Download the article pdf for FREE

INJURIES IN FOOTBALL

DIAGNOSIS, TREATMENT AND PREVENTION

Are you interested in a talk or presentation by the author?

Do you want to know more about the author?

CONTENTS

1. Introduction

2. Definition and type of injuries

3. Epidemiology

3.1. Frequency of occurrence

3.2. Distribution of injuries

3.3. Type of injuries

3.4. Severity level

3.5. Risk factor's

4. General treatment of injuries

5. General preventive measures

6. Analysis of the most frequent injuries in soccer

6.1. Spinal injuries

6.1.1. Whiplash or sprain

6.1.2. Injuries to the growing spine. Scoliosis

6.1.3. Low back pain

6.1.4. Sciatica

6.2. Upper limb injuries

6.2.1. Shoulder

6.2.1.1. Acromioclavicular pathology

6.2.1.2. Shoulder tendinopathy

6.2.1.3. Shoulder dislocation

6.2.2. Forearm

6.2.2.1. Ulna and / or radius fracture

6.2.3. Elbow

6.2.3.1. Epicondylitis - Epitrocleitis

6.2.3.2. Olecranial Bursitis

6.2.4. Wrist

6.2.4.1. Wrist sprain

6.2.4.2. Broken wrist

6.2.5. Hand and fingers

6.2.5.1. Finger sprain

6.2.5.2. Dislocations

6.2.5.3. Hammer toe

6.3. Lower limb injuries

6.3.1. Muscle injuries

6.3.2. Pelvis

6.3.2.1. Dynamic osteopathy of the pubis, osteitis or pubalgia

6.3.3. Knee

6.3.3.1. Knee sprain

6.3.3.2. Meniscopathy

6.3.3.3. Osteochondritis dissecantes of the knee (ODR)

6.3.3.4. Chondromalacia patella or SDFP

6.3.3.5. Osgood - Schlatter

6.3.4. Leg

6.3.4.1. Tibial periostitis

6.3.5. Ankle

6.3.5.1. Ankle sprain

6.3.5.2. Fractures

6.3.5.3. Footballer's ankle or anterior impingement

6.3.5.4. Tenosynovitis

6.3.5.5. Achilles tendinopathy

6.3.6. Foot

6.3.6.1. Stress fracture

6.3.6.2. Plantar fasciitis

6.3.6.3. Séver's disease

7. Analysis of a case. Biceps Femoral Muscle Injury

7.1. Definition and types

7.2. Anatomy

7.3. Injury incidence in soccer

7.4. Production mechanisms and risk factors

7.5. Treatment

7.6. Prevention

8. Bibliography

The high demands of this sport both in the amateur and professional fields, due to both the high number of matches and training sessions and the characteristics of this sport, put the player at high risk of injury.

If we take into account that an injury can affect both the physical and psychological health of the athlete, as well as the performance of the team if we refer to the professional field, it is vitally important that professionals in this field have information about the injuries that can be present in a footballer and how to help treat and prevent them.

In addition to the above, and in what an injury to one or more players could affect a club, if we look at the study by De Loes et al (2000) of 3611 subjects from different team sports, the total cost of the injury of knee of 3864 injuries was € 3,758,797, which means approximately € 1,000 the cost of each of them.

In the following work we will study soccer injuries from various points of view. In the first place, we will carry out an epidemiological study to analyze both the frequency of appearance and the distribution, the type of injury, the severity of the same and the possible risk factors. We will now carry out a detailed analysis of the

  1. Introduction

The most popular sport in the world is soccer, with more than 265 million people playing it (Junge and Dvorak, 2004; Arundale et al. 2015), of which 40 million are women. (Andersen et al, 2003; Eils et al, 2004). According to the 2010 Sports Habits in Spain survey, 24.6 percent of sports practitioners play soccer. (García and Llopis 2010).

Image source: radiohouse.hn

the most important injuries in football, according to the type of injury, production mechanism, recovery methodology and possible prevention strategies. Finally, we will analyze the study of a specific real case.

2. Definition and types of injuries

In soccer, there is no generally accepted definition of injury for epidemiological studies (Belloch et al, 2010). Among the most common criteria for the definition of injury are the absence of training or play (Chomiak et al, 2000), followed by the need for medical treatment (Dvorak et al, 2000; Ekstrand et al, 2004; Ekstrand et al. , 2006) and by the degree of damage suffered in the anatomical tissues and the time required by the athlete to return to sports practice, which may fluctuate, to be considered an injury, from one day (The National Athletic Injury Registration System [NAIRS] cited in Dvorak et al, 2000; Ekstrand et al 2004; 2006) up to one week (Junge et al., 2000).

Faced with this lack of agreement, FIFA has defined the injury as "any physical ailment suffered by a footballer and that has been caused by a football match or training, regardless of whether he needs medical attention and how long it takes to return to play". (Theron et al, 2013).

In general, the injuries that can appear or that a footballer can suffer can affect four different parts of his body:

- To the muscles: cramps, stiffness, contractures, fiber breaks, disinsertion, bruises, wounds, hernias and bruises.

- To the tendons: tendinitis, tenosynovitis, strains, partial tears and complete tears.

- To the joints: ligamentous, capsular and cartilage injuries. Meniscal dislocations and subluxations, instabilities and injuries

- To the bones: Fissures and fractures. Periostitis.

To the four previous sections we can add a general section to encompass other injuries that can also appear, but are less typical of the sport itself. As they are:

- Pale face

- Low postural tone, but retain reflexes

- Respiratory weakness

- Palpitation and state of anxiety

- Cold sweat on the forehead

- Altered vision "looks cloudy" Loss of consciousness

- Loss of balance Weak pulse

- Nausea and vomiting

3. Epidemiology

3.1. Frequency of occurrence

The degree of incidence of soccer injuries is defined as the number of injuries that occur during a specific period, divided by the total number of players exposed to that risk (Van Mechelen, Hlobil and Kemper 1992; Junge and Dvorak 2000).

