This document discusses the rehabilitation process for quadriceps muscle injuries from initial injury through return to play. It begins by covering injury classification and the muscle architecture of the quadriceps. It then discusses muscle mechanics in running and kicking sports. Rehabilitation stages are outlined from early isometric exercises to advanced functional training mimicking sports movements. A case study is presented of an athlete who suffered multiple quadriceps injuries and underwent a rehabilitation process focused on hypertrophy, tendon elasticity and returning to high intensity running.

1. Quadriceps Muscle Injury:
From Injury Day to Return to Play
VIIIth MuscleTech Network workshop
FC Barcelona, 3rd-4th October 2016
James Moore
Head of Performance Team GB
Intensive Rehabilitation Manager – British Olympic Association

2. Mechanism
Under striding vs. bwd lean vs. Hip extension vs. backswing vs. VGRF
Sports Mechanism
Sprinting vs. Kicking (high vs. low velocity of limb movement)
Location
Proximal vs. Mid vs. Distal / Tendon vs. Muscle vs. Fascia
Size / Grade
0, 1, 2, 3, 4
Functionality
Of the region (architecture) vs. The individual (kinetics) vs. Sport Specific
INJURY PROFILE / CLASSIFICATION
Marshall 2002

3. MUSCLE ARCHITECHTURE

4. MUSCLE ARCHITECHTURE
Muscle
Fibre Length
(cm)
Pennation
(degrees)
PCSA (cm2)
Peak Force
(N)
Psoas 11.69 – 10.4 10.6 – 8.0 7.7 – 14.8 370 – 479.7
Iliacus 10.66 – 10.0 14.3 – 7.0 9.9 – 17.2 430 – 621.9
Sartorius 40.30 – 57.9 1.3 – 0 1.9 – 1.7 105
Rectus Femoris 7.59 – 8.4 13.9 – 5.0 13.9 – 12.8 780 – 848.8
Vast Lateralis 9.94 – 9.9 18.4 -18.4 35.1 – 37.0 2255.4
Vast intermedialis 9.93 – 9.9 4.5 – 4.5 16.7 – 16.8 1024.2
Vast Medialis 9.68 – 9.7 29.6 – 29.6 20.6 – 23.7 1443.7
Ward 2009, Torry 2006, Arnold 2010
• Hip Flexors produced only a small amount of passive joint moment at
200 < 5Nm – only slightly exceed optimal fibre length in this position
• Largest contributors were Psoas, Adductor Longus and Iliacus – 1.2
normalised fibre length

5. MUSCLE PROFILE - ARCHITECHTURE
Ward 2009

6. Muscle stiffness is regulated by:
1. Muscle activation frequency (temporal summation) (Hill 1970)
2. Muscle fibre recruitment (spatial summation)(Moritani 1979)
3. The sarcomere length-tension relationship (Gordan 1966)
4. Sarcomere force-velocity relationship (Hill 1970)
5. Passive sarcomere length-tension relationships (Horowits 1987)
6. Intrafusal and extrafusal (muscle spindle)fibres feedback mechanisms
(Lieber 1992)
7. Muscle force and moment regulation by skeletal muscle architecture
(Gans 1982, Zajac 1992)
MUSCLE STIFFNESS

7. SPORT MECHANICS

8. MUSCLE FORCES IN WALKING AND SLOW RUNNING
Pandy 2010

9. MUSCLE CONTRIBUTION IN WALKING & RUNNING
Pandy 2010

10. RUNNING AT 3.4M/S
Pandy 2010

11. MUSCLE ACTIVATION IN RUNNING
Riley 2010

12. MUSCLE CONTRIBUTION TO SAGITTAL PLANE
Dorn 2012

13. MUSCLE RUNNING MECHANICS
Dorn 2012

14. VGRF MUSCLE CONTRIBUTION
Dorn 2012

15. Wiemann 1995
DEMANDS OF THE SPORT

16. Wiemann 1995
DEMANDS OF THE SPORT

17. Wiemann 1995
DEMANDS OF THE SPORT

18. Wiemann 1995
DEMANDS OF THE SPORT

19. Wiemann 1995
DEMANDS OF THE SPORT

20. PHYSICS OF KICKING
• During kicking – hip has the highest net
force with a ballistic impact
• 15% of kinetic energy is absorbed by the
ball
• Thigh is moving at up to 5000
/sec
• Remaining force dissipated through the
body
• Traction / eccentric load on the groin
Barfield 1998

21. MAXIMAL EFFORT KICKING IN SOCCER
Charnock 2009
Adductor longus was active throughout the
swing phase
Maximum activation and eccentric load
occurred at peak hip extension

22. ATHLETE PROFILE

23. MOVEMENT PROFILE OF THE ATHLETE

24. SPECIFIC PROFILE

25. LACTATE PROFILE

26. REHAB SELECTION

27. Effective DDx & Classification
1st 48 hours is critical – do not be afraid to off-load with crutches
Athlete Profile
Sport Profile
Athlete specific clinical outcome measures
Need to pass clinical measures at each stage – stretch, force, palpation
Capacity Assessment within the rehab
KEY DECISIONS

28. EARLY STAGE - Isometric
CKC, Hip focus OKC, Knee focus CKC, Ankle focus
Prescription – 6 second isometric, 5 reps, 4-8 sets

29. INTERMEDIATE STAGE - ECCENTRIC
Proximal vs. Distal focus
Prescription – 5 sets of 5, on 402 tempo

31. Repeated bike sprint efforts
(>140rpm) 30s duration – GH production (Stokes 2010)
Single leg strength endurance challenge
1 Leg Hack Squat vs. Step Ups
Speed frequency loading in Quadriceps
Velocity & Volume
Drop Jump capacity
Return to running

32. ADVANCED STAGE – FUNCTIONAL RTR
Prescription – 10 reps, 10 second x3 = 1 set

33. Decline Bench Dynamic Flexion
Gravity
Wt of limb
Contralateral
Ms Activation
&
Force

34. Standing Open Chain Flexion
• External light
resistance
• Velocity

35. Reactive Open Chain Flexion
Very light
resistance
Recoil with good
alignment

36. Single leg loading - Step ups
Vickers 2001

37. 60cm LANDING
44%
34%
22%
Pruyn 2014

38. MONITOR PROGRESSION
0
200
400
600
800
Mon Tue Wed Thu Fri Sat
S&C Bike
Training Load

39. PHILOSOPHY
CASE STUDY

40. OUR PHILOSOPHY

41. Diagnosis is key
Design based on architecture
Design based on sport demand
Design based on athlete profile
Use outcome measures that equate to running
Use outcome measures that equate to kicking
Add in variability
SUMMARY

42. Background -
• 2006 - CWG Gold – Bilateral Achilles repair.
• 2007 - WC Gold, 2008 OG Gold
• 2009 – WC 5th, Pars fracture and HHT
• 2010 – 80% complete rupture – direct & indirect heads of RF, 10cm
retraction
• Mechanism – High speed running in PPT, on foot contact
• Focus – hypertrophy of Iliacus & Psoas
• 2011 – recurrent myofascial tears distal MTU with tendonopathic changes
and Myositis Ossificans
• Focus – regaining tendon E absorption – L-T & F-V relationship.
ATHLETE CASE STUDY

43. THE RESULT

44. Rio medal haul 27 – 23 – 17
• Total medallists - 145
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