Isokitenic 2015: Clinical Practice Guidelines for Muscle Injury FC Barcelona and Aspetar Experience

http://muscletechnetwork.org/proyectos-id/publicaciones/
Clinical Practice Guidelines for Muscle Injury
FC Barcelona and Aspetar Experience

XXIV International Conference on Sports Rehabilitation and Traumatology
Clinical Practice Guidelines for Muscle Injury, FC Barcelona – Aspetar
11th-12th April, 2015 - London
Clinical Practice Guidelines
for Muscle Injury
(2015)
for Muscle Injury
(2009)
for Muscle Injury
(2018)
Previous consensus
(2017)

(UCL Elite Club Injury Study. 2013/2014 Season Report)

11%
28%
61%
43%
25%
32%
0%
10%
20%
30%
40%
50%
60%
70%
Quadriceps Adductor Hamstrings
FCB 1st Team
FCB Academy

1. Muscle injuries classification
2. Diagnosis and management of muscular injuries
3. Algorithm of rehabilitation
4. Return to play criteria
5. Primary and secondary prevention
CONTENTS

1. Muscle injuries classification
2. Diagnosis and management of muscular injuries
3. Algorithm of rehabilitation
4. Return to play criteria
5. Primary and secondary prevention

Introduction
Several grading and classification systems for muscle
injuries have been published; indeed, no validated
classification system exists.
To classify is necessary to have good epidemiological
data, which are basic to find the best therapeutic
option for an injury/disease.

The Proposal
In our opinion the evaluation of the amount of extracellular matrix
(ECM) damaged and its impact in force generation and transmission is
a key factor in muscle injuries clinics and prognosis; therefore the
classification is based on this concept.
We reviewed the literature to select and organize the knowledge
about muscle injuries:
• Mechanism.
• Clinic and imaging prognosis factors.
• Injury relation with MTJ and amount of connective tissue damage (indeed of
function).
• Evolution in time.
We organize and resume this concept in a 4 letters acronym structure.

Muscle Injury Mechanism
1. Direct injuries:
• Located in the place of the trauma.
• Size is not well correlated with the functional
impairment.
• Different clinical evolution than indirect injuries
(shorter time loss).
2. Indirect muscle injuries are located close
to a myotendinous junction (MTJ).
Lee J, Mitchell A, and Healy J. Imaging of muscle injury in the elite athlete. British Journal of Radiology 85: 1173-1185, 2012.
Thorsson O, Lilja B, Nilsson P, and Westlin N. Immediate external compression in the management of an acute muscle injury. Scandinavian journal of medicine & science in sports 7: 182-190,
1997.
Garrett WE, Nikolaou PK, Ribbeck BM, Glisson RR, and Seaber AV. The effect of muscle architecture on the biomechanical failure properties of skeletal muscle under passive extension. The
American journal of sports medicine 16: 7-12, 1988.

Extracellular matrix (ECM) damage
The evaluation of the amount/severity of ECM damaged is
done trough:
• Muscle injury relation with the MTJ (proximal or distal).
• % CSA as reflection of the amount of ECM damaged.
• If there is tendon gap/retraction/loss of tension.
Structure and function of the skeletal muscle extracellular matrix Gillies 2011

Mechanism Location Grade Re-injury

Mechanism
It describes the mechanism of injury, which could be a
direct blow or an indirect strain:
• Direct injuries D
• Indirect injuries I

Location for direct injuries
Is a lowercase regarding the anatomical location:
• p injuries located at the proximal third.
• m injuries located at the middle third.
• d injuries located at the distal third.

Is a capital letter followed or not by a lowercase regarding the
Location.
It describes the connective tissue damage location, tendon or MTJ.
• J for the injuries at the MTJ.
• T for injuries affecting the tendon: gap/retraction/loss of tension.
• After the T and J, as a sub-index, the proximal and distal location must be
specified (p for proximal and d for the distal).
Location for indirect injuries

Grade
Is a number from 0 to 4 regarding the Grade. MRI based, is referred to the
percentage of the cross sectional area (% CSA) of the affected muscle to total
muscle belly, in the axial plane where the injury is greater.
The affected area is considered where there is a hyper-signal change on fat
suppressed/STIR images.
If more than one muscle is injured, the muscle with the greater area of signal
abnormality or architectural distortion will be considered the primary site of
injury and the grading criteria will be taken for that particular muscle.

