of the musculoskeletal system. 2nd ed. Missouri: Mosby.

Improving Ankle Dorsiflexion: How to Do It?

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There are hundreds of variations of ankle mobility exercises on the internet, but while mobility training is an essential part of any training program, improving the range of motion (ROM) of a chronically restricted joint can be much more complex than doing a couple of stretches after training.

In the previous two articles, we discussed how limited ankle mobility can affect lower limb movement mechanics and explored various ankle dorsiflexion assessment methods. Now, it is time to design a training program for soccer players with ankle mobility restrictions.

In the book “Assessment and Treatment of Muscle Imbalance. The Janda Approach”, we find a very interesting classification of the musculature that tends to overactivation and the one that tends to weakness or inhibition. In the case of the ankle, the authors of this book state that the triceps surae muscles, especially the soleus, are prone to overactivation and stiffness, while other anterior lower leg muscles, such as the tibialis anterior, are prone to muscle weakness and inhibition. Authors such as Utku et al. (2018) have shown in their research the difference in the activation and inhibition patterns of the muscles of the triceps surae and the tibialis anterior. Their research showed stronger inhibition of the tibialis anterior compared to the triceps surae, which could be associated with specific neural control strategies of posture (Utku et al., 2018).

To address the muscular imbalance in the ankle joint, it is important to reduce the excessive tension and shortening of the posterior muscles while also activating and strengthening the anterior muscles. In a study by Lee et al. (2021), the effects of stretching the triceps surae alone were compared with the effects of combining the triceps surae stretching with tibialis anterior strengthening exercises (Image 1). The results showed that the group that performed the combination of triceps surae stretching and tibialis anterior strengthening increased ankle dorsiflexion ROM more than the group that performed stretching alone. After the exercises, the activity of the tibialis anterior muscle increased. The authors suggest that this increase could lead to reciprocal inhibition of the triceps surae musculature, thus increasing the ROM of the ankle. It is important to note that this study only looked at the immediate effects of the intervention, and there is very little research on the long-term effects of this type of intervention. Therefore, we do not know the chronic effects of applying this type of exercise.

^{Image 1. Tibialis anterior resistance exercise}

Static stretching has been proven to effectively improve flexibility and performance and reduce delayed-onset muscle soreness in the long term. However, it may have negative acute effects on muscle strength, potentially impairing sports performance (Grieve et al., 2022). On the other hand, alternative techniques like myofascial release have been shown to enhance the ROM without negatively affecting performance.

The use of the Foam Roller (FR) (Image 2) has gained much popularity in recent years, although many people are still unaware of its effects and how to use it properly. The review by Grieve et al. (2022) showed that the use of FR is effective in improving short-term ankle dorsiflexion ROM without detrimental effects on performance, making it a viable alternative to static stretching during warm-up. This improvement may be due to increased muscle temperature and pressure after using the FR. These changes would cause alterations in the density and fluidity of the muscle tissue (Aune et al., 2019). Other theories have also been suggested, such as the activation of the parasympathetic system after pressure is applied to the muscle. This activation would influence neural activity and reduce muscle tone (Aune et al., 2019).

^{Image 2. Self-myofascial release with Foam Roller}

More research is needed regarding the long-term effects of FR since the investigations’ results are very different due to the significant difference between protocols. In the review previously mentioned, most studies use the FR for 1.5 to 3 minutes, applying as much pressure as possible. The tempo of FR varies significantly across studies, making it very difficult to draw conclusions about it.

Another alternative to static stretching is dynamic stretching, which would be done in the same positions as static stretching but moving through the full ROM at a set pace.

The inclusion of this type of stretching of the lower limb muscles, including exercises for gastrocnemius and soleus (Image 3), has shown not only short-term improvements in ankle mobility but also improvements in performance compared to a protocol that did not include dynamic soleus stretches (Huang et al., 2022).

^{Image 3. Gastrocnemius (left) and soleus stretching (right)}

The results of these investigations suggest that combining FR with dynamic stretching may be a viable way to acutely improve ankle mobility and sports performance (Little & Williams, 2006).

This approach may be used during warm-ups prior to high-intensity sessions or competitions, although further research is necessary to determine the best way to apply both interventions.

Ankle dorsiflexion can also be limited by the restriction of posterior talus gliding, which is an essential movement for proper ankle joint motion (Jeon et al., 2015). To address this limitation in intra-articular mobility, mobilization techniques involving manual traction or straps have been suggested to assist with the posterior gliding of the talus during ankle dorsiflexion.

Jeon et al. (2015) compared the effect on ankle mobility of performing static triceps surae stretching alone with performing the same stretches using a strap that assisted posterior talus glide. In this technique, the strap was placed around the anterior aspect of the talus of the front foot, which was placed on a 10º inclined board. The other part of the strap was placed around the rear foot, which was on the ground, applying force on the front foot in a posteroinferior direction (Image 4).

^{Image 4. Ankle self-stretching using a strap (Jeon et al., 2015)}

From this position, the patient was asked to move the knee forward without pain or discomfort until stretching of the soleus of the front leg was felt.
This final position was held for 20 seconds. 15 repetitions were performed, with a 10-second rest between stretches. This intervention was performed 5 times a week for 3 weeks in both groups. The group that performed stretching with the assistance of a strap showed better results compared to those who only did stretching in terms of active and passive ankle dorsiflexion and flexion angle during a closed kinetic chain test.

Similarly, Kang et al. (2015) examined the effects of combining static stretching with talocrural mobilization. In this case, the therapist assisted the posterior gliding of the talus with his hand (see Image 5). The stretches were performed in 10 repetitions of 30 seconds with 30 seconds of rest between repetitions.

This study also found superior effects of this type of mobilization compared to static stretching alone regarding increased ankle dorsiflexion, time to heel-off during gait, and posterior gliding of the talus.

^{Image 5. Manual talocrural mobilization (Kang et al., 2015)}

Although eccentric exercise has been shown to increase muscle fascicle length effectively (Harris-Love et al., 2021), there is controversy surrounding its impact on improving ankle mobility. While authors such as Aune et al. (2019) have shown improvements following a training plan that included eccentric exercises, others such as Lagas et al. (2021) did not find any benefit; in fact, they observed a decrease in the flexibility of the triceps surae musculature.

This may be due to the difference between protocols. Lagas et al. (2021) performed the exercises 3 times per week following a progression that began with a very low training volume, 2 sets of 4 repetitions. The volume increased by about 20% each week until finishing the last week doing 3 sets of 15 repetitions. In the other study, Aune et al. (2019) performed the exercises daily for 4 weeks, starting directly with 3 sets of 15 and maintaining the same training volume throughout the intervention. Although eccentric training has been shown to be effective in improving muscle flexibility, more research is needed to determine the optimal training dose to improve ankle dorsiflexion ROM.

Certain medical conditions can limit joint ROM and need special clinical evaluation, but these cases are beyond the scope of this article.

