![[Case Studies] Managing a rectus femoris injury in a goalkeeper with Adam Johnson](https://cdn-images-3.listennotes.com/podcasts/physio-network/case-studies-managing-a-RQ0GgnSBAUF-4XkbG9UnLya.1400x1400.jpg "[Case Studies] Managing a rectus femoris injury in a goalkeeper with Adam Johnson")
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Welcome to this episode of Case Studies by Physio Network.
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Today I'm joined by Adam Johnson to discuss a real case of rectus femoris injury in a Premier League goalkeeper.
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Adam qualified as a physiotherapist back in 2010 and has an extensive experience working in professional football.
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He is currently the first team physiotherapist at Everton Football Club, has a particular interest in lower limb rehabilitation and has published research in peer-reviewed journals.
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He combines elements of elite sport experience and evidence-based practice to make him an ideal guest to help us unpack this challenging case.
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In this episode, we work through the case step by step from initial subjective history through to differential diagnosis, imaging findings, provisional diagnosis, and treatment planning.
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And we discuss why this presentation initially appeared relatively unremarkable, yet ultimately proved to be a significant injury for this player.
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Adam talks us through the rehabilitation process, including the importance of understanding the injured anatomy, the unique demands placed on the goalkeeper, objective criteria used to progress rehabilitation, and how he reverse-engineered the programme to safely return the player to training and competition.
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As always, we also reflect on what went well, what didn't go so well, and not so to plan, and the key decisions that influence a successful outcome, including managing expectations when symptoms don't always reflect the severity of the injury.
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And most importantly, for you, our listeners, we finish by drawing out the key clinical lessons, including the role of imaging, precision-specific rehabilitation, objective return to play testing, and how understanding sport-specific demands can optimise outcomes following muscle injury.
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I'm James Armstrong, and this is Case Studies.
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Adam, great to have you back on the podcast.
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We were just discussing off air, it's been too long actually since you've been on.
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So it's it's good to have you back.
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Yeah, thank you very much for having me.
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Yeah, it's always good to chat to you.
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So we're discussing an interesting case to today in elite football in the Premier League of a recfem injury.
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So it in some respects, we should think this is quite straightforward.
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But um, we'll hopefully pull out some really key takeaways that can help our listeners deal with these, manage them as in sort of the most current and up-to-date fashion from what we've learnt in elite sport.
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So talk us through the presentation, the the history of this chap.
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This case was in the goalkeeper, obviously high kind of kicking demands, which is something we'll we'll come on to.
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But this goalkeeper played the game, completed the game, didn't report anything, no kind of requirements to run onto the pitch or anything like that from a medical point of view.
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And then the next day, the squad were in for a kind of recovery-based day, and the player goalie reported to the treatment room, which interestingly is the first red flag in this case.
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This is a player who we never really saw, very low maintenance, goes about his work without needing a lot of input.
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So the fact that he reported to the treatment room, reporting something raises a few eyebrows, but just reported like a three, four-day history of just a sensation of tightness within that quad.
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Nothing that stopped him, hadn't even come in for treatment, hadn't reported anything trained, but just kind of felt this.
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And in his mind, it was just relating to a maybe gym session he'd done or a slight change in training content or volume.
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There was just kind of a bit of DOMS and thought it'd go away.
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Gone into the game and then just started to kind of feel it a little bit more than he would probably expect.
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But again, off the back of that three, four-day history, just thought it is what it is, it'll settle down, be there.
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Then he kind of woken up the next day thinking actually, this has changed a little bit now.
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This doesn't just feel like DOMS, it's a little bit more than that.
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Not loads of pain, but more aware of it than he thought he would be, which then brought him into the treatment room to see us.
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Coming into treatment, interesting one there, you you you've recognised a player that doesn't often look for treatment and and is now.
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So that kind of pricks your ears and probably allows you to sort of think, okay, what's what's going on here?
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So what did you find?
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What's what was your next step in in starting to unpick this, Adam?
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Yeah, so again, I think this is the challenge with these injuries for me.
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The the more you see of them, they are generally quite unremarkable on assessment.
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And again, like you alluded to, you'd think, okay, this will be pretty obvious.
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I think you come into this thinking, okay, goalkeeper that's got a quad injury, there'll be some big significant mechanism that and they're taking a goal kick, maybe they're drops to the floor.
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It'll be pretty obvious to the the 40,000 people in the stadium what's happened.
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But the there was none of that.
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There was no obvious mechanism, I'd say a bit of a history on assessment.
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Palpably there was no pain.
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There was just uh again that sensation that this just feels a bit tight and stiff when you when you're pressing through it, but no pain, and again, a a band of maybe six, seven, eight centimetres, so quite a diffuse area.
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Again, the only other areas that provoked any sort of symptoms and replicated this tightness and stiffness were pro-knee bends.
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So with them on the front, the hip at neutral and and that pro-knee bend, again, producing some tightness from 80, 90 degrees of knee flexion.
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So, again, nothing crazy, but that was there.
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Again, a little bit on Thomas test, but again, no pain, no obvious point, just a diffuse sensation of tightness.
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And that was it.