0 Grade 0: clinical suspicion of muscle injury with negative MRI.
1 Grade 1: ≤10% of CSA.
2 Grade 2: 11-25% of CSA.
3 Grade 3: 26-49% of CSA.
4 Grade 4: ≥50% of CSA.
In the future, the architectural distortion, more than the oedema, should
be the key in the imaging evaluation to grade the muscle injuries.
Grade

Re-injury
Describes the injury chronology (first episode or a re-injury):
R0: First episode,
R1: First re-injury, R2: Second re-injury… and so on.
A re-injury is defined as “injury of the same type and at the same site as an index
injury occurring no more than 2 months after a player’s return to full
participation from the index injury” (Ekstrand 2011).
If during the two months period after the RTP a new injury occur in the same
muscle but in a different location, it will also considered a re-injury.

Proposal
Mechanism Location Grade Reinjury
D (direct)
D p proximal third direct injury
0 negative MRI
1 < 10 % CSA
2 11 – 25 % CSA
3 26 – 49 % CSA
4 >50 % CSA
R0 1st episode
R1 1st reinjury
R2 2nd reinjury
..and so on.
D m medial third direct injury
D d distal third direct injury
I (indirect)
I T p proximal tendon injury
I T d distal tendon injury
I J p proximal MTJ injury
I J d distal MTJ injury

• Direct injury located in A:
– D-p-G-R0
• Direct injury located in B:
– D-m-G-R0
• Direct injury located in C:
– D-d-G-R0
A
B
C
Direct Injuries Codification

Indirect Injuries Codification
• Indirect injury located in A:
– I-Jp-G-R
• Indirect injury located in B:
– I-Jd-G-R
A
B

Indirect Injuries
Codification
• I-Tp-G-R

Take home messages
1. With an acronym we can describe the injury.
2. Allows communication among medical staff.
3. Flexible structure allowing to incorporate
knowledge in the future.
4. Easy to use.

Background
• Most of them are treated non-surgically.
• The clinical appearance is not always clear.
• Determining the optimal treatment for any injury can be difficult.
NEEDS
• Detailed history of the patient and about the injury mechanism.
• Careful examination.
• Imaging diagnosis:
– Magnetic Resonance Imaging (MRI)
– Ultrasound (US)
Critical goal is to differentiate between those patients with injuries possibly
requiring surgical treatment from patients with non-surgical injuries

1. Appropriate history
 About the player:
• Similar injuries before?
• Medications?
• Susceptibility…
 About the mechanism of injury:
• Direct blow or indirect strain?
• During training or competition?
• When and how did it start?
 About the initial progress:
• Stop or continue playing?
• Normal walk without pain?

2. Physical exam
• Looking for asymmetries.
• Pain.
• Colour.
• Muscle belly shape.
• Strength.
• ROM without pain.
• The athlete is unable to walk at a normal pain-free pace.
BF injury is more painful during stretching than contraction while a injury in
SM or ST will have more pain during contraction than during stretching.

3. Imaging of muscle injury
 RX: limited value unless an avulsion fracture with bony fragment or apophyseal
fracture in a skeletally immature individual.
 US and MRI:
• Describe the location (which muscle and tissue).
• The lesion size.
• The lesion nature (oedema/haemorrhage) by echotexture (US) and signal
intensity (MRI)

3.1 Ultrasound
• Cost effective.
• Radiologist experience dependent.
• Dynamic and interactive process
allowing “echopalpation” of painful
areas.
• It enables progress monitoring.
• Guide the evacuation of fluid
collections.
• Useful in distal hamstring injuries
(superficial anatomy).

3.2 Magnetic resonance imaging
To evaluate the involvement of tendons, fascia
and contractile tissue.
Routine MRI protocol:
• At least two orthogonal planes (axial,
coronal or sagital) and one of two pulse
sequences (STIR or T2 fat sat).
Restricted in routine assessment of injuries
(limited availability and high costs).
Its utilization in prognosis of return to play is
controversial.

MRI advantages
• To measure the size of injury (length
and cross-sectional area).
• Proximal hamstring injuries.
• Groin area injuries.
• In assessing the tendon retraction
(preoperative planning).
• In highlighting subtle edema.
• In evaluating injuries to deep injuries
of muscles.
• In evaluating injuries when a previous
injury is present (residual scarring).
• Discovering concomitant image.