In summary, a training plan aimed at improving ankle dorsiflexion ROM should include the following:

Myofascial release of the triceps surae
Talocrural mobilization with assistance to the posterior gliding of the talus
Stretching of the triceps surae (Dynamic stretching is recommended if performed before competition or training with high-intensity actions)
Specific strengthening of the dorsiflexor muscles
Eccentric exercises

Although isolated exercises can be very useful in improving certain risk factors for soccer injuries, we cannot forget that human movement is much more complex than the movement of a single joint. After correcting movement and strength deficits, sport-specific activities should be trained, including multi-articular exercises, plyometrics, and high-intensity actions such as sprinting, jumping, and changes of direction.

Injury prevention is a very complex process that requires daily effort. Achieving adequate mobility of all joints is critical to improving performance and minimizing the risk of severe injuries. As shown, the ankle joint plays a vital role in this process.

References

Aune, A. y otros, 2019. Acute and chronic effects of foam rolling vs eccentric exercise on ROM and force output of the plantar flexors. Journal of Sports Sciences, pp. 138-145.

Grieve, R. y otros, (2022). The effects of foam rolling on ankle dorsiflexion range of motion in healthy adults: A systematic literature review. Journal of Bodywork & Movement Therapies, pp. 53–59.

Harris-Love, M., Gollie, J. & Keogh, J. (2021). Eccentric Exercise: Adaptations and Applications for Health and Performance. Journal of functional morphology and kinesiology, 6(96).

Huang, S. y otros, 2022. Acute Effects of Soleus Stretching on Ankle Flexibility, Dynamic Balance and Speed Performances in Soccer Players. Biology, 11(374).

Jeon, I.-C.y otros, 2015. Ankle-Dorsiflexion Range of Motion After Ankle Self-Stretching Using a Strap. Journal of Athletic Training, 50(12), p. 1226–1232.

Kang, M.-H.y otros, 2015. Immediate combined effect of gastrocnemius stretching and sustained talocrural joint mobilisation in individuals with limited ankle dorsiflexion: A randomised controlled trial. Manual therapy, Volumen 20, pp. 827-834.

Lagas, I. F. y otros, 2021. Effects of eccentric exercises on improving ankle dorsiflexion in soccer players. BMC Musculoskeletal Disorders, 22(485).

Lee, J., Cynn, H., Shin, A. & Kim, B. (2021). Combined Effects of Gastrocnemius Stretch and Tibialis Anterior Resistance Exercise in Subjects with Limited Ankle Dorsiflexion. Physical Therapy Rehabilitation Science, 10(1), 10–15.

Little, T. & Williams, A., 2006. Effects of differential stretching protocols during warm-ups on high-speed motor capacities in professional soccer players. Journal of Strength and Conditioning Research, 20(1), pp. 203-207.

Page, P., Frank, C. & Lardner, R., (2012). Assessment and Treatment of Muscle Imbalance: The Janda Approach. Windsor, Ontario, Canada: Human Kinetics.

Utku, Y., Negro, F., Diedrichs, R. & Farina, D., 2018. Reciprocal inhibition between motor neurons of the tibialis anterior and triceps surae in humans. Journal of Neurophysiology, pp. 1699-1706.

Student blog: ACL rehabilitation in elite football

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SoccerDoc stimulates knowledge development and personal development of anyone working within the field of Football Medicine. In addition to our bloggers who provide solid evidence-based coverage of certain topics,
we provide a platform for students to submit their work and share it with the SoccerDoc-community.
Feel free to share any knowledge, experiences and or comments below the blog to learn from each other.

Introduction

Anterior cruciate ligament injuries rank among the most prevalent and devastating injuries, affecting both amateur and elite athletes (van Melick, 2016). Despite the advancements in research and clinical practice, players playing at a professional level have a recurrence rate of 17.8% (Wright et al., 2007). Despite notable strides in research and clinical practices, professional players face a concerning recurrence rate of 17.8% (Wright et al., 2007).
Moreover, rerupture rates post-reconstruction range from 3-22% on the reconstructed ligament and 3-24% on the contralateral side, further complicating the rehabilitation process. The risk of a subsequent second ACL tear is not the only barrier to a successful return to sport, the return to preinjury level participation post ACL surgery is reported to be as low as 65%, underlining the multifaceted challenges athletes encounter in their journey back to peak performance (Ardern et al., 2015).

Against this backdrop, this blog endeavours to explore strategies for optimising ACL rehabilitation within the context of a multidisciplinary team (MDT) working within an elite football team setting. By delving into the workings of the MDT, we aim to elucidate how proactive organisational structures, effective rehabilitation planning, and open communication channels can bolster the success of rehabilitation efforts. Through these avenues, we seek to empower medical teams to navigate the complexities of ACL rehabilitation ultimately fostering the return-to-performance of the athletes with confidence and resilience.

Operational Structure

In elite football, a typical multidisciplinary team comprises five distinct departments, each playing a vital role in the management and preparation of players: coaches, medical team, performance team, data science team, and analysis team (Transfermarkt, 2023).

Each department brings specialised expertise and responsibilities to the table, collectively contributing to the optimisation of player performance and well-being.

^{Image 1. Multidisciplinary Team}

Let’s briefly outline the roles and responsibilities associated with the two most prominent departments involved with the rehabilitation of a player with an ACL tear:

The Medical Department

The medical department consists of a sports medicine physician (club doctor) and typically 2-3 physiotherapists.

The Sports Medicine Physician
The sports medicine physician is typically the case manager and will oversee the rehabilitation period (Villa et al., 2019).

The Physiotherapist
The physiotherapists in the MDT will be responsible for the majority of the ACL rehabilitation. The regaining of range of motion, strength, power, hypertrophy, balance, and coordination are well-established and researched goals for the athlete to achieve under the guidance of the MDT; specifically the physiotherapist (Taberner et al., 2020).

The Performance Department

The performance department has a vital role to play in the reconditioning of the athlete back to the pre-injury level.

The strength and conditioning coach(s)
Here, the strength and conditioning coaches will reintroduce upper-body training and more dynamic and full-body movements once the initial protective phase has been completed (add more detail) at approximately 2-3 months post-surgery. The reconditioning of the body is crucial to regain the physical profile to compete at the highest level but also to build resilience to mitigate any further injuries (Bizzini et al., 2012).