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That was all that was there to see on the assessment, all resisted testing in terms of knee extension, resisted hip flexion in different ranges, lunges, things like that.
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All these things were again pain-free, normal.
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And that was why the player would kind of come in.
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He was thinking, this doesn't fit with normal DOMs, it's been here for too long.
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It's a little bit more intense than I'd be used to.
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But I don't really know if it is anything because I can function and I can I can do everything that I need to do, as proven by the fact they'd played a whole game the day before.
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So, what next?
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Because I mean, in our general population, we might just treat this as a watch and wait.
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It should settle down, keep it moving, though, you know, those sort of generic things.
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What did you do differently because of the setting you were in, perhaps?
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Again, I think it's looking at the the person in front of you.
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So, as you say, if this if this is someone that's coming in every day for treatment on something, or we used to seeing them in there, again, maybe we wouldn't have been quite so proactive in going out and seeking imaging, which is what we did.
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We went down a an MRI route.
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If you've got someone that, let's say, you've seen every day and they've got little things, they're very aware of their bodies, maybe it falls into that pattern.
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But the fact that we were seeing this person, this player when we never see them, there was a now by this point, five, six day history of symptoms again, making me think, okay, there might be something a little bit more going on here.
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It's progressing as well, it's not improving the longer it goes on, it's getting worse.
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So, again, just putting all those patterns together and taking the individual makes you more hyper-aware.
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So, yeah, we went down an MRI imaging route.
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I think again, you you could go down an ultrasound route, but it's not necessarily that sensitive, particularly with these injuries to the deeper tissues, which again is particularly relevant for this case, is they went for an MRI and it showed a grade 3B injury around the posterior aponeurosis.
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So, again, supporting the decision to go down an MRI route because it's unlikely with ultrasound we would have picked anything up that deep within the musculature.
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So you found that what's the next stage?
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And I suppose the question is at this point, is the patient is the player still training?
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And are they training effectively to the standard that they expect of themselves and the coaches?
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Yeah, so again, just purely off the timetable, really, the fact they'd come in for that recovery day the next day, they weren't expected to be outside the following day either due to a day off.
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That was part of the decision around that timetabling is okay, we've actually got a little window here to find out more information and allow us to formulate a plan.
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We don't want to leave this for two, three more days and just sit and see because by that point we're leaving it very late and we're gonna have to maybe be rushed into some decisions.
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So again, try to be proactive around that.
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Imaging gave us a period of time to look at it.
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Again, it's probably interesting what you say around what was the next steps and were they training?
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Yes, they obviously had been, had they played yes, to then go to one of these players and say, actually, you've got a relatively significant injury in here that we're seeing on imaging.
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There was some loss of tension around the posterior aponeurosis as well, which is a poor prognostic factor in these injuries, to then go to them and say, we think you're probably going to miss five, six weeks here with this injury, was one of the first challenges because that wasn't what they had in their heads.
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They almost felt like they they were going for the imaging to clear them, to allow them to keep performing and allow us to put a plan in place to keep them playing, not to come back to them and say, actually, you're gonna have to miss five, six weeks.
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So that that was a really interesting challenge with this case around player perception of what was gonna happen, and then ultimately what you're going to them with and and trying to formulate a plan, maintain engagement when someone isn't very symptomatic and has been functioning.
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So treatment then, obviously, you you're also dictated to, not dictated to, but driven by I need to get this player back.
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So your treatment is going to be, for want for a better word, needing to be efficient.
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So what did you go about and and how did you plan that in?
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Yeah, so interestingly, with this case, again, there's some kind of comments in a paper from Carlos Padret, which is very relevant to this.
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So the injury really was the muscle fibers coming away from that apineurosis, which was causing, ultimately taking away the scaffolding from that posterior apineurosis, which caused that loss of tension.
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It wasn't necessarily an injury through the aponeurosis, as you would imagine it.
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So there's there was some discussion again, exactly like saying we're trying to accelerate healing times as much as we possibly can.
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There was a decent sized hematoma in there sitting between those muscle fibers and the aponeurosis.
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And we made the decision to aspirate that hematoma because, again, if you look at Carlos's work, he talks about that hematoma is almost forming a barrier that will stop those muscle fibers joining back up and and aligning to that aponeurosis.
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So again, we didn't feel like we could sit and wait for that to be, I suppose, reabsorbed in a natural biological way.
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So that was something probably different with this case that we looked at.
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And again, you have to find the right specialist to do that, and your radiologist has to be skilled and on board with that.
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But that was something that we did in this case, and really again utilizing what you would class as your more basics, lots of compression, ice, time in the pool, really trying to again do everything we can to help remove that hematoma, minimize it, and allow for biology to then do its work and put the best environment around there for it.
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Absolutely.
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And then in terms of rehabilitation, how did you plan that around this treatment and then onwards?
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Yeah, so again, I think probably one of the challenges, but what I find most interesting about these repfem injuries is repfem does so much.
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It's a hip flexor, it's a knee extensor.
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But the flip side of that is there's loads and loads of different musculature that that assists it.
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So you've got your hip flexors, your ediosoas, you've got a ductolongus that assists as well, you've got your vastine musculature that assists at the distal end with the knee extension.
