Return to Play in Rectus
Femoris Muscle Injuries
Our Experience with
Professional Football Players
Juanjo Brau, Physiotherapist
Edu Pons, Sport Science
Ricard Pruna, MD, PhD
Javier Yanguas, MD, PhD
MuscleTech Network
Tuesday, 4th October 2016

• This is a proposal of specific in-field return-to-play process of a professional
football player.
• It can be open to opinions (of course), it’s only our contribution in terms of
searching a better way for healing football players in optimal conditions.
• This presentation reflects the opinion of the authors and we are consient that
this is not an absolut true.
FCBarcelona 1st Team Medical Staff
First of all…
MuscleTech Network
Tuesday, 4th October 2016

Short-axis US view
US exam 24 hours after injury
(Complete tear of rectus femoris involving direct and indirect heads)
Long-axis US view
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Tuesday, 4th October 2016

MRI exam 7 days after injury
(Complete tear of rectus femoris involving direct and indirect heads)
Axial MRI image Coronal MRI image Sagital MRI image
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Tuesday, 4th October 2016

Why conservative treatment… in this case?
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Tuesday, 4th October 2016
FCBarcelona Position Stand (Muscle Injuries Clinical Guide 3.0)
• Non dominant leg.
• Player’s opinion in a private meeting with medical staff.
• Opportunity to conservative treatment: up to 4 weeks.

The 4 steps of the in-field return-to-play process
Return to team
MuscleTech Network
Tuesday, 4th October 2016
Running circuits in dry sand
Main goals of the 1st step (running circuits in dry sand):
• Start running.
• Propioception and coordination (both controlled) actions.
Main goals of the 2nd step (circuits in dry sand including the ball):
• Increase the difficulty (propioception and coordination actions).
• Sport-specific movements.
• Increase strength (higher energy demands due to the instability of the surface and associated activation of accesory muscle groups).
Circuits in dry sand (including the ball)
Uphill & Downhill running
Main goals of the 3rd step (uphill & downhill running):
• Strength training (speed winnings) protecting rectus femoris.
• Specific (controlled) eccentric demands.
• Posterior muscle chain demands.
Specific football in-field circuits
Main goals of the 4th step (specific football in-field circuits):
• All specific football skills.
week 1 week 2 week 3 week 4 week 5 week 6 week 7 week 8 week 9 week 10
Injury
Gym & Phisiotherapy
All clear
PRP PRP PRP

Dry sand training: justification of its use (what bibliography says?)
MuscleTech Network
Tuesday, 4th October 2016

110 89
30 23
137
109
49 31 50 46
271 272
64 67
313 322
87 101 90 104
Left
Vertical
Impact
Right
Vertical
Impact
Total Left
Steps
Total
Right
Steps
Left Mag
Impact
Right Mag
Impact
Left
Lateral
Impact
Right
Lateral
Impact
Left Ant
Post
Impact
Right Ant
Post
Impact
85
61
17
3 2 1 1
129
80
27
13 6 2 2
Impacts Impacts Zone1 Impacts Zone2 Impacts Zone3 Impacts Zone4 Impacts Zone5 Impacts Zone6
6
4 4
16
5 4
Dynamic
Stress Load
PIC MAX
ACCEL
PIC MAX
DESAC
87
19
87
22
Distance Total Max Speed
24
8
4
7
2
26
10
4
8
2
HML Distance Accelerations
Z4 to Z6
Deceleration
Z4 to Z6
129
33
140
32
DISTANCIA EQUI.
METABOLIC
METABOLIC
DISTANCE
Dry sand training: justification of its use (our personal experience)
MuscleTech Network
Tuesday, 4th October 2016Juanjo Brau, 2015

3m 3m
3m
3m
3m 3m
5m
2 x 3 repetitions 3 repetitions
5 repetitions
1st Step: Running Circuits In Dry Sand
4 repetitions

MuscleTech Network
Tuesday, 4th October 2016
Main goals of the 1st step (running circuits in dry sand):
• Start running.
• Propioception and coordination (both controlled) actions.