Management of a muscle injury
Clinical
history
Physical
exam
US MRI Treatment
Immediate X X
Could be
made
anytime
Rest
Ice
Compression
Elevation
Analgesia
12 hours X X
24 hours X X
48 hours X X
Functional
tests
1st week
Monitorize
players
feelings
X x To evaluate
how the
progression of
loads are
assumed
Rehabilitatio
n
progressive
protocol
Weekly X X
Return to
play X X
For follow-up the functional recovery and sometimes to help to decide return to play:
• Muscle: Tensiomyography, electromyography and strength tests.
• Player: GPS, HR and self administered scales during and after the rehabilitation sessions on field.
Initial
acute
phase
Subacute
and
functional
phase

 Muscle injuries heal conservatively.
 Indications of surgical treatment:
• Total or subtotal (>50%) rupture with few or no agonist muscles.
• Large intramuscular hematoma.
• Complains of chronic pain (>4-6 months) in a previously injured muscle,
specially with ROM deficit.
Surgical procedure:
• Anatomic restoration when is possible.
• Surgical release of adhesions from the nerve and scar debridement in
chronic cases.
Surgical treatment

Bony avulsions
Muscle Part of muscle Tendon Treatment
Quadriceps
Proximal
ASIS
AIIS
Conservative; unless > 2cm
Distal Patellar avulsion
Surgical; (except non
displaced)
Hamstrings
Proximal Ischial tuberosity
Gap < 2cm conservative
Bigger gaps: surgical
Distal
All (rare)
( BF – SM )
Surgical reattachment must
be considered

Proximal
Distal
Rectus femoris

Tendon-bone disinsertions
Muscle Localization Tendon Treatment
Quadriceps Rectus Femoris
Proximal
Direct head Surgical reattachment
Indirect head
Little gap: Conservative
Big gap: Surgical
Direct + Indirect head Surgical
Hamstrings
Proximal
Biceps Femoris Long Head
and/or Semitendinosus
Surgical
Semimembranosus
Conservative.
If there were symptoms after 4
months: surgical reattachment
must be considered
Distal All (rare)
Surgical reattachment must be
considered

Ischion
Central
Tendon

Reattached

Comin J, Malliaras P, Baquie P, Barbour T, Connell D.
Return to competitive play after hamstring injuries
involving disruption of the central tendon. Am J Sports
Med. 2013;41(1):111-115.
• Long recovery times.
• Worse results.
• Biceps femoris 45%
• Recurrent injury.
New surgical indication for hamstring?

DISTAL
PROXIMAL
Proximal end
of Central
Tendon
Distal end
of Central
Tendon

Central Tendon injuries
MTJ injuries, when the Central Rectus Femoris Tendon or Common
Hamstring Tendon is involved with loss of tension
Muscle Part of muscle-tendon Treatment
Quadriceps
and
Hamstrings
< 2 cm from bone insertion
Reattachment to the
bone and reduce
tension at MTJ
More than 2 cm to bone
insertion
Surgical treatment:
Anatomical repair
with minimally
invasive approach

Take home messages
1. Clinical expertise in muscle injuries.
2. US and MRI to confirm diagnosis.
3. Surgical treatment when tendon is
affected.

Rehabilitation Program
LITERATURE
SEARCH
SCIENTIFIC
EVIDENCE
EXPERIENCE
CONSENSUS
THERAPEUTIC

Proposal of Algorithm
ALL PARAMETERS
DIAGNOSTIC PHASE ACUTE PHASE SUBACUTE PHASE FUNCTIONAL PHASE PHASE TO RTP
AND CONTROL TEST DESTRUCTION REPAIR REMODELLING
PHISICAL THERAPY X X X
MANUAL THERAPY X X X
FLEXIBILITY AND ROM X X X
PROPIOCEPTION X X X
CORE X X X
NEUROM-CONTROL X X X X
STRENGTH X X X
POWER X X
FITNESS X X
PAIN/FATIGUE X X X X X
BIOMECANICHS X X X X X
IMAGE X X X X X

Progression of exercises

Algorithm of Rhb
INJURY
DIAGNOSTIC PHASE
Goals
Criteria
Validation Test
Goals
Criteria
Validation Test
Goals
Criteria
Validation Test RTP