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So, although you may be going to be limited with these injuries in the acute phase, you can't, we're not going to want to load this at length under a lot of load, because again, we're looking to promote a good healing environment.
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We can work a lot of the other areas around it safely and try and build them up.
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So, again, then we looked at the screening data that we have for this player from pre-season.
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And again, in the context of this injury, you find some really interesting things.
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So you see that the adductor musculature on that right side, the kicking side, which was injured, was down compared to the the left side.
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So, again, that gives you some really early and easy to target.
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There was a kind of around a 25% deficit on that preseason screening.
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So you can go after that straight away.
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There's no reason why we can't.
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Again, thinking about kicking that adductor longness is going to play a really big role in that.
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So, can we bulk up that adductor strength and its ability to produce force to then help offload this injured rec femme when we get to being a little bit more functional?
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Again, you look at actually on the hip profile, their hip A B abduction on the opposite side again, was down not massively, but about 10% compared to the right side.
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And we're thinking, okay, what does that mean for the the stability of that stance leg when they're kicking?
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We want them to be able to kind of be stiff and kind of produce force through that chain.
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Whereas if they're not able to kind of stabilize that pelvis in the stance limb, what does that mean then for what the kicking limb's having to do?
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So again, we could target that left side as much as we wanted.
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We weren't going to interfere with anything in that acute phase and really go after all these different things within the kind of early to mid-stages to help them when we become more functional, help offload the injured tissue.
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Again, deep hip flexion work where we know Iliosos is going to be more of a contributor and staying away from mid-range work where we think the rectus femoris will be kicking in.
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And what was your time frames?
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What sort of time frames were you looking at with this?
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Or did you end up with Yeah?
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So again, I think within the literature, if we were looking for a guide, there's the work of Steve McAlea and the guys at British Athletics around three Bs, they actually had two 3B injuries within their retrospective study.
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And they both interestingly came back at 34 days.
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However, the other point to consider on this is it was a small cohort in terms of the 3B injuries that they had.
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There's only two, but both of them re-injured.
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So it was a real challenge.
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Think, okay, is around this five-week mark appropriate, or does it need to be more?
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Because actually the two that came back at that time both reinjured within an athletic setting.
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Is that applicable to our setting or are we looking at something different?
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So this actually came back at just over three and a half weeks, which was a really kind of positive turnaround for us to not lose the player for kind of well, to lose them for less than four weeks was a really positive outcome.
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And at this point that we're talking, we're almost three years down the line now, and touch wood, there's there's been no further further injury to that area, and they've tolerated everything well.
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So again, this is where these injuries are relatively unpredictable because again, if you think what's that apineurosis having to do, it's having to provide kind of elastic energy resist forces in different planes of movement.
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It's so hard to know how they're doing until you get to the top end of rehab.
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And I think that's why they function so well and test so well, because you it's so difficult to stress the elastic elements of it in uh an isolated gym-based environment.
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It's so hard to replicate a maximal goal-kicking action where someone's limbs moving at 200 degrees a second and they're having to be these massive amounts of force.
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So, again, that was really positive for us.
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But to go through that process and kind of really understand, I think is such a case-by-case basis, understanding their biomechanics, their anatomy, the other structures that are going on.
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And again, I think the positive in this is you rescreen the hip profile and you've brought the hip adductors actually to be stronger on that right side.
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You've had a really big jump just with a targeted three and a half, four-week block of real work starting from day one.
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You've improved the stance work, whether that be A Bduction forces or even the calf, thinking about what that's doing to stabilize.
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So you're letting the kind of biology do its thing with the injury, but you've got such a fantastic window to work on the other bits that might have actually contributed.
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You're not just rehabbing a grade three B rep femme, you're trying to improve that athlete in all the the other contribution areas.
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Oh, you mentioned there in in terms of that reducing as much as possible the risk of reinjury, like you said there in that perspective study that's previously been done, which small cohort both did at a certain point.
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What sort of return to play testing did you find or do you find most useful with this group of patients and this sort of injury?
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Yeah, so I think again, that that is one of the challenges because it's hard to do.
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So we use like the ISO kinetic machine, the biodex to try and replicate some knee extension actions at varying different speeds and trying to get it as quick as we can, getting up to like 120, 150 degrees per second on that.
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But again, that's a false environment, but it gives you something to try and understand.
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Again, within the case study we discussed, there was some asymmetries from when we first tested it at 14 days up to the point that clearance testing at day 24, there was an improvement all the way through.
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So again, it might not be the beal and end all, but you're getting information that's telling you that things are normalizing.
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And then hopefully you can take that into the functional setting.
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Again, things like, as I discussed, it's hard to replicate things at speed, jump space testing, because again, it's something where you can get some really nice information around like the eccentric loading going into that kind of squat jump or something like that, and you're getting information about kind of a functional movement performed at speed.
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And are they trying to offload?
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Are they going slower on one side into that eccentric element than another?
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And just trying to piece that information together because I say until you perform a maximal goal kick, you you're not going to be able to replicate it.