The sports psychologist
However, the reconditioning of the mind is equally important and can be less straightforward (Ardern, 2015). Often overlooked, the psychological aspect of an ACL injury in an elite footballer cannot be underestimated. Mental training techniques to manage pain and reduce anxiety associated with injury are essential (Clement &Arvinen-Barrow, 2013). The sport psychologist provides screening and support for the player, with early identification of psychological barriers being crucial. Specific questionnaires to assess athletes’ fear, confidence, and perceptions of risk can help tailor interventions to their needs. This proactive approach can prevent psychological issues from hindering physical recovery (Ardern et al., 2013). Setting specific, measurable, achievable, relevant, and time-bound (SMART) goals helps athletes build confidence and stay motivated during their recovery (Ardern et al., 2022). The psychologist also encourages autonomy and control by advising the player to take an active role in their rehabilitation alongside the medical staff. Positive mental imagery, such as visualisation techniques, helps athletes imagine a successful return to the football pitch, reducing anxiety and fostering a positive mindset toward recovery and performance (Ardern et al., 2013). ACL rehabilitation is not a straightforward process, and setbacks are inevitable. The sport psychologist helps athletes develop coping strategies, emphasising relaxation exercises, cognitive-behavioural strategies, and ensuring adequate social support (Ardern et al., 2022).

Furthermore, it is my opinion that both the medical department and performance department may help with easing uncertainty, doubt, and fear of re-injury from the start. The medical and performance staff’s plan should give the players objective and measurable targets to hit. Players are natural competitors, and a long-term ACL injury rips away a big part of their life that motivates them daily. Measurable and objective short-term goals and targets can help feed that competitive urge and motivate the player. In addition to this, speaking with another player who has gone through the same long-term injury can allow the sharing of experiences, challenges, and solutions that we as non-playing staff members can not relate to.

^{Image 2. Graded Exposure RTP Plan}

Planning

A return to sport training plan should be completed within the first week of the ACL reconstruction. This plan should be coordinated and led by the ‘case manager’ (CM). The CM is typically the sports medicine physician within the organisation that leads the rehabilitation from start to finish. Their role is to give strategic and practical advice to the MDT on a daily basis and in key decision-making throughout the recovery process. When surgery is needed, the case manager liaises with the surgeon regarding the stages of tissue healing and the appropriate loading of the knee post-surgery (Villa et al., 2019). There are logistical factors such as travel requirements, budget, resources, MDT meeting schedule, and testing schedule. The recovery timeline should be forecast by taking into consideration the datasets of previous players who underwent ACL surgery. However, some covariates that need to be taken into consideration are previous knee injuries, the time of the season, and concurrent injuries such as a chondral injury, a meniscal tear or multi-ligament injuries (Jordan et al., 2015).

From my personal experience as a practitioner, a plan with clear milestones and progression/regression criteria enables the athlete to have a bird’s eye view of the rehabilitation plan and can help with any doubts or fears they may have. ACL rehabilitation is a long journey and there may be setbacks along the way.

Communication

Acute stage
Acute injuries such as an ACL tear challenge the resilience and organisation of the MDT and emphasise the importance of teamwork and communication in such situations. On match days, at least one team doctor and at least one senior physiotherapist will make up the medical team on the sideline (The Football Association, 2023). In the event of an ACL tear, the medical team needs to be well-equipped to handle this scenario by coordinating their efforts effectively and following a clear and pre-planned protocol. Below I have illustrated the process of coordinating an ACL tear in training or on a match day.

Acute Injury protocol:

^{Image 3. Acute ACL Injury Protocol}

Following the receipt of the imaging report, the CM follows a carefully controlled protocol. This allows discussion and communication of the injury, initially with one decision-maker, then with the Head Physio, a specialist if relevant, with the player, with the manager, director of football, medical team, logistics team and finally the board. Crucially, any media announcements should only be made after all the above individuals and teams have been informed and discussed the injury (Ahmad, n.d).

Use of Whatsapp

The day-to-day life of a footballer when not injured is carefully laid out and structured around team training, gym, tactical sessions and recovery. When our athlete is undergoing ACL rehabilitation, we should try to minimise the change of routine and help the athlete adjust to their new routine. The use of WhatsApp groups for rehabilitation can allow members of the medical team to quickly and effectively transfer information to athletes about training programmes, at-home rehabilitation and logistics around when and where to be day to day. Additionally, WhatsApp allows files, photos, and videos to be shared and stored for future reference. This can be of great benefit in the initial weeks post-surgery, as many players will travel abroad to undergo their surgery with their desired surgeon. WhatsApp messaging allows the player to relay information regarding their surgery, the status of their knee such as swelling, pain and range of motion and their overall well-being to the staff daily. It is important to note that this form of communication does not replace standard check-ins via video call or phone, but instead enhances the communication in between check-ins. Due to the understandable anxiety players feel around more sensitive information such as x-ray results and MRI scan results, this sharing of information should ideally be done in person or on the phone. This is not the purpose of the WhatsApp group. Continuous and effective communication is warranted within the caregivers’ team. Having a communication model (e.g., digital clinical records) and periodic (daily if necessary) meetings are the milestones of a well-organised service. Formal and informal communication is key to enhancing the relationship between the different players. The more you communicate within the team, the more you can maximise the patient or athlete’s perception of the recovery path and minimise the risk of misleading information to the patient (Ahmed et al., 2020). The use of WhatsApp groups does however bring the privacy of the patient and the ethical dilemma of sharing private medical information. Depending on the country, the laws around this topic vary, thus ensuring you are in line with your governing body and the specific privacy laws in your jurisdiction.

Conclusion
In conclusion, optimising ACL rehabilitation in professional football requires a comprehensive approach integrating structured multidisciplinary teamwork, meticulous planning, and open communication channels. By establishing clear operational structures within the multidisciplinary team, defining staff roles and responsibilities, and implementing effective planning strategies, such as coordinating return-to-sport training plans early on, the rehabilitation process can be streamlined for optimal outcomes. Moreover, leveraging communication tools like WhatsApp enhances the flow of information between medical staff and athletes, fostering a supportive environment crucial for successful recovery. With these strategies in place, the goal of leaving no stone unturned in ACL rehabilitation within elite football becomes more achievable, ensuring athletes can return to the field with confidence and resilience.

References

Football club doctor – An evolving role – injury rehab network event. Sterosport, https://sterosport.co.uk/dr-imtiaz-ahmad-football-club-doctor-an-evolving-role/

Ahmed, O. H., Carmody, S., Walker, L., & Ahmad, I. (2020). The need for speed! 10 ways that WhatsApp and instant messaging can enhance communication (and clinical care) in sports and exercise medicine. British Journal of Sports Medicine, 54(19), 1128-1129. https://doi.org/10.1136/bjsports-2019-101707

Ardern, C. L. (2015). Anterior cruciate ligament reconstruction—not exactly a one-way ticket back to the pre-injury level. Sports Health: A Multidisciplinary Approach, 7(3), 224-230. https://doi.org/10.1177/1941738115578131

Ardern, C. L., Hooper, N., O’Halloran, P., Webster, K. E., & Kvist, J. (2022). A psychological support intervention to help injured athletes “get back in the game”: design and development study. JMIR Formative Research, 6(8), e28851. https://doi.org/10.2196/28851