Diagnostic Phase
Kerkhoffs, G., et al. "Diagnosis and prognosis of acute hamstring injuries in athletes”, 2013
INJURY !!!
• PRESSION (together with Cryotherapy 3 times/day, every 3h, 20’-30’)
• REST (sporting, not total)
• ICE (Cryotherapy 3 times/day, every 3h., 20’-30’)
• IMMOBILISATION (3-4 days, every 3-4h, between 15-20’)
• ELEVATION (upper the heart level and different positions)
• ANAMNESIS (Injury analysis, antecedents,...)
• COMPLEMENTARY PROOFS (RN, ECO, ...)
• GENERAL TESTS (Assessment muscular, articular,...)
• SPECIFIC TESTS (types of pain, localisation, function)
• PSICOLOGIC SUPPORT OF PLAYER
• DIFFERENTIAL DIAGNOSTIC
• FINAL DIAGNOSTIC

Acute Phase

Goals and Criteria
Acute Phase
- NO PAIN or discomfort during exercises
- During exercises to maintain neutral spine in static position to Bosu or Board
- To work from Low to Moderate Intensity
- Isometric knee flexion 15º, decubitus prono (ISOM)/(CONC)/(ECC)
- Work with flexion knee to 45° and hip 0°>50% (CKC) / (OKC)
- Uninjured leg (dynamometer or similar 50%.)
- (SBET) with 30º Flexion Knee +(SLS) +(ESH) <70 avoiding pain
- Walk/Run to treadmill until 70% -3% (ESH) decrease
CKC: Close Kinetic Chain, OKC: Open Kinetic Chain, ISOM: Isometric, CONC: Concentric, ECC: Eccentric, ROM: Range of Motion; ESH
(Elongation Stresson Hamstrings.). DST: (Deep squat test). SLS: Single leg squat. RPT: Runner post test. AKET: Active Knee Ext Test:

Subacute Phase

Goals and Criteria
Subacute Phase
- NO PAIN or discomfort during exercises.
- Not tilting the pelvis or flattening the spine during dynamic exercises
- To work from Moderate to High Intensity
- Isometric knee flexion strength decubitus supine knee flexion 25°
- hip flexion 45°, less than 10% asymmetry (OKC)/(CKC)
- Work uninjured leg (dynamometer or similar 70%.)
- Isometric hip extension strength, knee 0º, Hip 70º less than 10%
- (ESH) Stretch < 70 +(SLS) +(DST) painless
- Start Walking on the treadmill to <8 km/h 5% (ESH)

Functional Phase

Goals and Criteria
Functional Phase
- No PAIN or discomfort during exercises.
- Correct spine control and strength transfer during exercises
- To work from High to Explosive Intensity
- Integrate strength, neuromuscular and proprioceptive work
- Achieved in contralateral leg no asymmetry (dynamometer/encoder 100%)
- Uninjured leg (Encoder or isokinetic 100%.)
- Isokinetic criteria: We should avoid differences higher than 20%
- (RPT)+(AHFT)+(AKET) No asymmetry
- Test of the feed and games

Criteria-based progression
Development of an approach

Physio
On-field
100%
0%

Physio On-field
Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 Stage 6
Painless single leg squat
Painless bike 150W, 5 mins
Full knee Ext supine
Run > 70%
ROM SLR & HS Θ > 75%
100% running
Painless direction change
Light Football Training
Session
In-between Football
Training Session
Heavy Football Training
Session

Passive
movement
Massage – no
pain
Massage -
discomfort
Active range of
motion
Eccentric outer
range
Slow run
Concentric
through range
Fast run
Direction change
Isometric – inner
range
Eccentric inner
range
Outer range
ballistic
Stretching Trunk control Cardio (bike)
Isometric outer
range
Painless single leg squat
Painless bike 1.5*BW, 5 mins
Full knee Ext supine
Run > 70%
ROM SLR & HS Θ > 75%
100% running
Painless direction change

Gait
• Walk
• Jog
• Run
• Triple extension
• Late swing (“A drill”)
• Direction change
4 laps =8 ‘sprints’ X 3 sets
~ 700m
11s → 3.1 s
10% → 100%
3 reps
12s → 9s
60% → 100%

0
20
40
60
80
100
120
140Percentofuninjuredside Inner range
Mid range
Outer range

Take home messages
1. Sequential and progressive.
2. Dynamic and open.
3. Adaptable to each player.
4. Criteria-based progression
5. Based on knowledge and experience.