This can be estimated fairly accurately taking into account the exposure time of soccer players both in matches and in training. Specifically, the risk of injury according to the exposure time is calculated by dividing the number of injuries produced by the time that all players spend in training and matches. (Van Mechelen et al 1992; Inklaar, 1994; Junge and Dvorak, 2000).

In the literature, most studies on the incidence of soccer injuries focus on adult male professional players during a season. (Junge and Dvorak, 2004).

In a review carried out by Belloch et al (2010), the results obtained (Table 1) in terms of the injury rate range from 2.3 to 7.6 every 1000h of training and from 12.7 to 68.7 every 1000h of competition . Regarding the total average, the figures obtained range from 1.1 to 9.4 every 1000 hours of exposure of the players. According to Noya and Silleros (2013), in the players of the professional Spanish teams of the first and second division, an injury rate of 8.9 les / 1000h of professional soccer sports was found in the 2008/2009 season, being within the range Obtained by Belloch in 2010.

Depending on the league or country, Junge and Dvorak (2004) found that the injury rate is higher in players from the US professional league (Morgan and Oberlander, 2001) and the Icelandic National League (Arnason et al. 1996), while the lowest incidences were for the Dutch League (Inklaar et al, 1996) and Denmark (Nielsen and Yde J, 1989).

According to training or match, the injury rate of matches is 4 to 6 times higher than during training (Junge and Dvorak 2004; Belloch et al, 2010; Noya and Silleros, 2013)

By gender, two studies that looked at injuries during soccer tournaments reported a higher incidence in men than in women. (Junge et al, 2004; Cunningham C and Cunningham S, 1996). However, some types of injuries, such as the anterior cruciate ligament

Table 1. Average injuries in training and competition

(LCA), are more common in women than male athletes. (Arendt and Dick, 1995; Harmon and Dick, 1998).

According to age, in young soccer players the number of injuries seems to increase with age (Schmidt-Olsen et al, 1991). The 17-18 year age group appears to have a similar or even higher incidence of injury than adults (Inklaar et al, 1996; Peterson et al, 2000). The same observation was reported in a study of injuries during 12 international tournaments of players of different age categories and skill level. (Junge et al, 2004)

According to the time of the season, Noya and Silleros (2013) found that the month with the highest number of injuries was November, with July being the one with the lowest number of injuries.

According to the demarcation, the forwards are the players with the highest injury rates (IL = 11.7 les / 1000h.), Followed by the central defenders (IL = 8.1 les / 1000h.), The wing defenders (IL = 5, 8 les / 1000h.) And the interiors (IL = 5.6 les / 1000h.) Goalkeepers are always the players with the lowest IL (IL = 1.3 les / 1000h.) (Noya and Silleros, 2013).

Depending on the time of the game, the injury rate is higher in the second half (58.1% of all injuries) compared to the first. (41.9%). If, in turn, we divide it into 15-minute fractions, we find that during the first half, as time passed, the frequency of injury increased. However, in the second half these results were not the same, where it was in the second period (minute 61-75), in which the highest probability of suffering an injury was found (22.8% of all injuries occurring occur in the game) and decreasing in the third period (16.7% of injuries) with values ​​lower than the first period of the second half (18.6% of injuries) (Graph 1) (Noya and Silleros, 2013) .

Graph 1. Injuries in competition per minute

Depending on the role of the team in terms of home or visitor, there are practically no differences between them. Noya and Silleros (2013) recorded 50.9% of injuries at home and 48.2% as visitors.

According to the scoreboard, there is a greater number of injuries when the result is a tie (39.2%), over other situations such as when the team is winning (35.6%) or losing (25.2%). (Noya and Silleros, 2013). This could be due to the fact that the intensity of the match in moments of tie is higher.

According to the origin of the injury, in a study conducted on 91 professional English teams over two seasons, 38% of injuries were caused by contact, 37% without contact, and 25% were other types of injuries (Hawkins et al. , 2001).

3.2. Distribution of injuries

The percentage of injuries registered in the lower body for male players ranges between 63% and 93%, (Belloch et al, 2010), very similar to that presented by McGrath and Ozanne (1997) in their review, in which they established a percentage of 75% to 93%. Lesions affecting the upper limb, trunk and head represent between 2.9% and 11.4% of the total.

Table 2. Frequency of injury depending on the body location of the lower body

According to Hawkins and Fuller (1999), the vast majority of injuries are associated with the dominant part of the body (52.3%) versus the non-dominant (38.7%). Results that coincide with those of the study by Noya and Silleros (2013) in which 54.4% of the injuries occurred in the dominant part, compared to 36.5% that occurred in the non-dominant part.

Regarding injuries to the lower body, the results of the exact location in each of the body regions have been compiled in the following table (Table 2), the most affected regions being the knee, ankle and thigh, coinciding this is the case with what has been stated by various authors (Junge et al 2000; Lilley et al 2002). If men and women are compared, Hägglund (2007) states that the location of the lesions varies.

Table 3. Frequency of injury as a function of body location

In the same way, Noya and Silleros (2013) indicated that the highest frequency of injury was centered on the posterior thigh (16.3% of all injuries), followed mainly by the hip / adductor regions (14.5%), anterior thigh (14.2%), ankle (13.3%), and knee (11.9%) of all injuries respectively. (Table 3).

Regarding injuries in the upper body, the table below (Table 4) presents a summary of several published works on the location of injuries in soccer.

The most common type of head injury is a concussion from a collision with another player. Regarding the trunk (Chomiack et al 2000), the lesions are usually accompanied by

affected by an intrinsic problem (such as spondylolysis, scoliosis or Scheuermann's disease), which is aggravated by the activity itself or by contact with a player. Lastly, it should be noted that in the case of the upper limbs, McGrath and Ozanne (1997) state that the percentage of injuries is higher in lower categories.

Table 4. Frequency of injury depending on the body location of the upper body

3.3. Type of injury

Regarding the type of injury, the results of the study by Noya and Sillero (2013) indicate that muscle injuries were those that occurred with the highest frequency (49.1%), including overloads, contractures and muscle tears (Table 6). Ekstrand (2011), in a study carried out on 51 European soccer teams between 2001 and 2009, obtained that muscle injuries account for 31% of all injuries produced, being the cause of 27% of the total time of absence of activity due to injury. (Navarro et al, 2015).