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And I think that is, again, one of the positives around the fact that it was a goalkeeper and probably allowed it, allowed a quicker return, is that the demands placed upon them are so specific and so almost controlled that if this was an outfield player, I I believe it the process would have had to take longer because I'm I'm needing to know if they can sprint, I'm needing to know if they can decelerate, change direction, cross, play short passes, long passes, all different sorts of skills versus this goalkeeper who we again were very lucky.
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We can get all the data around.
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And we know in the previous six games, I think it was, they'd averaged 8.8 long goal kicks a game.
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So that gives us something to work back from and something to work towards to go, okay.
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We know the worst cases in the last six games have taken 12 goal kicks, the best cases have taken six, and they average around nine.
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So we can engineer everything around that and actually go, okay, we've shown that this player can exactly meet the demands of what they're gonna need to do in a game, versus an outfielder that's a lot more challenging.
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It's there's a lot of tactical elements to it, a lot of chaos involved, whereas that that position I think allowed us this quicker return because it was so controlled and easy to work back from.
00:21:06.240 --> 00:21:07.279
Adam, that's brilliant.
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A really interesting case, and it's always really good for us and the listeners to listen to how the top athletes are treated and and how things may well sound.
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I'm sure some listeners are saying, well, there's no way I can do that, this or the other.
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But you've really highlighted some of the key things that we can do and that we should be doing that to make these athletes' journeys far better and outcomes better and potentially reducing the risk of re-injury down the line as well.
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So, Adam, thank you so much again for your for your time.
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Listeners, check out the case studies.
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We'll put a link in the show notes below on how you can get access to those.
00:21:41.200 --> 00:21:45.839
Do check them out because they they're full of a lot of information for you to use in your practice.
00:21:46.079 --> 00:21:47.039
Adam, thanks again.
00:21:47.279 --> 00:21:48.319
Thanks very much for having me in.
00:21:48.400 --> 00:21:51.279
Yeah, it's great to great to always chat on injuries.
00:21:51.519 --> 00:21:52.000
Brilliant.
00:21:52.160 --> 00:21:53.039
Take care.
00:00:03.120 --> 00:00:06.559
Welcome to this episode of Case Studies by Physio Network.
00:00:06.719 --> 00:00:12.960
Today I'm joined by Adam Johnson to discuss a real case of rectus femoris injury in a Premier League goalkeeper.
00:00:13.199 --> 00:00:19.440
Adam qualified as a physiotherapist back in 2010 and has an extensive experience working in professional football.
00:00:19.600 --> 00:00:28.559
He is currently the first team physiotherapist at Everton Football Club, has a particular interest in lower limb rehabilitation and has published research in peer-reviewed journals.
00:00:28.800 --> 00:00:37.679
He combines elements of elite sport experience and evidence-based practice to make him an ideal guest to help us unpack this challenging case.
00:00:37.920 --> 00:00:47.840
In this episode, we work through the case step by step from initial subjective history through to differential diagnosis, imaging findings, provisional diagnosis, and treatment planning.
00:00:48.000 --> 00:00:56.479
And we discuss why this presentation initially appeared relatively unremarkable, yet ultimately proved to be a significant injury for this player.
00:00:56.719 --> 00:01:14.079
Adam talks us through the rehabilitation process, including the importance of understanding the injured anatomy, the unique demands placed on the goalkeeper, objective criteria used to progress rehabilitation, and how he reverse-engineered the programme to safely return the player to training and competition.
00:01:14.319 --> 00:01:29.120
As always, we also reflect on what went well, what didn't go so well, and not so to plan, and the key decisions that influence a successful outcome, including managing expectations when symptoms don't always reflect the severity of the injury.
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And most importantly, for you, our listeners, we finish by drawing out the key clinical lessons, including the role of imaging, precision-specific rehabilitation, objective return to play testing, and how understanding sport-specific demands can optimise outcomes following muscle injury.
00:01:47.040 --> 00:01:50.239
I'm James Armstrong, and this is Case Studies.
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Adam, great to have you back on the podcast.
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We were just discussing off air, it's been too long actually since you've been on.
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So it's it's good to have you back.
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Yeah, thank you very much for having me.
00:02:00.959 --> 00:02:02.400
Yeah, it's always good to chat to you.
00:02:02.719 --> 00:02:11.919
So we're discussing an interesting case to today in elite football in the Premier League of a recfem injury.
00:02:12.080 --> 00:02:16.080
So it in some respects, we should think this is quite straightforward.
00:02:16.240 --> 00:02:28.479
But um, we'll hopefully pull out some really key takeaways that can help our listeners deal with these, manage them as in sort of the most current and up-to-date fashion from what we've learnt in elite sport.
00:02:28.719 --> 00:02:32.400
So talk us through the presentation, the the history of this chap.
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This case was in the goalkeeper, obviously high kind of kicking demands, which is something we'll we'll come on to.
00:02:38.879 --> 00:02:48.479
But this goalkeeper played the game, completed the game, didn't report anything, no kind of requirements to run onto the pitch or anything like that from a medical point of view.
00:02:48.639 --> 00:03:01.280
And then the next day, the squad were in for a kind of recovery-based day, and the player goalie reported to the treatment room, which interestingly is the first red flag in this case.