Ardern, C. L., Taylor, N. F., Feller, J. A., & Webster, K. E. (2013). A systematic review of the psychological factors associated with returning to sport following injury. British journal of sports medicine, 47(17), 1120–1126. https://doi.org/10.1136/bjsports-2012-091203

Arsenal FC – Staff. (n.d). Transfermarkt. Retrieved February 5, 2024, from https://www.transfermarkt.com/fc-arsenal/mitarbeit/verein/11

Bizzini, M., Hancock, D., & Impellizzeri, F. M. (2012). Suggestions from the field for return to sports participation following anterior cruciate ligament reconstruction: soccer. Journal of Orthopaedic & Sports Physical Therapy, 42(4), 304-312. https://doi.org/10.2519/jospt.2012.4005

Brinlee, A. W., Dickenson, S., Hunter‐Giordano, A., & Snyder‐Mackler, L. (2021). Acl reconstruction rehabilitation: clinical data, biologic healing, and criterion-based milestones to inform a return-to-sport guideline. Sports Health: A Multidisciplinary Approach, 14(5), 770-779. https://doi.org/10.1177/19417381211056873

Christakou, Α. and Lavallee, D. (2009). Rehabilitation from sports injuries: from theory to practice. Perspectives in Public Health, 129(3), 120-126. https://doi.org/10.1177/1466424008094802

Clement, D., & Arvinen-Barrow, M. (2013). Sport medicine team influences in psychological rehabilitation: A multidisciplinary approach. In M. Arvinen-Barrow & N. Walker (Eds.), The psychology of sport injury and rehabilitation(pp. 156–170). Routledge/Taylor & Francis Group.

Football Association. (2023). Premier League Medical regulations. Appointment of medical personnel, 2.1. theFA.com. https://www.thefa.com › rules-of-the-association

Jordan, M. J. and Aagaard, P. (2017). Anterior cruciate ligament injury/reinjury in alpine ski racing: a narrative review. Open Access Journal of Sports Medicine, Volume 8, 71-83. https://doi.org/10.2147/oajsm.s106699

Taberner, M., Dyk, N. v., Allen, T., Jain, N., Richter, C., Drust, B., … & Cohen, D. D. (2020). Physical preparation and return to performance of an elite female football player following ACL reconstruction: a journey to the FIFA women’s World Cup. BMJ Open Sport & Exercise Medicine, 6(1), e000843. https://doi.org/10.1136/bmjsem-2020-000843

Van Melick, N., Van Cingel, R., Brooijmans, F., Neeter, C., Van Tienen, T. G., Hullegie, W., & Sanden, M. W. N. D. (2016). Evidence-based clinical practice update: practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus. British Journal of Sports Medicine, 50(24),1506–1515. https://doi.org/10.1136/bjsports-2015-095898

Villa, F., Villa, S., & Mendes, J. E. (2019). Multidisciplinary sports medicine team. The Sports Medicine Physician, 3-11. https://doi.org/10.1007/978-3-030-10433-7_1

Wright, R. W., Dunn, W. R., Amendola, A., Andrish, J. T., Bergfeld, J. A., Kaeding, C. C., … & Spindler, K. P. (2007). Risk of tearing the intact anterior cruciate ligament in the contralateral knee and rupturing the anterior cruciate ligament graft during the first 2 years after anterior cruciate ligament reconstruction. The American Journal of Sports Medicine, 35(7), 1131-1134. https://doi.org/10.1177/0363546507301318

Ankle Dorsiflexion Mobility Assessment

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The previous article demonstrated how restricted ankle dorsiflexion can impact landing mechanics by increasing ground reaction forces and causing medial knee displacement (Taylor et al., 2021). If you haven’t read it yet, we recommend that you do so in order to understand the importance of ensuring adequate ankle mobility in football players. Read here.

Football is a high-intensity sport with a high number of eccentric muscle actions that occur during changes of direction, jumps or decelerations. Continuous exposure to these types of movement may increase the tightness of the muscles and tendons and cause muscle damage, which will affect the neural properties of the myotendinous unit, reducing the total range of motion throughout the season (Moreno- Pérez et al., 2020), increasing the risk of injury (Mason-Mackay et al., 2017) and negatively influencing sports performance (Gonzalo-Skok et al., 2015).

Although there is general agreement that the lack of ankle dorsiflexion increases the risk of lower limb injuries (Mason-Mackay et al., 2017), there is a notable difference in the evaluations utilized in various scientific articles and in the cut-off values for each test. In addition, there is no consensus on the optimal amount of mobility of this joint and how (lack of) mobility is associated with injury risk.

The tests used to assess ankle mobility can be classified into three categories:

Open Kinetic Chain (OCC)
Closed Kinetic Chain (CCC)
Landing mechanics

Different methods have been used to measure the results of each test, such as a goniometer, inclinometer, or analysis of digital models. In this article, we will not discuss the measurement method.

Open Kinetic Chain (OKC)

This type of evaluation is the least functional to sports activity since all the actions where ankle mobility is important are performed in closed kinetic chains (landings, changes of direction, running, etc.). Although this type of test will not provide us with any information about the control and mobility that the football player has in specific actions, it can be very useful when evaluating mobility restrictions or pain on specific structures.

In these tests, ankle dorsiflexion is evaluated with the patient sitting or lying on the treatment table. The ankle is passively dorsiflexed until the limit of movement is reached. This test should be performed first with the knee extended to assess flexibility of the gastrocnemius muscle, and then with the knee flexed at 90º to assess flexibility of the soleus. (Stovitz & Coetzee, 2004). Stovitz & Coetzee (2004) recommend testing this musculature with the subtalar joint in a neutral position while lateral force is applied to the neck of the talus and the forefoot is pushed medially (Image 1).

In this way, the foot is locked, preventing the eversion of the calcaneus, which could give a false impression of greater flexibility. Ankle dorsiflexion can be limited not only by restrictions in muscle flexibility, but also by intra-articular factors such as tightness of the talocrural posterior capsule, positional faults of the fibula, or reduced posterior glide of the talus relative to the ankle mortise (Howe, 2020).

^{Image 1. OKC ankle mobility assessment. (Stovitz & Coetzee, 2004)}

Several authors recommend that the range of motion in these tests should reach 20º of dorsal flexion (Brockett & Chapman, 2016) (Magee, 2014). Stiffler et al. (2014), compared range of motion values during this type of test in individuals who do not show medial knee displacement during an overhead squat compared to those who do (Image 2). Individuals with greater ankle dorsiflexion range of motion showed less medial knee displacement.

^{Image 2. Range of motion in OKC tests in the study by Stiffler et al. (2014); MKD – Medial knee displacemen}

Due to the significant variation among studies, it is challenging to propose cut-off values. It is essential to compare both legs and ensure the absence of unilateral deficits. There is not much reference data on this type of evaluation in soccer players.