Graph 2. Most frequent injury typology in soccer

In the same way, the results of the study by Zahínos et al, (2010) indicated that the highest frequency of appearance of injuries was of the muscular type (80% of the total) (Graph 2). These data are consistent with other studies reviewed (Wood et al., 2002; Walden et al., 2005), which also indicate that after muscle injuries, joint injuries, ankle sprains and knee injuries follow in incidence. knee.

On the other hand, 66% of muscle injuries affected the hamstrings. These data coincide with the study by Waldén et al. (2005), in which it is stated that most of the muscle injuries were located in the thigh region (61%) or in the groin (21%), mainly in those areas related to the hamstring muscles.

Table 5. Frequency of injury according to type

According to Hawkins (1999), there were 27.7 injuries per 1000 hours of competition in these muscles, in a study on four English soccer teams. Arnason (2004) found a similar injury incidence (24.6 injuries / 1000 hours of competition) in 306 soccer players in Iceland. Walden

Image source: marca.com

(2005) observed 30.5 injuries / 1,000 hours of competition in 266 players from eleven teams of the European elite.

Recently, Hagglund (2013) reported that 42% of the injuries that affected the lower limbs of 26 European teams between 2001 and 2010 were hamstring injuries, and that it was more frequent in the dominant lower limb (D). According to Woods et al. (2004) and Ekstrand et al. (2011) of all injuries to a soccer team, 12% occur to the hamstrings and constitute an average of five injuries per season. Among all of them, the femoral biceps is the one with the highest incidence (Heiderscheit et al., 2010; Goldman and Jones, 2011), as also stated by Mallo et al. 2011, saying that 1.0 injuries occur in these muscles per 1000 hours.

Due to the results of these studies and to this reality, muscle injuries and, specifically, hamstring injuries, is an issue that worries professionals in the world of football today, both coaches and physical trainers, as well as the body. doctor. For this reason, in the last part of this work we will carry out a detailed analysis of this injury, studying the possible mechanisms of its production, and offering a working methodology for both its treatment and prevention.

3.4. Severity level

The classification of injuries most used by researchers is that which groups them according to the number of days the athlete misses training or matches, classifying injuries into three categories. As can be seen in the following table (Table 6), most authors classify injuries based on the player missing at least one training session or game, but there are others that, although they also divide them into three categories, the minimum period of involvement should last at least a week. (Belloch et al, 2010).

Table 6. Classification of injuries according to their severity

The time lost in sports practice by the athlete is an effective indicator of the importance of the injury, but it has the disadvantage that it has a certain subjective component, since it depends on which person (doctor, physiotherapist, coach, athlete, etc. .) who makes the decision that the athlete returns to normal training. Furthermore, media pressure means that athletes do not always meet the recovery periods that would be adequate for the severity of the injury they suffer (Adamczyk and Luboiñski, 2002).

In other works (Arnason et al, 1996; Chomiack et al, 2000; Junge, 2004) injuries are divided into the following types: sprains (elongation of ligaments beyond the so-called elastic limit), muscle-tendon strains, contusions, tendinitis (which includes bursitis) and bone fractures. Injuries grouped as “other” include skin abrasions, concussions, and so on. (Table 7).

In general terms, it can be said that the risk of suffering an injury that entails a recovery period of less than a week would be between 12.5 and 62% probability. These are generally muscle-tendon sprains and strains. For those lasting less than four weeks, the probability is between 18.75 and 38%. Finally, for injuries over four weeks, the probability range would be between a

9 and 43.75%. These figures are quite similar to those obtained in other reviews (McGrath and Ozanne, 1997; Morgan, 2001). It is noteworthy that, according to these authors, the position of the player on the pitch does not affect the type of injury. (Belloch et al, 2010)

Table 7. Frequency of injuries according to the type of injury

3.5. Risk factor's

Regarding risk factors, in the literature we find two types: intrinsic factors, or those of the athlete; and extrinsic or external factors to the athlete. Although later on we will detail in each lesion the mechanism of its production and the factors that intervene in it, below we will present the different factors referred to by different authors in their studies (Hägglund et al, 2013; Navarro et al. , 2015; Orchard, 2001; Stege et al. 2011; Árnason et al, 2004; Call et al, 2014; Hrysomallis, 2013; Beijsterveldt et al, 2014; Hägglund et al, 2006; Henderson et al, 2010; Árnason et al , 2004)

Intrinsic

  • Age

  • Race

  • Anatomical aspects

  • Body composition

  • Sex

  • Inappropriate training

  • Inadequate treatment or rehabilitation

  • Muscle strength deficits (muscle imbalances)

  • Technique efficiency

  • Lack of flexibility

  • Having had a previous injury

  • Lack of synchronization between agonist and antagonist muscles of the kinetic chain

  • Fatigue

  • Lack of concentration

  • Mechanical instability in the joints (mainly ankles or knees)

Extrinsic

  • Actions of the sport

  • Playing surface conditions

  • Environmental conditions

  • equipment

  • Violation of the rules of the game

  • Game results

  • Moment of the season

  • Demarcation

  • Coach tactical decisions

  • Inappropriate gesture

  • Media or competition impact (importance of the match)

4. General treatment of injuries

According to Hontoria et al (1997), in the face of an injury there are a series of general guidelines that every soccer player and sports professional should know and take into account.

Repose

When noticing the first discomfort, sports activity should be stopped until it is evaluated by the doctor, immobilizing the affected part and being able to carry out other activities that maintain the physical condition without interfering in the healing process, the role of a specialist or recuperator being fundamental. This must be maintained for the exact time required by the injury

Image source: mundodeportivo.com

Apply cold (Cryotherapy)

It is the first measure that must be taken initially in almost all injuries: it reduces swelling, calms pain, reduces muscle spasm and favors recovery. The application of the ice should not be carried out directly on the skin as we would damage it. For this you can use different methods or strategies:

  • Reusable gels or bags of crushed ice wrapped in cloths or moistened towel in the area of contact with the skin. Ice can be applied initially in 15-20 minute periods, several times the first 24-48 hours.