00:03:01.439 --> 00:03:08.879
This is a player who we never really saw, very low maintenance, goes about his work without needing a lot of input.
00:03:09.039 --> 00:03:21.840
So the fact that he reported to the treatment room, reporting something raises a few eyebrows, but just reported like a three, four-day history of just a sensation of tightness within that quad.
00:03:22.000 --> 00:03:28.800
Nothing that stopped him, hadn't even come in for treatment, hadn't reported anything trained, but just kind of felt this.
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And in his mind, it was just relating to a maybe gym session he'd done or a slight change in training content or volume.
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There was just kind of a bit of DOMS and thought it'd go away.
00:03:42.319 --> 00:03:47.840
Gone into the game and then just started to kind of feel it a little bit more than he would probably expect.
00:03:48.000 --> 00:03:53.919
But again, off the back of that three, four-day history, just thought it is what it is, it'll settle down, be there.
00:03:54.159 --> 00:03:59.599
Then he kind of woken up the next day thinking actually, this has changed a little bit now.
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This doesn't just feel like DOMS, it's a little bit more than that.
00:04:03.439 --> 00:04:11.280
Not loads of pain, but more aware of it than he thought he would be, which then brought him into the treatment room to see us.
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Coming into treatment, interesting one there, you you you've recognised a player that doesn't often look for treatment and and is now.
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So that kind of pricks your ears and probably allows you to sort of think, okay, what's what's going on here?
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So what did you find?
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What's what was your next step in in starting to unpick this, Adam?
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Yeah, so again, I think this is the challenge with these injuries for me.
00:04:33.199 --> 00:04:38.480
The the more you see of them, they are generally quite unremarkable on assessment.
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And again, like you alluded to, you'd think, okay, this will be pretty obvious.
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I think you come into this thinking, okay, goalkeeper that's got a quad injury, there'll be some big significant mechanism that and they're taking a goal kick, maybe they're drops to the floor.
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It'll be pretty obvious to the the 40,000 people in the stadium what's happened.
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But the there was none of that.
00:04:58.000 --> 00:05:02.319
There was no obvious mechanism, I'd say a bit of a history on assessment.
00:05:02.560 --> 00:05:04.959
Palpably there was no pain.
00:05:05.120 --> 00:05:19.600
There was just uh again that sensation that this just feels a bit tight and stiff when you when you're pressing through it, but no pain, and again, a a band of maybe six, seven, eight centimetres, so quite a diffuse area.
00:05:19.759 --> 00:05:28.079
Again, the only other areas that provoked any sort of symptoms and replicated this tightness and stiffness were pro-knee bends.
00:05:28.160 --> 00:05:37.360
So with them on the front, the hip at neutral and and that pro-knee bend, again, producing some tightness from 80, 90 degrees of knee flexion.
00:05:37.439 --> 00:05:40.000
So, again, nothing crazy, but that was there.
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Again, a little bit on Thomas test, but again, no pain, no obvious point, just a diffuse sensation of tightness.
00:05:47.279 --> 00:05:48.319
And that was it.
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That was all that was there to see on the assessment, all resisted testing in terms of knee extension, resisted hip flexion in different ranges, lunges, things like that.
00:05:58.480 --> 00:06:02.000
All these things were again pain-free, normal.
00:06:02.160 --> 00:06:04.879
And that was why the player would kind of come in.
00:06:04.959 --> 00:06:08.959
He was thinking, this doesn't fit with normal DOMs, it's been here for too long.
00:06:09.120 --> 00:06:11.600
It's a little bit more intense than I'd be used to.
00:06:11.759 --> 00:06:21.120
But I don't really know if it is anything because I can function and I can I can do everything that I need to do, as proven by the fact they'd played a whole game the day before.
00:06:21.360 --> 00:06:22.160
So, what next?
00:06:22.240 --> 00:06:28.720
Because I mean, in our general population, we might just treat this as a watch and wait.
00:06:28.879 --> 00:06:33.360
It should settle down, keep it moving, though, you know, those sort of generic things.
00:06:33.519 --> 00:06:36.959
What did you do differently because of the setting you were in, perhaps?
00:06:37.279 --> 00:06:41.040
Again, I think it's looking at the the person in front of you.
00:06:41.279 --> 00:06:57.519
So, as you say, if this if this is someone that's coming in every day for treatment on something, or we used to seeing them in there, again, maybe we wouldn't have been quite so proactive in going out and seeking imaging, which is what we did.
00:06:57.600 --> 00:06:59.439
We went down a an MRI route.
00:06:59.600 --> 00:07:07.040
If you've got someone that, let's say, you've seen every day and they've got little things, they're very aware of their bodies, maybe it falls into that pattern.
00:07:07.120 --> 00:07:19.600
But the fact that we were seeing this person, this player when we never see them, there was a now by this point, five, six day history of symptoms again, making me think, okay, there might be something a little bit more going on here.
00:07:19.759 --> 00:07:24.879
It's progressing as well, it's not improving the longer it goes on, it's getting worse.
00:07:25.040 --> 00:07:31.120
So, again, just putting all those patterns together and taking the individual makes you more hyper-aware.
00:07:31.199 --> 00:07:33.759
So, yeah, we went down an MRI imaging route.