Injured player
Total time 0:28:54
Total distance 1856
Peak speed 16,78
HML distance 186,16
HML distance / min 6,42
Average Metabolic Power 5,81
Total impacts 996
Impacts Z1 (3 to 5 G) 923
Impacts Z2 (5 to 7 G) 68
Impacts Z3 (7 to 9 G) 5
Impacts Z4 (9 to 11 G) 0
Impacts Z5 (11 to 13 G) 0
Impacts Z6 (13 to 15 G) 0
DSL 25,95
DSL / HML distance 0,14
Impacts are identified as maximum accelerometer magnitude values above
2G in a 0.1 second period. Different impacts zones are presented: Z1 (from 3
to 5G), Z2 (from 5 to 7G), Z3 (from 7 to 9G), Z4 (from 9 to 11G), Z5 (from 11
to 13G) and Z6 (from 13 to 15G).
Dynamic Stress Load (DSL) is the total of the weighted impacts, which is
based on accelerometer values of magnitude above 2G. Impacts are a mixture
of collisions and step impacts while running. In sports such as soccer DSL is
very much dominated by running step peak impacts.
High Metabolic Load (HML) Distance is the distance (metres) travelled by a
player when their Metabolic Power (Energy Consumption per Kilogramme per
second) is above the value of 25.5 W/Kg. This value of 25.5 corresponds to
when a player is running at a constant speed of 5.5m/s on grass or when they
are performing significant acceleration or deceleration activity, for example if
they are accelerating from 2 to 4m/s over 1 second.
Average Metabolic Power is the energy expended by the player per second
per kg for the player based on running on grass. The unit is W/Kg. The
measures combine the energy expenditure associated with constant speed
activity as well as acceleration and deceleration activity.
MuscleTech Network
Tuesday, 4th October 2016

2nd Step: Running Circuits In Dry Sand With The Ball
MuscleTech Network
Tuesday, 4th October 2016
Main goals of the 2nd step (circuits in dry sand including the ball):
• Increase the difficulty (propioception and coordination actions).
• Sport-specific movements.
• Increase strength (higher energy demands due to the instability of the
surface and associated activation of accesory muscle groups).

Injured player Team B Team A
Total time 0:19:23 0:52:25 0:52:25
Total distance 1286,88 1693,98 3740,9
Peak speed 16,34 24,08 24,72
HML distance 113,67 206,2 574,43
HML distance / min 5,86 3,93 10,95
Average Metabolic Power 5,61 5,12 6,96
Total impacts 927 695 2403
Impacts Z1 (3 to 5 G) 780 484 1754
Impacts Z2 (5 to 7 G) 134 143 467
Impacts Z3 (7 to 9 G) 12 51 125
Impacts Z4 (9 to 11 G) 1 11 37
Impacts Z5 (11 to 13 G) 0 3 10
Impacts Z6 (13 to 15 G) 0 1 8
DSL 28,31 61,34 151,68
DSL / HML distance 0,25 0,29 0,25
MuscleTech Network
Tuesday, 4th October 2016
Group of players after National Team’s matches
Rest of the FCB 1st team

Example of circuit for phase-progression
criteria
21.03.16 28.03.16 15.04.16
Max speed (km/h) 15 17,1 17,4
HML distance 31,7 125,2 175,3
HML efforts 5 19 29
Total Accelerations 46 41 36
zone 1 (0-1 m/s2) 11 6 5
zone 2 (1-2 m/s2) 27 29 23
zone 3 (2-3 m/s2) 8 6 8
zone 4 (3-4 m/s2) 0 0 0
zone 5 (4-5 m/s2) 0 0 0
zone 6 (5-6 m/s2) 0 0 0
Total Declerations 38 37 34
zone 1 (0-1 m/s2) 3 4 1
zone 2 (1-2 m/s2) 34 13 15
zone 3 (2-3 m/s2) 1 20 18
zone 4 (3-4 m/s2) 0 0 0
zone 5 (4-5 m/s2) 0 0 0
zone 6 (5-6 m/s2) 0 0 0
Metabolic power 8,4 9 8,5
Equivalent metabolic distance 763,5 821,4 831
Total Impacts 326 322 371
zone 1 (from 3 to 5 G) 313 293 301
zone 2 (from 5 to 7 G) 13 28 55
zone 3 (from 7 to 9 G) 0 1 14
zone 4 (from 9 to 11 G) 0 0 0
zone 5 (from 11 to 13 G) 0 0 0
zone 6 (from 13 to 15 G) 0 0 1
DSL 7,4 8,9 15,5
MuscleTech Network
Tuesday, 4th October 2016
Repeat several times and check the improvement of the player.
Limitations are:
• Pain.
• Discomfort of the player performing exercises.
• Non satisfactory GPS results.
6 diagonal runs x 5 reps
(1 min of resting between reps)

Uphill/Downhill running: justification of its use (what bibliography says?)