  • ice mixed with water in a container until reaching a temperature between 13º and 18º.

  • Ice massage, describing circles around the injured area. The duration ranges from 3 to 10 minutes, and can be repeated every 2 to 3 hours.

* Precautions : it should not be used in people with poor circulation, who have excess sensitivity to cold or frequently suffer from chilblains.

Compression

It is helpful in reducing bleeding and swelling. It also helps to support the injured joint. It must be done by experts, using adhesive elastic bandages or not.

Image source: everyfutbol.co

Image source: elfutbloglin.blogspot.com.es

Elevation

Avoid stagnation of blood in the area of the injury and promote its return to the heart. For this, the injured structure must be kept elevated in such a way that it is located at the level of the heart.

Image source: woundstejidosblandospa.blogspot.com

Hot

We will use heat as long as 48 hours have passed since the acute phase of the injury. Through this method we favor the blood supply that facilitates wound healing and also relieves muscle contracture.

It should be applied using wet or dry cloths in the area of the injury, hot baths, electric blanket or rubefacient ointments.

* Precautions : You should never apply heat immediately after an injury, when you have a fever or with problems with blood circulation or sensitivity alterations.

Image source: pedafutbolfemenino.webnode.es

5. General preventive measures

Use correct technique

Prior medical examination

Image source: realmadrid.com

Adequate training level

Image source: chiledeportivo.cl

Image source: elmundo.es

Adequate recovery

Control of training and competition loads

Image source: larioja.com

Optimal warm-up prior to competition

Image Source: metemosgolhacemostry.blogspot.com

Image source: docentrenadores.com

Carry out preventive protocols

Correct hydration and nutrition

Image source: abc.es

Appropriate sports equipment in good condition

Image Source: metemosgolhacemostry.blogspot.com

Image Source: youtube.com

6. Analysis of the most frequent injuries in soccer

6.1. Spinal injuries

6.1.1. Whiplash or sprain

Diagnosis : from a simple stretch or tear of one of the ligaments that joins the cervical vertebrae (sprain) to a possible vertebral fracture.

Symptoms : cervical spine pain, possible MMSS irradiation, painful reflex contractures of the paravertebral muscles, decreased mobility, a “stretched out” attitude or torticollis and may associate peripheral or central neurological signs (impaired strength or sensation, pain headache, feeling dizzy, numb, etc.)

Production mechanism : forced hyperflexion or hyperextension movement, usually in a head jump undergoing a sudden load in the air.

Treatment : initially immobilize the neck with a collar.

Prevention : balanced strengthening of the neck and back muscles, correct jumping technique, using the arms to protect against collisions in front of other players and maintaining balance in the air, adequate warm-ups of the area and stretching in the return to calm .

6.1.2. Injuries to the growing spine. scoliosis

Diagnosis : multifactorial disease based on an abnormal maturation of the central nervous system associated with an imbalance of the axial skeleton.

Symptoms : Contrary to what has been believed for years, idiopathic scoliosis is not a cause of back pain or, usually, other health problems, but only a "cosmetic peculiarity."

Mechanism of production : Scoliosis can be due to malformations. In this case they are congenital (that is, they exist from birth); This happens, for example, in cases due to the lack of formation of half a vertebra. They can also appear as one more manifestation of other diseases (such as neurofibromatosis, Marfan syndrome or neuromuscular diseases). However, the majority of scoliosis, which appear in healthy children, are "idiopathic scoliosis." This type of scoliosis can be considered “mechanical syndromes of the spine”. The exact mechanisms by which scoliosis appears are not yet known, but several genes are known to be involved; Some seem to be linked to the appearance or predisposition to the appearance of the scoliotic curve, and others to its progression.

Treatment : electrical currents, exercise (nonspecific and specific), different types of corset, and surgery.

Prevention : postural scoliosis can be prevented with proper postural hygiene, but true scoliosis, being congenital, cannot be prevented so easily.

6.1.3. Low back pain

Diagnosis : localized pain in the lower or lower back, whose origin has to do with the musculoskeletal structure of the spine.

Symptoms : local or radiating pain, inflammation and the presence of muscle contractures.

Production mechanism : multifactorial origin, although sport generates a series of tirelessly repeated microtrauma, in addition to the unavoidable trauma of sports.

Treatment : rest (the most comfortable position for this is on the side and with the legs slightly bent); lumbar and gluteal massage therapy (therapeutic massage); muscle treatment: psoas, quadratus lumbar, pyramidal…. (physiotherapy); treatment of iliolumbar, intervertebral ligaments ...; electrotherapy: microwave, short wave, TENS, Infrared, ultrasound; Osteopathy; stretching exercises for the lower back; muscle strengthening; postural ergonomics.

Prevention : have a good muscular balance especially in the CORE area, perform stretching exercises for the lumbar area, adopt a brave mental attitude towards pain and comply with the rules of postural hygiene.

6.1.4. Sciatica

Diagnosis : pain, weakness or tingling in the leg, caused by compression of the sciatic nerve, which begins in the lumbar spine and runs down the back of the leg and controls the muscles of the back of the leg and also provides sensitivity throughout this region down to the sole of the foot.

Symptoms : tingling, pain, burning sensation, if it is very severe it prevents the person from moving. This pain can get worse after standing or sitting, at night, when sneezing, coughing, laughing, bending over, walking ...

Production mechanism : Piriformis or pyramidal syndrome (the pyramidal muscle, which is located in the gluteus, compresses the passage of the sciatic nerve in that area); herniated disc; degenerative disc disease; spinal stenosis; injury or fracture of the pelvis.

Treatment : The treatment of this pathology will be the same as the treatment of Low Back Pain, but also adding neural mobilization and focusing more on the treatment of the pyramidal muscle.

Prevention : have a good muscular balance especially in the CORE area, perform stretching exercises for the lumbar area, adopt a brave mental attitude towards pain and comply with the rules of postural hygiene.