00:07:33.839 --> 00:07:54.639
I think again, you you could go down an ultrasound route, but it's not necessarily that sensitive, particularly with these injuries to the deeper tissues, which again is particularly relevant for this case, is they went for an MRI and it showed a grade 3B injury around the posterior aponeurosis.
00:07:54.720 --> 00:08:03.680
So, again, supporting the decision to go down an MRI route because it's unlikely with ultrasound we would have picked anything up that deep within the musculature.
00:08:03.920 --> 00:08:06.639
So you found that what's the next stage?
00:08:06.720 --> 00:08:10.399
And I suppose the question is at this point, is the patient is the player still training?
00:08:10.480 --> 00:08:15.360
And are they training effectively to the standard that they expect of themselves and the coaches?
00:08:15.600 --> 00:08:25.199
Yeah, so again, just purely off the timetable, really, the fact they'd come in for that recovery day the next day, they weren't expected to be outside the following day either due to a day off.
00:08:25.360 --> 00:08:34.320
That was part of the decision around that timetabling is okay, we've actually got a little window here to find out more information and allow us to formulate a plan.
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We don't want to leave this for two, three more days and just sit and see because by that point we're leaving it very late and we're gonna have to maybe be rushed into some decisions.
00:08:45.039 --> 00:08:47.200
So again, try to be proactive around that.
00:08:47.360 --> 00:08:49.679
Imaging gave us a period of time to look at it.
00:08:49.840 --> 00:08:54.639
Again, it's probably interesting what you say around what was the next steps and were they training?
00:08:54.799 --> 00:09:03.840
Yes, they obviously had been, had they played yes, to then go to one of these players and say, actually, you've got a relatively significant injury in here that we're seeing on imaging.
00:09:04.080 --> 00:09:21.279
There was some loss of tension around the posterior aponeurosis as well, which is a poor prognostic factor in these injuries, to then go to them and say, we think you're probably going to miss five, six weeks here with this injury, was one of the first challenges because that wasn't what they had in their heads.
00:09:21.440 --> 00:09:36.159
They almost felt like they they were going for the imaging to clear them, to allow them to keep performing and allow us to put a plan in place to keep them playing, not to come back to them and say, actually, you're gonna have to miss five, six weeks.
00:09:36.240 --> 00:09:54.159
So that that was a really interesting challenge with this case around player perception of what was gonna happen, and then ultimately what you're going to them with and and trying to formulate a plan, maintain engagement when someone isn't very symptomatic and has been functioning.
00:09:54.559 --> 00:09:58.320
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00:09:58.480 --> 00:10:10.720
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00:10:10.960 --> 00:10:15.759
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00:10:19.600 --> 00:10:28.240
So treatment then, obviously, you you're also dictated to, not dictated to, but driven by I need to get this player back.
00:10:28.559 --> 00:10:33.279
So your treatment is going to be, for want for a better word, needing to be efficient.
00:10:33.519 --> 00:10:37.840
So what did you go about and and how did you plan that in?
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Yeah, so interestingly, with this case, again, there's some kind of comments in a paper from Carlos Padret, which is very relevant to this.
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So the injury really was the muscle fibers coming away from that apineurosis, which was causing, ultimately taking away the scaffolding from that posterior apineurosis, which caused that loss of tension.
00:10:59.759 --> 00:11:04.639
It wasn't necessarily an injury through the aponeurosis, as you would imagine it.
00:11:04.799 --> 00:11:11.039
So there's there was some discussion again, exactly like saying we're trying to accelerate healing times as much as we possibly can.
00:11:11.200 --> 00:11:18.879
There was a decent sized hematoma in there sitting between those muscle fibers and the aponeurosis.
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And we made the decision to aspirate that hematoma because, again, if you look at Carlos's work, he talks about that hematoma is almost forming a barrier that will stop those muscle fibers joining back up and and aligning to that aponeurosis.
00:11:36.720 --> 00:11:45.440
So again, we didn't feel like we could sit and wait for that to be, I suppose, reabsorbed in a natural biological way.
00:11:45.600 --> 00:11:50.240
So that was something probably different with this case that we looked at.
00:11:50.399 --> 00:11:57.360
And again, you have to find the right specialist to do that, and your radiologist has to be skilled and on board with that.
00:11:57.440 --> 00:12:20.720
But that was something that we did in this case, and really again utilizing what you would class as your more basics, lots of compression, ice, time in the pool, really trying to again do everything we can to help remove that hematoma, minimize it, and allow for biology to then do its work and put the best environment around there for it.
00:12:21.440 --> 00:12:22.000
Absolutely.
00:12:22.240 --> 00:12:29.120
And then in terms of rehabilitation, how did you plan that around this treatment and then onwards?
00:12:29.440 --> 00:12:39.200
Yeah, so again, I think probably one of the challenges, but what I find most interesting about these repfem injuries is repfem does so much.
00:12:39.360 --> 00:12:41.600
It's a hip flexor, it's a knee extensor.
00:12:41.759 --> 00:12:47.039
But the flip side of that is there's loads and loads of different musculature that that assists it.