Closed Kinetic Chain (CKC)

In comparison to OKC tests, CKC assessments provide more information about ankle joint mobility in positions similar to those that occur during sports activities. Movement deficits during this type of test have been related to movement alterations that increase the risk of injury, such as knee valgus, excessive hip adduction, or greater trunk inclination (Ivana Hanzlíková et al., 2022).

There are many variations of CKC assessment. One test that is frequently applied is the Weight Bearing Lunge Test (WBLT) or Wall Test (Image 3). In this test, the subject is placed in a lunge position facing a wall, with one leg in front of the other. From this position, the patient lunges forward until the knee touches the wall, keeping the heel on the floor. If there is contact with the wall, the foot is moved back until finding the farthest distance where the knee contacts the wall while the heel remains entirely in contact with the ground. When the limit of movement is reached, the therapist measures the distance from the wall to the tip of the big toe.

^{Image 3. Weight Bearing Lunge Test or Wall test}

There are variations of this test, such as the Leg Motion System Test (Moreno-Pérez et al., 2020) or the Half Kneeling Dorsiflexion Test (Gourlay et al., 2019), but they all consist of the same movement, only varying the measuring device or the position of the rear leg.

Dill et al. (2014) suggested a cutoff value of 44.02º for this test, while other authors, such as Moreno-Pérez et al. (2020), did not specify cutoff values in their studies but indicated that differences of more than 2 cm between legs should be considered as asymmetries that increase the risk of injury. Once again, it is challenging to establish exact cutoff values for soccer players due to the wide range of results in different studies.

The Modified Weight-Bearing Lunge Test, also known as the Ankle Clearing Test (Image 4), is performed with the patient standing with one leg in front of the other. The heel of the front leg is in contact with the toes of the back leg. A dowel is given to the patient to help maintain balance. From this position, the patient moves the knee of the rear leg forward as far as possible, keeping the heel in contact with the ground.

The therapist measures the position of the knee in relation to the medial malleolus of the ankle of the front leg: behind, in line, or beyond (Gourlay, et al., 2019). This test has been shown to be a valid tool in evaluating ankle dorsiflexion and has been compared with the values obtained in the WBLT.

The modified WBLT score corresponds to 33.5 ± 2.0 degrees if the knee is behind the medial malleolus of the front leg, 38.6 ± 1.2 degrees if it is in line, and 43.0 ± 0.78 degrees if it is beyond (Gourlay, et al., 2019). Therefore, soccer players with adequate ankle mobility should be able to move the knee beyond the medial malleolus of the front leg.

^{Image 4.
Modified Weight Bearing Lunge Test or Ankle clearing test}

Image 5 shows two other ankle dorsiflexion tests. One with the knee in extension (Right, the gastrocnemius will limit the result of this test to a greater extent) and another with the knee in flexion (Left, the soleus will limit the result of this test to a greater extent).

^{Image 5.
Tests variations for the measurement of ankle dorsiflexion. Knee in flexion (Front leg; Left); Knee Extension (Back Leg; Right)}

López-Valenciano et al. (2019), in a study with professional soccer players, used cut-off values of <17º for the test with the knee in extension and &<34º for the test with the knee in flexion. Lower values in these tests would be considered movement restrictions, increasing the risk of lower limb injuries.

Landing Mechanics

Various types of landing mechanics assessment have been used to assess lower limb movement mechanics. To summarize, we propose three groups: Bilateral, unilateral, and jump after landing. Once again, due to the wide variety in methodology (such as jump height, measurement method, and instructions during landing), it is challenging to propose standard tests and cut-off values.

^{Image 6. Unilateral and bilateral landing}

One of the most used tests in research is the Landing Error Scoring System” (LESS) test. It is performed from a 30 cm high box, from which the subject jumps forward at a distance equivalent to 50% of the subject’s height. In this test, the landing is bilateral. The system utilizes a 17-item scoring method to identify athletes who are at risk of injury. It is used to assess the ankle and the entire lower limb. In a study conducted by Padua et al. (2015), an example is provided to demonstrate how this evaluation method can be applied to soccer players. You can find the details in the references.

Whitting et al. (2011), conducted a study based on single-leg drop landings from heights of 32 and 72 cm. Malloy et al. (2014) assessed landing mechanics by having participants perform a maximum vertical jump immediately after landing from a box jump, with the height of the box matching the maximum height reached in a previous vertical jump by each participant. In both studies, researchers observed altered movement patterns in participants with limited ankle mobility measured by static tests.

Conclusion
OKC evaluations can help us detect deficits in isolated structures in the early stages of rehabilitation. However, once we have corrected the deficits, we must progress to tests and exercises with more functionality (e.g. CKC tests) and ensure the player is ready for competition.

The CKC tests are a quick and effective way to assess ankle mobility and identify soccer players at higher risk of injury. This makes them a good option when planning injury prevention programs. However, there is debate about whether static assessments are useful in predicting injuries. Even if a football player has good ankle mobility, we don’t know if they use an appropriate landing strategy. There may also be other deficits that predispose the football player to a higher risk of injury, such as excessive knee valgus due to weakness of the gluteal muscles, lack of lumbopelvic control or poor ankle stiffness.

Evaluating the landing mechanics of soccer players who have suffered long-term injuries, such as to the anterior cruciate ligament, or who experience chronic pain, for example, in the Achilles tendon or patellofemoral area, can provide essential information before they finish their rehabilitation and return to train or match play.

In our upcoming blog, the last of this series, we will explore different methods to enhance ankle mobility. We will identify which structures limit the movement and which ones are weakened or inhibited and propose targeted mobilizations and exercises to improve ankle dorsiflexion.

References

Brockett, C., & Chapman, G. (2016). Biomechanics of the ankle. Orthopaedics and trauma, 30(3), 232-238.

Dill, K., Begalle, R., Frank, B., Zinder, S., & Padua, D. (2014). Altered Knee and Ankle Kinematics During Squatting in Those With Limited Weight-Bearing–Lunge Ankle Dorsiflexion Range of Motion. Journal of Athletic Training, 49(6), 723-732.

Gonzalo-Skok, O., Serna, J., Rhea, M. R., & Marin, P. J. (2015). Relationships between Functional Movement Tests and Performance Tests in Young Elite Male Basketball Players. International Journal of Sports Physical Therapy, 10(5), 628-638.

Gourlay, J., Bullock, G., Weaver, A., Matsel, K., Kiesel, K., & Plisky, P. (2019). The Reliability and Criterion Validity of a Novel Dorsiflexion Range of Motion Screen. Athletic Training and Sports Health Care, 12(1).

Howe, L. P. (2020). Restrictions in ankle dorsiflexion range of motion and its effect on landing mechanics. Thesis, Ede Hill University.

Ivana Hanzlíková, I., Richards, J., & Hébert Losier, K. (2022). The influence of ankle dorsiflexion range of motion on unanticipated cutting kinematics. Sport Sciences for Health.