6.2. Upper limb injuries

6.2.1. Shoulder

6.2.1.1. Acromioclavicular pathology

Diagnosis : from acromioclavicular sprain and dislocation to clavicle fracture. Classification based on those published by Mansat M and Mansat CH (1985), Rowe (1988) and Bannister et al (1992).

Type I : Sprain. There is no loss of joint relationship, it is only a ligamentous sprain. Radiologically, no alterations are observed.

Type II : Subluxation (incomplete dislocation). Superior acromioclavicular ligament tear, with partial capsular tear and sprain of the coracoclavicular ligaments. Radiologically, there may be no superior displacement of the external clavicular end or it is less than its thickness.

Type III : Complete upper dislocation. The AC joint is totally dislocated and the coracoclavicular ligaments are totally or partially torn. No or minimal muscle injury occurs. Radiologically, elevation of the external clavicular end over the acromion is observed greater than its thickness.

Type IV : Severe superior dislocation. Dislocation of the AC joint with complete rupture of the coracoclavicular ligaments and tear of the muscular attachments of the external clavicular third. Radiologically, the clavicle is very elevated above the acromion. Posterior dislocation: The coracoclavicular ligaments are not usually torn and the clavicle is displaced posteriorly. Inferior dislocation: Lower displacement of the clavicle. It is rare and the coracoclavicular ligaments usually remain intact. Complete and simultaneous dislocation of both joint ends: dislocation of the acromioclavicular and sternoclavicular joint.

Symptoms : localized pain in the anterior and superior face of the joint, which can radiate to the neck and trapezius. In the examination, the increase in pain with the maneuver of adduction and crossing of the contralateral arm to shoulder is characteristic, producing a compression in the joint. Deformity can also be seen with a tumor or subcutaneous relief of greater or lesser intensity depending on the severity. In the case of an open fracture, the wound caused by the fractured bone would also be appreciated.

Production mechanism : Fall on the arm in abduction-retropulsion, very abrupt downward pulls or by a direct impact on the arm stump (excessively abrupt fall or load). The clavicle rests on the first rib which blocks its internal movement and as a consequence there is a distention or breakage of the articular stabilizing elements or a fracture of the clavicle. In the most severe cases, tearing of the clavicular attachments of the trapezius and deltoid muscles can occur. (Lizaur et al, 1994)

Treatment : place a so-called 8-bandage, which allows stabilization of the joint. Mild fractures require orthopedic treatment and serious ones require surgical treatment. Through an arthroscopic procedure, it is possible to resect the arthritic area while preserving the superior acromioclavicular ligaments, which are the most powerful stabilizers of this joint. If osteoarthritis is part of a global degenerative painful shoulder, there is no clear consensus and, in the case of surgery, in addition to resection of the external quarter of the clavicle, other techniques may be associated. (Nourissat et al, 2014).

Prevention : balanced strengthening of the shoulder and back muscles, correct jumping technique, using the arms to protect against collisions in front of other players and maintaining balance in the air, adequate warm-ups of the zone and stretching in the return to calm .

6.2.1.2. Shoulder tendinopathy

Diagnosis : damage or irritation to the rotator cuff tendons.

Symptoms : localized pain in the anterolateral region of the shoulder. Very frequent the appearance of referred or radiating pain to the middle third of the arm.

Production mechanism : excessive mechanical and intensive functional stress linked to sport, especially above the level of the head. Subacromial syndrome

Treatment : rest and physiotherapy, based on kinesotherapy exercises (passive mobilizations carried out by the therapist or active ones carried out by the player). Other treatments include leaks, without long-term results, and surgery, in relation to subacromial syndrome. The re-education of the sporting gesture is fundamental and the work with elastic bands as well.

Prevention : balanced strengthening of the shoulder and back muscles, adequate warm-ups of the area and stretching in the cool down.

6.2.1.3. Shoulder dislocation

Diagnosis : very painful injury that occurs when the proximal humerus or "head" slips out of place, that is, the glenoid.

Symptoms : spectacular fall with one arm in irreducible abduction, “epaulet” deformity, in which the shoulder acquires a 90-degree angular appearance and not its normal rounded and blunt appearance, functional impotence and, above all, extremely intense pain that alarm about severity.

Production mechanism : Fall on the elbow and hand with the shoulder abducted-retropulsion-external rotation.

Treatment : urgent transfer for reduction. It is essential not to touch the shoulder or manipulate it until arrival at the medical center. A recurrent dislocation, with repeated dislocations from time to time, would imply corrective surgery.

Prevention : balanced strengthening of the shoulder and back muscles, adequate warm-ups in the area and correct technique in the event of a fall to the ground.

6.2.2. Forearm

6.2.2.1. Ulna and / or radius fracture

Diagnosis : violent break in one or both bones of the forearm. They can occur near the wrist at the farthest (distal) end of the bone, in the middle of the forearm, or near the elbow at the top (proximal) end of the bone. A child's bones are also subject to a unique injury called a growth plate fracture (epiphyseal plate). These plates are made of cartilage near the ends of children's bones and help determine the length and shape of mature bone.

Symptoms : In most cases, a fractured forearm causes severe pain. The forearm and hand may also feel numb.

Production mechanism : Fall on the hand with the arm extended.

Treatment : Some minor fractures, such as bun fractures, may only need the support of a splint or cast until they heal. For more severe fractures that have formed at an angle, the doctor may be able to push (manipulate) the bones into proper alignment without surgery, as long as the bones have not broken through the skin. A stable fracture, such as a buckle fracture, may require 3 to 4 weeks in a cast. A more serious injury, such as a

Monteggia fracture-dislocation, may need to be immobilized for 6 to 10 weeks. On the other hand, surgery to align the bones may be required if any of the following occur: the skin is broken, the fracture is unstable (the ends of the broken bones do not stay aligned), the bone segments have displaced, the Bones cannot be properly aligned with manipulation alone, the bones have already started to weld at an angle or in the wrong position. After the bones are aligned, the doctor may use nails, metal implants, or a cast to hold them in place until they have welded together.

Prevention : avoid blows to the hands or falls to the ground with the arm extended and, if they occur, perform them with good landing technique.