00:12:47.120 --> 00:12:57.279
So you've got your hip flexors, your ediosoas, you've got a ductolongus that assists as well, you've got your vastine musculature that assists at the distal end with the knee extension.
00:12:57.519 --> 00:13:07.840
So, although you may be going to be limited with these injuries in the acute phase, you can't, we're not going to want to load this at length under a lot of load, because again, we're looking to promote a good healing environment.
00:13:08.000 --> 00:13:13.360
We can work a lot of the other areas around it safely and try and build them up.
00:13:13.440 --> 00:13:18.159
So, again, then we looked at the screening data that we have for this player from pre-season.
00:13:18.240 --> 00:13:22.879
And again, in the context of this injury, you find some really interesting things.
00:13:23.039 --> 00:13:31.600
So you see that the adductor musculature on that right side, the kicking side, which was injured, was down compared to the the left side.
00:13:31.679 --> 00:13:35.759
So, again, that gives you some really early and easy to target.
00:13:35.919 --> 00:13:39.919
There was a kind of around a 25% deficit on that preseason screening.
00:13:40.000 --> 00:13:41.679
So you can go after that straight away.
00:13:41.759 --> 00:13:43.039
There's no reason why we can't.
00:13:43.200 --> 00:13:47.759
Again, thinking about kicking that adductor longness is going to play a really big role in that.
00:13:47.919 --> 00:13:58.960
So, can we bulk up that adductor strength and its ability to produce force to then help offload this injured rec femme when we get to being a little bit more functional?
00:13:59.200 --> 00:14:12.879
Again, you look at actually on the hip profile, their hip A B abduction on the opposite side again, was down not massively, but about 10% compared to the right side.
00:14:13.120 --> 00:14:19.200
And we're thinking, okay, what does that mean for the the stability of that stance leg when they're kicking?
00:14:19.360 --> 00:14:25.600
We want them to be able to kind of be stiff and kind of produce force through that chain.
00:14:25.759 --> 00:14:34.159
Whereas if they're not able to kind of stabilize that pelvis in the stance limb, what does that mean then for what the kicking limb's having to do?
00:14:34.320 --> 00:14:37.679
So again, we could target that left side as much as we wanted.
00:14:37.840 --> 00:14:51.440
We weren't going to interfere with anything in that acute phase and really go after all these different things within the kind of early to mid-stages to help them when we become more functional, help offload the injured tissue.
00:14:51.600 --> 00:15:02.080
Again, deep hip flexion work where we know Iliosos is going to be more of a contributor and staying away from mid-range work where we think the rectus femoris will be kicking in.
00:15:02.240 --> 00:15:03.440
And what was your time frames?
00:15:03.600 --> 00:15:05.279
What sort of time frames were you looking at with this?
00:15:05.360 --> 00:15:07.519
Or did you end up with Yeah?
00:15:07.679 --> 00:15:20.480
So again, I think within the literature, if we were looking for a guide, there's the work of Steve McAlea and the guys at British Athletics around three Bs, they actually had two 3B injuries within their retrospective study.
00:15:20.559 --> 00:15:23.840
And they both interestingly came back at 34 days.
00:15:24.080 --> 00:15:30.480
However, the other point to consider on this is it was a small cohort in terms of the 3B injuries that they had.
00:15:30.559 --> 00:15:32.960
There's only two, but both of them re-injured.
00:15:33.200 --> 00:15:34.639
So it was a real challenge.
00:15:34.799 --> 00:15:40.320
Think, okay, is around this five-week mark appropriate, or does it need to be more?
00:15:40.399 --> 00:15:44.720
Because actually the two that came back at that time both reinjured within an athletic setting.
00:15:44.879 --> 00:15:48.000
Is that applicable to our setting or are we looking at something different?
00:15:48.159 --> 00:16:01.519
So this actually came back at just over three and a half weeks, which was a really kind of positive turnaround for us to not lose the player for kind of well, to lose them for less than four weeks was a really positive outcome.
00:16:01.679 --> 00:16:12.720
And at this point that we're talking, we're almost three years down the line now, and touch wood, there's there's been no further further injury to that area, and they've tolerated everything well.
00:16:12.799 --> 00:16:27.919
So again, this is where these injuries are relatively unpredictable because again, if you think what's that apineurosis having to do, it's having to provide kind of elastic energy resist forces in different planes of movement.
00:16:28.159 --> 00:16:34.240
It's so hard to know how they're doing until you get to the top end of rehab.
00:16:34.639 --> 00:16:45.840
And I think that's why they function so well and test so well, because you it's so difficult to stress the elastic elements of it in uh an isolated gym-based environment.
00:16:46.080 --> 00:16:57.519
It's so hard to replicate a maximal goal-kicking action where someone's limbs moving at 200 degrees a second and they're having to be these massive amounts of force.
00:16:57.759 --> 00:17:00.559
So, again, that was really positive for us.
00:17:00.720 --> 00:17:11.200
But to go through that process and kind of really understand, I think is such a case-by-case basis, understanding their biomechanics, their anatomy, the other structures that are going on.
00:17:11.359 --> 00:17:19.200
And again, I think the positive in this is you rescreen the hip profile and you've brought the hip adductors actually to be stronger on that right side.