The decision-making process of returning an injured or ill player to competition

All clear to play
Huge reinjury risk (14-16%)
Criteria
1. Clinical/ Anatomical
2. Imaging (US)
3. Functional
Specific Physical Test
High workloads Highest competition level No reinjury
HEALTHY INDIVIDUALS
WHEN?

Return to play
Anatomical, imaging and functional CRITERIA have to be taken into
consideration in order to provide:
Personalized return to play:
1. Injury location/connective tissue involved
2. Anatomical variability
3. Imaging
4. Player position/GPS

1. Injury location/connective tissue

2. Anatomical variability

A
B
C
Semimembranosus injuries

3. Imaging

4. Player position / GPS

COMPARISON THE PLAYERS SAME POSITION WITH THE PLAYER INJURED
0 50 100 150 200 250 300
AVE HSR SET 5
PLAYER INJURY
AVE HSR SET 6
PLAYER INJURY
AVE SPRINT SET 5
PLAYER INJURY
AVE SPRINTS SET 6
PLAYER INJURY
AVE ACEL SET 5
PLAYER INJURY
AVE ACEL SET 6
PLAYER INJURY
AVE DEC SET5
PLAYER INJURY
AVE DEC SET 6
PLAYER INJURY
AVE VEL.MAX SET5
PLAYER INJURY
AVE VEL.MAX SET6
PLAYER INJURY
SUMMARY
DATAWEEKS5/6
Comparision with the same players injured player position return to train with the group

COMPARED TO OTHER DEFENDER SAME POSITION DURING 60’ MINUTS THE FRIENDLY MATCH
43 51
32 37 38
55
49 45
45 44 42
59
0
20
40
60
80
100
120
HIGH ACEL/DESA <3mts/s
DESA.MAXIMES
ACEL.MAXIMES
202,91 211,5
290,59 303,53 292,24
542,61
0
100
200
300
400
500
600
DEFENDER 1DEFENDER 2DEFENDER 3DEFENDER 4DEFENDER 5 PLAYER
INJURED
HSR DISTANCE <21K/h
15
20 21
15
19
25
0
5
10
15
20
25
30
DEFENDER 1DEFENDER 2DEFENDER 3DEFENDER 4DEFENDER 5 PLAYER
INJURED
TOTAL SPRINTS
29,88
30,38
29,12
34,31
31,68
32,73
26
28
30
32
34
36
DEFENDER 1 DEFENDER 2 DEFENDER 3 DEFENDER 4 DEFENDER 5 PLAYER
INJURED
PEAK SPEED MAX

Take home messages
1. Personalized.
2. Technology and experience.
3. Six training sessions.
4. Friendly matches.

PRIMARY PREVENTION
Prevent the onset of muscle injury
Addressing risk factors
Enhancing resistance to exposure
Part of the general football training
(all players)

Avoidance of a new muscle injury when the
player has suffered a previous injury
SECONDARY PREVENTION
Individual, personalized, specific program

PREVENTION “SNAPSHOT”
PLAYER INDIVIDUAL STRENGTH PROGRAMME
SQUAD PREVENTION PROGRAMME (SPECIFIC EXERCISES)
WARM UPS PREVENTION OBJECTIVES DAILY
STRENGTH CIRCUITS
FOOTBALL CIRCUITS
GYM
GYMPITCH SMALL GROUPS CIRCUITSPITCH

PRIMARY PREVENTION
GYM
strength training
of the hamstrings
Image Code Description weight Ser/Repet weight Ser/Repet frequency When
Musculador belt STh1
Eccentric working withvariants indop:
drop withrotation, different angles of
flexion..
body weight or body
weight with3kg
3x4
body weight or body
weight with3kg
3x8
1x7 (1 competition)/10
days( 2 competitions)
Before or afther 48
hours to match
Splits withbody
flexion
STh2 Work hamstring body weight 4 repetitions body weight 8 repetitions once or twice a week
Alternate days ,
never before or
afther to match
Angel STh3 Work hamstring body weight 4 repetitions body weight 8 repetitions once or twice a week
Alternate days ,
never before or
afther to match
minimum stimulus maximum stimulus
StrengthTraining
Primary Prevention

PRIMARY PREVENTION
DAY -4.
ECCENTRIC
STRENGHT.
TIRANTE
MUSCULADOR
DAY -3.
RUNNING
TECHNIQUE &
PROPIOCEPTION
EXERCISES.
DAY -2.
AGILITY AND
COORDINATION
SKILLS.
DAY -1.
SPEED REACTION
AND FEET
WORK…
GYM
PITCH

PRIMARY PREVENTION
DAY -4.
ECCENTRIC
STRENGHT.
TIRANTE
MUSCULADOR

PRIMARY PREVENTION
DAY -2.
AGILITY AND
COORDINATION
SKILLS.