6.2.3. Elbow

6.2.3.1. Epicondylitis-Epitrocleitis

Diagnosis : tendonitis or insertional tendinosis of the epicondylar or epitrochlear muscles. Called tennis elbow and golfer's elbow respectively.

Symptoms : local pain on palpation or when extending the arm, periarticular calcifications, intratendionic micro calcifications

Mechanism of production : manual efforts of flexion-extension movements, in combination with forearm pronosupination, wrist extension and finger flexion. It is possible to find a biomechanical origin that must be corrected

Treatment : rest, anti-inflammatories, physiotherapy, orthosis: Brace, local corticosteroids and surgery.

Prevention : Strengthen the muscles involved, warm up well before the activity and a correct return to calm with stretching.

Image source: cvelparque.es

6.2.3.2. Olecranial bursitis

Diagnosis : Inflammation of the olecranon bursa located under the skin of the elbow with a protective function.

Symptoms : pain and increased volume

Production mechanism : repeated microtrauma from falls on the elbows

Treatment : physical therapy, aspiration and understanding

Prevention : avoid falls to the ground on the elbow and, if they occur, perform them with good falling technique.

Image source: salud.uncomo.es

6.2.4. Wrist

6.2.4.1. Wrist sprain

Diagnosis : from a global involvement (ligaments of the radiocarpal or mediacarpal joint) or localized (carpal joint, or lunopyramidal destabilization, or scapholunate, or inner radiocunital.

Symptoms : dorsal dormancy, feeling of instability and protrusion (cracking) with certain movements, limitation of extension and swelling or inflammation.

Production mechanism : fall on the palm of the hand with a hyperextended position or, by a violent bending or twisting.

Treatment : Apply cold (ice) in the hours following the injury, immobilize the area and place the arm up, to avoid edema. It is convenient to move your fingers. At approximately 10 days, perform draining massage, active mobilization and without resistance, and when the pain decreases, we will begin with muscle strengthening exercises.

Prevention : Wear protective gear (bandage), warm-up and then appropriate stretch, and learn proper landing technique.

6.2.4.2. Broken wrist

Diagnosis : from Colles' fracture (evident deformity in "dorsum of the fork", complete fracture of the distal third of the radius), to "greenstick" fracture (the bone is broken, but the periosteum is intact) or to the fracture in Rodete (also known as a “bamboo cane” fracture, the bone twists or bends but does not break. These fractures occur only in children, since their bones are more flexible than those of adults).

Symptoms : pain, swelling, and bruising on the injured wrist; pain that gets worse when you grasp or squeeze something; weakness and loss of sensation or tingling in the injured hand or wrist; Difficulty moving your wrist, hand, or fingers; and change in wrist shape

Production mechanism : result of a fall on the outstretched hand. They can also be caused by a direct hit with a hard object. Some medical conditions, such as osteoporosis (brittle bones), can make your wrist more likely to break.

Treatment : conservative treatment (immobilization with a cast or splint) or more aggressive (surgery). It will depend on the stability of the fracture focus and the possible functional sequelae. You may be given medicine to relieve pain. You may also need to take an antibiotic or get a tetanus shot if your skin has broken open.

Prevention : Wear protective gear (bandage), warm up and then stretch appropriately, learn proper landing technique, and avoid hand impacts.

6.2.5. Hand and fingers

6.2.5.1. Finger sprain

Diagnosis : From the sprain in the Meta-Carpus-Phalangeal joint of the thumb (internal lateral ligament) to the sprain of the proximal interphalangeal (complete separation of the contact between the articular surfaces of the head and the base of two adjacent phalanges and is usually associated with Capsuloligamentous ruptures: On physical examination, a shortened and extending finger is observed, showing an easily detectable deformity.

Symptoms : inflammation, skin coloration (especially ecchymosis), functional impotence to grasp objects or perform daily tasks and elastic stiffness, which recovers as soon as the reduction is carried out. (Ortin and Medina, 1994)

Production mechanism : in the first case, it can originate with a fall on the hand with the finger in abduction or hyperabduction due to the ball. In the second case it is usually due to a direct blow or a forced hyperextension of the finger. (Rozas et al, 2007)

Image source: ortopediadiagonalmar.es

Treatment : reduction in primary care (PHC) will be performed, if not associated with bone fracture, with finger traction. It will be referred to the traumatologist if it is associated with a bone fracture, and when after reduction an unstable joint remains. (Rozas et al, 2007). After reduction, the affected joint will be immobilized for 20 days with a semi-flexed digitopalmar splint, to replace the injured capsuloligamentous structures. (Romo et al, 2010). Irreducible fracture dislocations require surgery. Treatment consists of reducing the middle phalanx and restoring the fractured joint surface, the objective of which is to regain the greatest possible flexion-extension mobility of the range of motion, weeks after the end of the treatment, although this is not fully recovered in all patients. . (Green et al, 1992).

Prevention : Use protective equipment (bandage) and avoid impacts on the hand, especially on the fingers.

6.2.5.2. Dislocations

Diagnosis : the most typical are dorsal dislocation (the most frequent of dislocations that affect this joint, occurring after a shock or violent trauma in hyperextension. The middle phalanx moves dorsally) and lateral dislocation (produced by a forced movement of the radial or ulnar inclination with rupture of the collateral ligament and at least partial avulsion of the volar plate. Rupture of the radial collateral ligament is less frequent than that of the ulnar. Occasionally, a small bone fragment is included from the distal or proximal insertion). (Quesnot et al, 2010).

Symptoms : pain and rapid inflammation in the area. When moving, the bones of the finger are immobilized because they are not in place, the skin could be cut, scraped or bruised.

Production mechanism : falls and blows with objects, in sport with the blows of the ball at the tips of the fingers.

Treatment : they will require traction and reduction as early as possible, and always after an exact diagnosis by a specialist. Afterwards, the finger will be immobilized as little as possible (what is necessary to reduce the inflammation). A splint or splint will be used for immobilization for the first few days to ensure that the joint is stabilized and the swelling is gone. Later exercises will be carried out for his recovery.

Prevention : join the finger where you have had the injury with the adjacent one to avoid relapses.