López-Valenciano, A., Ayala, F., Vera-García, F., De Ste Croix, M., Hernández, S., Ruiz, I., Cejudo, A., Santonja, F. (2019). Comprehensive profile of hip, knee and ankle ranges of motion in professional football players. The Journal of Sports Medicine and Physical Fitness, 59(1), 102-109.

Magee, D. (2014). Orthopedic Physical Assessment (Sixth ed.). St Louis, Missouri: Elsevier.

Malloy, P., Meinerz, C., Geiser, C., & Kipp, K. (2015). The Association of Dorsiflexion Flexibility on Landing Mechanics during a Drop Vertical Jump. Knee Surgery, Sports Traumatology, Arthroscopy, 23(12).

Mason-Mackay, A., Whatman, C., & Reid, D. (2017). The effect of reduced ankle dorsiflexion on lower extremity mechanics during landing: A systematic review. Journal of Science and Medicine in Sport, 20, 451–458.

Moreno-Pérez, V., Soler, A., Ansa, A., López-Samanes, Á., Madruga-Parera, M., Beato, M., & Romero-Rodríguez, D. (2020). Acute and chronic effects of competition on ankle dorsiflexion ROM in professional football players. European Journal of Sports Science, 20(1), 51-60.

Padua, D., DiStefano, L., Beutler, A., de la Motte, S., DiStefano, M., & Marshall, S. (2015). The Landing Error Scoring System as a Screening Tool for an Anterior Cruciate Ligament Injury–Prevention Program in Elite-Youth Soccer Athletes. Journal of Athletic Training, 50(6), 589-595.

Stiffler, M., Pennuto, A., Smith, M., Olson, M., & Bell, D. (2014). Range of Motion, Postural Alignment, and LESS Score Differences of Those With and Without Excessive Medial Knee Displacement. Clinical journal of sport medicine: official journal of the Canadian Academy of Sport Medicine, 25, 61-66.

Stovitz, S., & Coetzee, C. (2004). Hyperpronation and Foot Pain – Steps Toward Pain-Free Feet. The Physician and Sportsmedicine, 32(8), 19-26.

Taylor, J., Wright, E., Waxman, J., Schmitz, R., Groves, J., & Shultz, S. (2021). Ankle dorsiflexion affects hip and knee biomechanics during landing. Sports health.

Whitting, J., Steele, J., McGhee, D., & Munro, B. (2011). Dorsiflexion Capacity Affects Achilles Tendon Loading during Drop Landings. MEDICINE & SCIENCE IN SPORTS & EXERCISE, 43(4), 706-713.

Ankle mobility and landing mechanics

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Football is a sport with a high incidence of knee injuries. Among them, the anterior cruciate ligament (ACL) rupture occurs frequently. ACL injury can lead to significant time off the field for players as they undergo months of rehabilitation and training before being cleared to compete again. Several risk factors have been associated with ACL tears, with a particular emphasis on aspects related to thigh muscle strength, hip and trunk stability, and the player’s ability to stabilise their lower limb during movements such as landings and changes of direction. However, ankle dorsiflexion limitations are often overlooked as a risk factor, but they can profoundly impact the mechanics of movement in the entire lower limb, including muscle activation and even the positioning of the trunk. In this article, we will show why it is essential to ensure that our team players have optimal ankle mobility and use correct motor control strategies during landing.

Research has identified two biomechanical patterns associated with knee injuries: dynamic valgus of the lower limb and limited knee flexion. (Taylor, et al., 2021)(Figure 1). Although it may not seem like it, ankle dorsiflexion largely determines the outcome of these two movement patterns.

^{Figure 1. Knee valgus (Left), restricted knee flexion during landing (Middle) and unrestricted knee flexion during landing (Right).}

When ankle dorsiflexion movement is restricted, the ability to flex the knee during landing is limited since knee flexion must be accompanied by ankle dorsiflexion and hip flexion to maintain balance. Otherwise, the body’s center of gravity would shift backwards, and we would lose our balance and fall backwards. This lack of lower limb flexion will lead to stiffer landing techniques and changes of direction, increasing ground reaction forces (Mason-Mackay, et al., 2017) and the load on the lower limb joints (Ivana Hanzlíková, et al., 2022), especially the knee and lower back (ankle mobility deficits are usually compensated by excessive forward lean).

In addition, this stiffness and lack of flexion of the lower limb during landings is also associated with compensatory movements that increase the risk of injury. Lack of ankle dorsiflexion has been associated with increased foot and ankle pronation, greater knee abduction, and increased hip adduction (Taylor, et al., 2021)(Figure 2).
These compensatory movements cause the knee to be displaced medially (known as knee valgus), increasing the chances of sustaining ACL injuries.

^{Figure 2. Flexed landing (Left) vs stiff landing (Right)}

Therefore, football players with ankle mobility restrictions (widespread in players who have suffered ankle sprains) will use landing strategies with a more extended knee and greater medial knee displacement (Mason-Mackay, et al., 2017). When a hyperextended and valgus knee undergoes a sudden rotation, it reaches “the point of no return,” which often results in an ACL tear.

After each jump, landing or change of direction, the football player’s lower limb supports very high loads. Hence, mobility, strength and control of the entire kinetic chain are crucial in preventing knee injuries. The foot and the ankle are located in the distal part of this kinetic chain and will condition force transmission and movement mechanics of the entire lower limb.

It is vital to know how to assess and correct these deficits, and we must also know how to teach efficient and safe landing strategies that minimise the risk of injury. Our bodies use large muscle chains to generate movement. Any deficiency in mobility, strength, or control of any part of this chain can create movement compensations, which may increase the risk of injury and impair performance. Assessing and correcting deficits and functionally training the ankle joint should be an essential part of our training programs.

This is the first in a series of three blog posts about ankle dorsiflexion. In the next one, we’ll dive into how to assess ankle dorsiflexion mobility, and in the last one, we’ll cover how to correct and train restricted ankle mobility.

Follow us for a lot more!

References

Ivana Hanzlíková, I., Richards, J. & Hébert Losier, K., 2022. The influence of ankle dorsiflexion range of motion on unanticipated cutting kinematics. Sport Sciences for Health.

Mason-Mackaya, A., Whatmana, C. & Reidb, D., 2017. The effect of reduced ankle dorsiflexion on lower extremity mechanics during landing: A systematic review. Journal of Science and Medicine in Sport, Volumen 20, p. 451–458.

Taylor, J. y otros, 2021. Ankle dorsiflexion affects hip and knee biomechanics during landing. Sports health.

Hamstring injuries in football, pt 3

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Part 3: Post-injury evaluation

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Before starting any training program, we must know how to assess post-injury deficits and the player’s movement. We can do hundreds of tests, but what is essential is the muscle function or movement being evaluated. We will provide several examples.