00:17:19.279 --> 00:17:25.759
You've had a really big jump just with a targeted three and a half, four-week block of real work starting from day one.
00:17:25.920 --> 00:17:35.200
You've improved the stance work, whether that be A Bduction forces or even the calf, thinking about what that's doing to stabilize.
00:17:35.359 --> 00:17:44.319
So you're letting the kind of biology do its thing with the injury, but you've got such a fantastic window to work on the other bits that might have actually contributed.
00:17:44.480 --> 00:17:53.359
You're not just rehabbing a grade three B rep femme, you're trying to improve that athlete in all the the other contribution areas.
00:17:53.599 --> 00:18:05.440
Oh, you mentioned there in in terms of that reducing as much as possible the risk of reinjury, like you said there in that perspective study that's previously been done, which small cohort both did at a certain point.
00:18:05.680 --> 00:18:15.359
What sort of return to play testing did you find or do you find most useful with this group of patients and this sort of injury?
00:18:15.680 --> 00:18:21.680
Yeah, so I think again, that that is one of the challenges because it's hard to do.
00:18:21.759 --> 00:18:37.359
So we use like the ISO kinetic machine, the biodex to try and replicate some knee extension actions at varying different speeds and trying to get it as quick as we can, getting up to like 120, 150 degrees per second on that.
00:18:37.440 --> 00:18:42.799
But again, that's a false environment, but it gives you something to try and understand.
00:18:43.039 --> 00:18:57.039
Again, within the case study we discussed, there was some asymmetries from when we first tested it at 14 days up to the point that clearance testing at day 24, there was an improvement all the way through.
00:18:57.200 --> 00:19:05.440
So again, it might not be the beal and end all, but you're getting information that's telling you that things are normalizing.
00:19:05.599 --> 00:19:08.319
And then hopefully you can take that into the functional setting.
00:19:08.480 --> 00:19:28.400
Again, things like, as I discussed, it's hard to replicate things at speed, jump space testing, because again, it's something where you can get some really nice information around like the eccentric loading going into that kind of squat jump or something like that, and you're getting information about kind of a functional movement performed at speed.
00:19:28.480 --> 00:19:29.839
And are they trying to offload?
00:19:29.920 --> 00:19:34.000
Are they going slower on one side into that eccentric element than another?
00:19:34.160 --> 00:19:43.839
And just trying to piece that information together because I say until you perform a maximal goal kick, you you're not going to be able to replicate it.
00:19:43.920 --> 00:20:19.359
And I think that is, again, one of the positives around the fact that it was a goalkeeper and probably allowed it, allowed a quicker return, is that the demands placed upon them are so specific and so almost controlled that if this was an outfield player, I I believe it the process would have had to take longer because I'm I'm needing to know if they can sprint, I'm needing to know if they can decelerate, change direction, cross, play short passes, long passes, all different sorts of skills versus this goalkeeper who we again were very lucky.
00:20:19.440 --> 00:20:20.799
We can get all the data around.
00:20:20.880 --> 00:20:27.599
And we know in the previous six games, I think it was, they'd averaged 8.8 long goal kicks a game.
00:20:27.680 --> 00:20:32.079
So that gives us something to work back from and something to work towards to go, okay.
00:20:32.400 --> 00:20:40.799
We know the worst cases in the last six games have taken 12 goal kicks, the best cases have taken six, and they average around nine.
00:20:41.039 --> 00:20:54.720
So we can engineer everything around that and actually go, okay, we've shown that this player can exactly meet the demands of what they're gonna need to do in a game, versus an outfielder that's a lot more challenging.
00:20:54.799 --> 00:21:05.839
It's there's a lot of tactical elements to it, a lot of chaos involved, whereas that that position I think allowed us this quicker return because it was so controlled and easy to work back from.
00:21:06.240 --> 00:21:07.279
Adam, that's brilliant.
00:21:07.440 --> 00:21:16.880
A really interesting case, and it's always really good for us and the listeners to listen to how the top athletes are treated and and how things may well sound.
00:21:16.960 --> 00:21:20.240
I'm sure some listeners are saying, well, there's no way I can do that, this or the other.
00:21:20.319 --> 00:21:33.759
But you've really highlighted some of the key things that we can do and that we should be doing that to make these athletes' journeys far better and outcomes better and potentially reducing the risk of re-injury down the line as well.
00:21:33.839 --> 00:21:36.240
So, Adam, thank you so much again for your for your time.
00:21:36.400 --> 00:21:38.079
Listeners, check out the case studies.
00:21:38.160 --> 00:21:41.119
We'll put a link in the show notes below on how you can get access to those.
00:21:41.200 --> 00:21:45.839
Do check them out because they they're full of a lot of information for you to use in your practice.
00:21:46.079 --> 00:21:47.039
Adam, thanks again.
00:21:47.279 --> 00:21:48.319
Thanks very much for having me in.
00:21:48.400 --> 00:21:51.279
Yeah, it's great to great to always chat on injuries.
00:21:51.519 --> 00:21:52.000
Brilliant.
00:21:52.160 --> 00:21:53.039
Take care.