6.2.5.3. Hammer toe

Diagnosis : rupture of the common extensor of the fingers at the level of its insertion in the distal phalanx.

Symptoms : pain and actively irreducible finger flexion deformity.

Production mechanism : trauma with hyperflexion of the Distal Interphalangeal joint.

Treatment : requires medical treatment: Stack or Prior splint until surgery.

Prevention : Use protective equipment (bandage) and avoid impacts on the hand, especially on the fingers.

6.3. Lower limb injuries

6.3.1. Muscle injuries

Diagnosis : depending on their severity, they are classified into contracture, muscle cramps and / or DOMS (grade 0), fibrillar micro-tear, and / or elongation (grade I), fibrillar tear (grade II) and muscle tear (grade III)

Image source: temadeporte.blogspot.com

Symptoms : depending on the severity, some symptoms or others will appear. In contractures, muscle cramps and / or stiffness (DOMS) there is pain and muscle stiffness associated with lack of training originating after sports practice and which can extend up to 2 or 3 days later. In the case of contractures, the symptoms are similar to those of fibrillar micro-rupture, in which diffuse pain appears and an increase in tone can be seen on palpation and slight pain on contraction against resistance and stretching. In the fibrillar and muscular ruptures a punctual pain appears, an increase of the tone around it, inflammatory signs and pain with the contraction against resistance and stretching. Hematoma usually appears.

Production mechanism : depending on the way they originate, we divide them into extrinsic, contusion with the opponent or an object, and in intrinsic, application of a tensioning force greater than the resistance of the tissue when it is in active contraction (mainly eccentric contraction).

Treatment : depending on the severity, one treatment or another will be carried out. For contractures, muscle cramps and / or stiffness, massage and stretching, cryotherapy just after performing the activity and water contrasts in the following days are suitable. For fibrillar and muscle ruptures, use cryotherapy, avoid massage or any type of manipulation and resort to analgesic drugs.

Prevention : the latest techniques used by soccer professionals are functional strength, eccentric strength, lumbo-pelvic balance (CORE), balance and proprioception, range of motion and flexibility, plyometrics, neuromuscular and correct coordination training load. (Da Silva et al, 2014)

6.3.2. Pelvis

6.3.2.1. Dynamic osteopathy of the pubis, osteitis or pubalgia

Diagnosis : pubic crossroads pain syndrome, referred pain in the pubic area (Gal, 2001)

Symptoms : inguinal or pubic pain in the adductor region that increases with physical exercise. It can present in the form of a fibrillar tear in the abdominal or adductor muscles a few months or weeks before.

Production mechanism : Forced abduction while adducting the thigh, for example, when hitting the ball or kicking. At the beginning of the hit, you start from a position of extension, external hip rotation and knee flexion. Meanwhile, the contralateral limb is in hip flexion and adduction. Next, to perform the shot, one passes to internal rotation, hip flexion, lower limb adduction and knee extension; at the same time that the contralateral limb begins the extension of the hip. Finally, the braking phase seems to mark the key moment in the appearance of the injury. Maximum internal rotation (hitting with the inside), and maximum adduction, which supposes a position of enormous instability for the lower limb. With all this, an asynchronous movement is produced in mill blades with a predominance of the lower traction (adductors) and maximum traction at the level of the symphysis pubis.

Image source: @brais_acebal

dynamic inguinal hernia that could be generating local space conflict, a herniorrhaphy is performed.

Prevention : Strengthening of the CORE muscles, especially the abdominal wall, adequate balance between these muscles and the adductors, stretching of the adductors and hamstrings, correct running and striking technique, especially in the positioning of the pelvis.

Treatment : rebalancing the muscular balance between the abdominal muscles and the adductors; promote the stability of the pubis. Surgical intervention is rarely performed. If it is a

Image source: @brais_acebal

6.3.3. Knee

6.3.3.1 Knee sprain

Diagnosis : sudden stretch or partial or total tear of any of the four ligaments that support the knee joint (LLI, LLE, LCA, LCP). Depending on the severity, it can be elongation / strain (grade I), partial tear (grade II) or total tear (grade III).

Symptoms : continuous pain, when trying to walk and / or touch, decreased ability to move the joint and stiffness of the same, difficulty walking, swelling and redness of the affected area, internal bleeding causing the appearance of a bruise In the event of a tear, a dislocation and instability sensation appears, accompanied by a snapping sound at the time of injury and severe knee inflammation in the next few hours.

Production mechanism : LLE: forced varus associated or not with internal rotation or complex mechanisms; LLI: forced valgus associated or no external rotation; ACL: by contact (force in valgus or varus), without contact (turns with the foot supported in rotation and the knee very slightly flexed, approximately 21º); LCP: sudden movements, combined movements (flexion-valgus-external rotation, flexion-varus-internal rotation, hyperextension accidents)

Treatment : for elongations or strains, apply a conservative treatment based on the application of ice, taking anti-inflammatories and the use of an articulated knee brace that will keep the ligament in place and control knee movements. If a spill has occurred and the fluid is not reabsorbed, it may be necessary to remove it by puncture. I know

Image Source: sidneygomez.com

the rehabilitation process will begin in a few days. If the sprain is Grade II, it is necessary to keep the knee immobilized so that the ligament can heal properly. The use of crutches and a period of physical therapy will be necessary after the cast is removed. And finally, if a total rupture has occurred, a surgical treatment (plasty of the semitendinous or patellar tendon) and rehabilitation (to achieve joint range of motion, achieve levels of strength and muscle mass, proprioception work and re-education of the sporting gesture) will be needed. .

Prevention: knee strengthening programs, balance and proprioception training, neuromuscular coordination between agonist and antagonist muscles, playing field in perfect condition, use of appropriate surface function boots (cleats).