Assessment
Pain
Pain is one of the most used criteria in injury rehabilitation protocols. During each test, we must assess pain, as well as during strength and conditioning exercises. Some research has shown significant improvements after rehabilitation protocols using pain thresholds compared to pain-free rehabilitation
(Hickey et al., 2020). However, there is still a large amount of research recommending pain-free training. We must be cautious when training athletes with movement deficits or associated injuries like low back pain.

Several rehabilitation guides recommend tenderness to palpation as one of the criteria that we must control. Aspetar Hamstring Protocol recommends recording the length and width of the area of maximum pain and the distance between it and the ischial tuberosity.

In this first phase, we can record pain in daily activities such as walking, going up and down stairs, sitting and getting up, etc.
It is also essential to record pain in each test we perform.

Strength
The hamstrings, in addition to knee flexors and hip extensors, are knee stabilisers, especially during high-intensity running. As the rehabilitation progresses,
we will progress in speed, resistance, and range of motion. Isokinetic evaluation is the most precise and used method in research, but we can also use a dynamometer or manual resistance. The latter is the fastest and most effective assessment when we want to detect painful positions, although the other two forms will give us much more precise data at the end of the rehabilitation.

Knee flexion – The soccer player is lying prone for the first test, with the hip extended and the knee in 90º of flexion (Image 1). In this position, the soccer player performs three maximum isometric contractions of 3 seconds each, with a few seconds of rest between repetitions (If there is pain, we must stop). If there is no pain in this position, we can progress to the next test with the knee at about 30º of flexion and then in full extension. The progression continues with the player lying supine with the hip in 90º of flexion to evaluate the force with the knee at 90º, 45º, and maximum extension (Image 1).

^{Image 1. Different positions to measure knee flexion strength}

Hip extension – The glute bridge exercise may be used to assess hip extension ability. Although we will see how to evaluate the hip hinge pattern later, this exercise is also very useful and can help detect movement deficits. In this exercise, it is prevalent for players to exert more effort with the uninjured leg due to pain or fear after injury. If we detect this, I recommend evaluating the hip extension strength with the Prone Hip Extension Test (Image 2), placing the resistance in the popliteal region.

^{Image 2. Prone hip extension test (Schuermans, et al., 2017)}

Lower limb stability – In several rehabilitation guides, evaluating the athlete’s stability and proprioception is also recommended. To begin, we can perform a Single Leg Squat to assess the stability of the lower limb and core and hip strength (Ugalde et al., 2015). If there is pain or insecurity, the test may be started by sitting on a high bench or a massage table, standing up with one leg, and returning to the starting position (Image 3).
In this test, we must evaluate if there is knee valgus or pelvic sway (Trendelenburg Sign) or if balance is lost due to instability of the upper limb.

^{Image 3. Single leg Squat (Aspetar Hamstring Protocol)}

If the footballer cannot perform a single leg Squat, the Trendelenburg Test may be used (Image 4 and Video 1). This test evaluates the stability of the pelvis and trunk during unilateral support (Wilshaw et al., 2020).
There is a modified version of the Trendelenburg Test that is arguably better suited for evaluating muscle function in athletes. In this test, the wall is not used as support, and the arms are free.

Deficits in trunk and pelvic control during the Modified Trendelenburg Test have been shown to be a risk factor in lower limb injuries
(Image 5), especially of the knee (Anterior cruciate ligament) (Leppänen et al., 2020).
The hamstrings play a crucial role in stabilising the knee. Deficits as a result of a hamstring injury, in combination with poor lumbopelvic control, can significantly increase the risk of suffering serious knee injuries.

^{Video 1. Trendelenburg Test}

^{Image 4. Trendelenburg gait (Gandbhir, et al., 2021)}

^{Image 5. Lateral pelvic hike during the standing knee lift test and proportion of subjects with knee injuries (Leppänen et al., 2020).}

Range of Motion (ROM)

Hip flexion and knee extension ROM may be affected after a hamstring injury. I have chosen several tests based on different hip and knee positions to evaluate it. Each test can be performed actively or passively. In all tests, we must ensure no compensatory movement in the lumbopelvic area, especially at the end of the movement.

The Straight Leg Raise Test (Image 6A) is one of the most used tests to assess hip flexion ROM. With the patient lying supine, the leg is raised with the knee extended to the point where there is an onset of pelvic movement, or the patient feels a robust and tolerable stretch without pain (López-Valenciano et al., 2019).

The Knee Extension Test (Image 6B) also begins in a supine lying position, but now, the hip is flexed 90º, and the hands are held behind the knee. The maximum possible stretch is performed in this position following the same criteria as in the previous test (López-Valenciano et al., 2019). We can also evaluate knee extension ROM with the hip in maximum flexion as the Aspetar guide recommends. This test can also assess the maximum hip flexion angle prior to knee extension (Image 6 C).

Thomas Test (Image 7). In this test, the athlete lies supine with the hips on the table’s edge. With both arms, one leg is held in maximum hip flexion while the other is relaxed with the hip in extension. In this test, there are several movement patterns that can provide much information.

Restricted hip flexion (Image 7A) – This may be due to pain after an injury or muscle restrictions in the posterior musculature of the leg being held.

Restricted hip extension (Image 7B) –
The psoas is a muscle that tends to shorten and can generate anterior pelvic tilt. It is usually associated with excessive tension in the anterior thigh muscles. This shortening is also associated with gluteus maximus weakness due to reciprocal inhibition (Buckthorpe et al., 2019).

Restricted knee flexion (Image 7C) – A prevalent pattern in soccer players, big and powerful quadriceps, but shortened and under excessive tension.

Knee external rotation (Image 7D) –
One of the most common causes is excessive tension in the iliotibial band. The tensor fascia lata may be overactive due to weakness of the gluteal muscles (Selkowitz, et al., 2013).

This movement pattern is also associated with increased internal hip rotation and knee adduction, increasing the risk of knee injuries (Baker & Fredericson, 2016).

^{Image 7. Thomas Test}

In professional soccer players, ankle mobility deficits have been observed (López-Valenciano et al., 2019). Research has shown that myofascial connections through the whole posterior muscle chain can transmit forces through the joints (Wilke et al., 2016), in this case, at the knee (Wilke et al., 2020). Although the relationship between hamstring injuries and mobility restrictions of the ankle-joint complex has not been researched, it may be interesting to investigate this further.

Although there are several tests to evaluate ankle mobility
(Mason-Mackay et al., 2017), weight-bearing variations seem to be most representative of the function performed by the lower limb during sports activities (Powden et al., 2015). In Image 8, two tests are shown, one with a flexed knee (Image 8A) and another with an extended knee (Image 8B).

^{Image 8. Ankle mobility tests (López-Valenciano et al., 2019)}

Table 1 shows reference values that have been used to evaluate hip, knee, and ankle ROM.

Lumbopelvic motor control

Pelvic control during high-intensity actions is crucial to the prevention of hamstring injuries. This is especially important for young football players.