MuscleTech Network
Tuesday, 4th October 2016
In uphill running the low activation
of RF (injured muscle) can protect
it aginst muscle soreness

3rd Step: Uphill & Downhill Running (10% Slope)
MuscleTech Network
Tuesday, 4th October 2016
Main goals of the 3rd step (uphill & downhill running):
• Strength training (speed winnings) protecting rectus femoris.
• Specific (controlled) eccentric demands.
• Posterior muscle chain demands.

Injured player Forward 1 Forward 2 Forward 3 Forward 4
Total time 0:17:43 1:05:26 1:05:26 1:05:26 1:05:26
Total distance 1307 4058 4890 3392 4646
Peak speed 29,3 26,53 28,37 27,97 25,78
Sprints 19 15 13 12 15
HML distance 368,24 784,27 762,39 460,77 765,37
HML distance / min 20,78 11,98 11,65 6,76 11,69
Max accelerations 16 60 53 36 47
Max decelerations 17 51 51 16 50
Average Metabolic Power 7,43 6,16 7,15 4,63 6,91
Total impacts 43 338 198 114 166
DSL 37,99 232,69 171,17 90,76 156,64
DSL / HML distance 0,10 0,30 0,22 0,2 0,2
5 uphill & downhill runs + 2 flat runs (30 m)
5 uphill & downhill runs + 2 flat runs (30 m)
5 uphill & downhill runs + 2 flat runs (20 m)
MuscleTech Network
Tuesday, 4th October 2016
Sprint. The speed above 5.5 m/s must be maintained for
at least 1 second and it stops when the speed falls below
80% of sprint threshold.
Acceleration. The increase in speed must take place for
at least half a second with maximum acceleration in the
period at least 0.5m/s2. The acceleration finishes when
the player stops accelerating.
Decceleration. The decrease in speed must take place
for at least half a second for an activity to be counted as
deceleration. Also, the maximum deceleration in the
period must be at least 0.5m/s/s.

Injured player Forward 1 Forward 2 Forward 3 Forward 4
Total time 0:32:24 1:15:40 1:15:40 1:15:40 1:15:40
Total distance 2213 3485 5263 5270 4201
Peak speed 28,51 25,7 32,98 29,02 28,91
Sprints 15 4 4 14 14
HML distance 508,54 434,27 920,77 907,4 819
HML distance / min 15,69 5,74 12,17 11,99 10,82
Total impacts 68 121 163 238 284
DSL 57,38 107,88 146,95 216,83 191,62
DSL / HML distance 0,11 0,25 0,16 0,24 0,23
Av Metabolic Power 6,67 4,32 6,86 6,85 5,47
Max accelerations 27 30 70 75 54
Max decelerations 20 23 77 63 63
4th Step: Specific Football In-Field Circuits
MuscleTech Network
Tuesday, 4th October 2016
Main goals of the 4th step (specific football in-field circuits):
• All specific football skills.

MRI or US follow-up could not be optimal… but the symptomatology of the player drives the
process
MuscleTech Network
Tuesday, 4th October 2016
22.03.16 (11 days from injury) 05.04.16 (25 days from injury) 13.04.16 (33 days from injury) 27.04.16 (47 days from injury)
US/MRI looks a little worse?  Pain-free exercises?  Go on!

The end of the process (1/2)
(Axial view comparison)
MuscleTech Network
Tuesday, 4th October 2016
Javier Yanguas and Sandra Mechó, 2016

The end of the process (2/2)
(Sagital view comparison)
MuscleTech Network
Tuesday, 4th October 2016
Javier Yanguas and Sandra Mechó, 2016

Take Home Messages
MuscleTech Network
Tuesday, 4th October 2016
• According to the severity of the injury, this in-field proposed plan can be shorter or longer in
time.
• We believe in early dynamic exercises in the field as soon as possible.
• An injured player can perform all different specific skills and capabilities, all depends of the
intensity of the proposed work.
• We plead for progress according pain-free exercises and the feelings of the player (RPE scale).
• GPS data is an useful tool that can show us the satisfactory progression of the work.

Thank you very much
for your attention