PRIMARY PREVENTION
W/O BALL BOXES PASSING DRILLS POSSESSION GAMES
HAMSTRINGS
QUADRICEPS
ADDUCTOR MUSCLES
CORE STABILITY
COORDINATION / AGILITY
PROPIOCEPTION
UPPER BODY
STRENGTH CIRCUITS
GYMPITCH

PRIMARY PREVENTION
MULTISTATIONS
WITHOUT BALL
MULTISTATIONS
WITH BOXES
MULTISTATIONS
WITH PASSING
DRILLS
MULTISTATIONS
WITH POSSESSION
GAMES
HAMSTRINGS
QUADRICEPS
ADDUCTOR MUSCLES
CORE STABILITY
PROPIOCEPTION
UPPER BODY
STRENGTH CIRCUITS ON THE FIELD

PRIMARY PREVENTION
STRENGTH CIRCUITS ON THE FIELD
MULTISTATIONS
WITHOUT BALL
MULTISTATIONS
WITH BOXES
MULTISTATIONS
WITH PASSING
DRILLS
MULTISTATIONS
WITH POSSESSION
GAMES
HAMSTRINGS
QUADRICEPS
ADDUCTOR MUSCLES
CORE STABILITY
PROPIOCEPTION
UPPER BODY

STRENGTH CIRCUITS
FOOTBALL CIRCUITS
GYMPITCH
PRIMARY PREVENTION

RELATIONSHIP BETWEEN
TECHNICAL, TACTICAL AND
CONDITIONING CIRCUITS.
CONDITIONING OR PREVENTION
STATION PREVIOUS TO THE
FOOTBALL ACTION.
DECISSION MAKING +
MULTIPLE OPTIONS
CLOSER TO OUR
STYLE OF PLAY/
GAME PLAN
PRIMARY PREVENTION

LEVEL PROGRAMME FREQUENCY
CATEGORIES
OBJECTIVE
EXERCISES
1. Indoor Prevention
Squad Prevention Programme 1 p week Stretching
STrength
St 1
STq1, STq2Player Individual Strength Programme 2 p week
2. Daily Prevention
Warm Ups
Eccentric Training 1 p week Stretching
STrength
PRoprioception
CoreStability
AGility
St2, St3, St4
STh1, STh3
PR2
CS1, CS2, CS3
AG 2
Proprioception 1 p week
Agility & Coordination 1 p week
Speed Reaction 1 p week
3. Multi Stations
Prevention Circuits
Multi Station Circuit Not Ball
1-2 p week
Stretching
STrength
PRoprioception
CoreStability
AGility
MultiInterv
St2,
STh1, STh2,ST
q3
PR2, PR3
CS1,CS2,CS3
AG 1
MI 1, MI 2, MI 3
Multi Station Circuit with Boxes
Multi Station Circuit with Passing Drills
Multi Station Circuit with Pos Games
4. Football Circuit
Drills
Football Specific Strength Circuits 1-2 p week
STrength
PRoprioception
AGility
STh1, STq3
PR 3
AG 1
PRIMARY PREVENTION

SECONDARY PREVENTION
STRENGTH CIRCUITS
FOOTBALL CIRCUITS
GYM 2
PITCH 2
GYMPITCH

Hamstrings injury prevention
Seated eccentric knee flexor stretch (Seated Straight-Leg Raise)

Eccentric hip extensor stretch with inertial technology (VersaPulley)

Eccentric knee flexor extension with inertial technology (Yo-Yo Knee Extension)

Take home messages
1. Evolving knowledge.
2. Primary prevention linked with
training.
3. Secondary prevention: personalized.

…It has been demonstrated that hamstring injuries
typically occur at this musculotendinous junction: either at
the proximal or distal ‘‘free’’ ends or, more commonly, at
the central intramuscular tendon...
Comin et al. Am J Sports Med. 2013;41(1):111-115

Isokitenic 2015: Clinical Practice Guidelines for Muscle Injury FC Barcelona and Aspetar Experience

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Isokitenic 2015: Clinical Practice Guidelines for Muscle Injury FC Barcelona and Aspetar Experience