In addition to specific motor patterns that require correct hip function, we must also evaluate lumbar stabilisation capacity when extension, flexion, rotation, and lateral flexion forces are exerted (Adelt et al., 2021).

The hip hinge is a fundamental movement pattern for the correct and effective execution of most exercises. If not performed well, the lumbar spine will compensate for the hip’s lack of mobility and strength. The Waiters Bow (Image 9A) is a test used to detect a lack of motor control during hip flexion.
This test evaluates the ability to flex the hip (50-70º) while standing in a neutral lumbar position (Luomajoki et al., 2007).
The test result will be negative if there is lumbar flexion or inability to reach at least 50º of hip flexion.

To evaluate control capacity over lateral flexion forces, we can use tests such as the modified Trendelenburg Test or the One Leg Stance Test (Meier et al., 2021) (Image 9B). The lateral displacement of the trunk in the last test should be less than 10 cm, and the difference between the right and left sides should be lower than 2 cm (Luomajoki et al., 2007).

Control over lumbar rotation can be evaluated with the crook lying test (Luomajoki et al., 2007) (Image 9C), in which abduction and external hip rotation are performed while lying supine with the knees flexed. There should be no compensatory movement of the pelvis or hip ROM deficits.

Lumbar hyperextension can cause excessive pelvic anterior tilt, increasing the risk of injury. For example, the Rocking Forwards Test (Image 9D) has been recommended to evaluate movement deficits in patients with low back pain (Meier et al., 2021). From the quadruped position, the hips are extended, and the body leans forward. As in all other tests, the result will be positive if the lumbar area is kept in a neutral position while the movement is performed.

^{Image 9. Lumbopelvic assessment (Luomajoki et al., 2007); A: Waiters bow; B: One leg stance test; C: Crook lying test; D: Rocking forwards Test}

For those of you who are interested in more lumbar stability assessment, I recommend the following literature: Adelt et al. (2021), Biele et al. (2019), and the work of Stuart McGill, especially his book Ultimate Back Fitness and Performance (2004).

References

Adelt, E., Schoettker-Koeniger, T., Luedtke, K., Hall, T., & Schafer, A. (2021). Lumbar movement control in non-specific chronic low back pain: Evaluation of a direction-specific battery of tests using item response theory. Musculoskeletal Science and Practice, 55.

Aspetar. (s.f.). Aspetar Hamstring Protocol. Orthopae dic & Sports Medicine Hospital.

Baker, R., & Fredericson, M. (2016). Iliotibial band syndrome in runners. Biomechanical implications and exercise interventions. Physical Medicine and Rehabilitation Clinics of North America, 27, 53-77.

Biele, C., Möller, D., von Piekartz, H., Hall, T., & Ballenberger, N. (2019). Validity of increasing the number of motor control tests within a test battery for discrimination of low back pain conditions in people attending a physiotherapy clinic: a case–control study. BMJ Open, 9.

Buckthorpe, M., Stride, M., & Della Villa, F. (2019). Assessing and treating gluteus maximus weakness – A clinical commentary. The International Journal of Sports Physical Therapy, 655-670.

Gandbhir, V., Lam, J., & Rayi, A. (2021). Trendelenburg gait. Obtenido de https://www.ncbi.nlm.nih.gov/books/NBK541094/

Hickey, J., Timmins, R., Maniar, N., Rio, E., Hickey, P., Pitcher, C., . . . Opar, D. (2020). Pain-free versus Pain-threshold rehabilitation following acute hamstring strain injury: A randomized controlled trial. Journal of Orthopaedic & Sports Physical Therapy, 50(2), 91-103.

Leppänen, M., Marko, R., Jari, P., Ari, H., Sami, A., Ton, K., . . . Kati, P. (2020). Altered hip control during a standing knee lift test is associated with increased risk of knee injuries. Scandinavian Journal of Medicine and Science in Sports, 30(5), 922-931.

López-Valenciano, A., Ayala, F., Vera-García, F., De Ste Croix, M., Hernández, S., Ruiz, I., . . . Santonja, F. (2019). Comprehensive profile of hip, knee and ankle ranges of motion in professional football players. The Journal of Sports Medicine and Physical Fitness, 59(1), 102-109.

Luomajoki, H., Kool, J., de Bruin, E., & Airaksinen, O. (2007). Reliability of movement control tests in the lumbar spine. BMC Musculoskeletal Disorders, 8(90).

Mason-Mackay, Whatman, C., & Reid, D. (2017). The effect of reduced ankle dorsiflexion on lower extremity mechanics during landing: A systematic review. Journal of Science and Medicine in Sport, 20, 451-458.

Mcgill, S. (2009). Ultimate back fitness and performance (Fourth ed.). Waterloo: Wabuno Publishers.

Meier, R., Emch, C., Gross-Wolf, C., Pfeiffer, F., Meichtry, A., Schmid, A., & Luomajoki, H. (2021). Sensorimotor and body perception assessments of nonspecific chronic low back pain: a cross-sectional study. BMC Musculoskeletal Disorders, 22(391).

Pollock, N., James, S., Lee, J., & Chakraverty, R. (2014). British athletics muscle injury classification: A new grading system. British Journal of Sport Medicine, 48, 1347-1351.

Powden, C., Hoch, J., & Hoch, M. (2015). Reliability and minimal detectable change of the weight-bearing lunge test: A systematic review. Manual Therapy, 20(4), 524-532.

Schuermans, J., Van Tiggelen, D., & Witvrouw, E. (2017). Prone Hip Extension Muscle Recruitment is Associated with Hamstring Injury Risk in Amateur Soccer. International Journal of Sports Medicine, 696- 706.

Selkowitz, D., Beneck, G., & Powers, C. (2013). Which Exercises Target the Gluteal Muscles While Minimizing Activation of the Tensor Fascia Lata? Electromyographic Assessment Using Fine-Wire Electrodes. Journal of Orthopaedic & Sports Physical Therapy, 43(2).

Ugalde, V., Brockman, C., Bailowitz, Z., & Pollard, C. (2015). Single Leg Squat Test and its relationship to dynamic knee valgus and injury risk screening. American Academy of Physical Medicine and Rehabilitation(7), 229-235.

Wilke, J., Debelle, H., Tenberg, S., Dilley, A., & Maganaris, C. (2020). Ankle motion is associated with soft tissue displacement in the dorsal thigh: An in vivo investigation suggesting myofascial force transmission across the knee joint. Frontiers in Phisiology, 11(180).

Wilke, J., Krause, F., Vogt, L., & Banzer, W. (2016). What is evidence-based about myofascial chains: A systematic review. Archives of physical medicine and rehabilitation, 454-461.

Yildirim, M., Tuna, F., Kabayel, D., & Sut, N. (2018). The Cut-off values for the diagnosis of hamstring shortness and related factors. Balkan Medical Journal, 35, 388-393.