6.3.3.2. Meniscopathy

Diagnosis : damage to the structure of the menisci. They can be of four basic types: longitudinal, transverse, horizontal and oblique. Complex injuries were considered as a complication of more than one of the above. (Sánchez et al, 2004)

Symptoms : pain in the femorotibial joint interline, joint effusion and knee locks. Its intensity will depend on the size and stability of said break. (Masouros et al, 2008)

Production mechanism: rotational mechanism of the knee when the limb in support is in semi-flexion, which would explain why the medial meniscus is involved 5 to 7 times more than the lateral. With the knee in semi-flexion and with support, when rotating, the rim of the femoral condyle rests directly on the medial perimeter of the meniscus, exerting shear, since it subjects it to two forces in the opposite direction, while its capsular periphery, which is longer than that of the lateral meniscus, it undergoes traction. Hyperextension or hyperflexion also cause injuries, especially

of the anterior or posterior horns of the menisci. Likewise, abrupt varus or valgus knee positions often cause meniscal tears. (Busto et al, 2009)

Treatment : conservative: strengthen and make the muscles more flexible, generally using isometric exercises and eccentric contractions, focusing on the proprioceptiveness of the joint; in the same way, physical anti-inflammatory means such as thermotherapy, ultrasound, magnetotherapy and electroanalgesia are used. Surgical: arthroscopy (meniscal remodeling, meniscal suture, meniscal transplant) and rehabilitation therapy in the postoperative period, which contributes significantly to obtaining good results (Heckmann et al, 2006).

Prevention : knee strengthening programs, balance and proprioception training, neuromuscular coordination between agonist and antagonist muscles, playing field in perfect condition, use of appropriate surface function boots (cleats).

Image source: meds.cl

Image source: meds.cl

6.3.3.3. Osteochondritis dissecantes of the knee (ODR)

Diagnosis : A condition in which a subchondral bone fragment and its articular cartilage separate from the overlying bone. Its classic location for ODR is the external portion of the medial femoral condyle. Aichroth (1971) has reported a distribution of 85% of the lesions in the medial femoral condyle, 13% in the external femoral condyle, and 2% in the femoral trochlea.

Symptoms : vague and poorly located. Nonspecific knee pain is the most common presentation. Plain X-rays will help detect the injury. Another form of presentation is that of the articular free body, which causes blockage, inflammation and mechanical symptoms. Sometimes the injury is discovered by chance, when taking X-rays for any other reason. Physical examination may reveal pain, joint effusion, instability, blockage, and muscle atrophy (Rodríguez et al, 2002).

Mechanism of production : growth disorders, epiphyseal abnormalities, endocrine imbalances, familial predisposition, trauma, and avascular necrosis (Schenck and Goodnight, 1996).

Treatment : The treatment to be followed will depend on whether the fragment is stable or loose, whether the fragment is considered repairable or not, and the state of the articular cartilage near the injury. There are the following possibilities: splinting (rest), multiple perforations, fixation or excision of the lesion, and the autologous osteochondral graft (De Smet et al, 1996). Initial treatment in the child should be conservative (non-surgical), unless the lesion is unstable or there is a loose free body (Birch et al, 2001). If after 3 to 6 months of treatment it fails, surgical intervention would be justified. Small lesions can be excised and perforated arthroscopically, while large defects may require open scaling, followed by reduction and fixation.

Prevention : knee strengthening programs, balance and proprioception training, neuromuscular coordination between agonist and antagonist muscles, playing field in perfect condition, use of appropriate surface function boots (cleats).

6.3.3.4. Chondromalacia patella or SDFP

Diagnosis : incorrect alignment of the patella with respect to the mechanical axis of the lower limb, in which the patella moves towards the external part and the contact in this part with the femur increases, thus causing pain due to the sensation of pressure and compression.

Symptoms : diffuse pain in the anterior region of the knee, usually insidious and slow, aggravated by activities that increase compressive forces on the patellofemoral joint, such as going up and down stairs, running and / or walking, bending, as well as standing sitting for an extended period. (Piazza et al, 2014).

Production mechanism : they have multifactorial origin and are related to several factors that lead to malalignment of the patella (Sutvile et al., 2004), such as, for example, muscle weakness of the quadriceps, especially the Vastus Medialis; alterations in the biomechanics of the lower extremities (Thijs et al., 2007), highlighting the excessive pronation of the subtalar joint, which leads to a biomechanical overload of the patellofemoral joint (Venturini et al., 2006). According to Powers (2003) the posterior part of the varus foot leads to excessive subtalar pronation with the consequent excessive internal rotation of the tibia, changing the force vector acting on the patella, generating greater tension in the lateral soft tissues and can lead to patellofemoral pain.

Treatment : according to several reviews cited in the study by Domínguez and López (2010), there is a discrepancy in the literature regarding the treatment of this lesion. In 2001 Brosseau et al, after reviewing 85 studies, concluded that there are no clinically important beneficial effects of ul-

transsound in the treatment of SDFP. In 2002, D'Hont et al, after reviewing 5 clinical trials with 362 patients, concluded that it is inappropriate to make any clinical recommendation regarding the use of knee and foot orthoses for the conservative treatment of PPSD. In 2004 Heintjes et al, after reviewing 780 publications, ended up stating that despite the widespread use of non-steroidal anti-inflammatory drugs for PPSD, there is only limited evidence of their effectiveness in relieving pain, and the evidence is limited to the short term only. And finally, in 2003, after reviewing 12 clinical trials out of a total of 750 publications, Heintjes et al concluded that there is limited evidence on the effectiveness of exercise therapy for PPSD. Open kinetic chain exercises and closed kinetic chain exercises are equally effective. Based on limited evidence of effectiveness, clinicians may consider exercise therapy for patients with PPSS. This treatment is focused on balancing the muscles, mainly strengthening the Internal Vastus and Adductors, and unloading or stretching the Tensor fascia lata and iliotibial band, the External Vastus, Biceps femoris, Popliteus, Gluteus medius and minor and Psoas.

Prevention : Balance in the thigh muscles, at the intramuscular level of the quadriceps in terms of its external and internal vastus, and at the intermuscular level between the quadriceps and the posterior kinetic chain; and an adequate technique in the tread.

6.3.3.5. Osgood-Schlatter

Diagnosis : osteochondrosis or apophysitis that affects the ossification nucleus of the tibial tuberosity in the area of insertion of the patellar tendon, mainly in the growing age.

Image source: physiotherapy-lepe.blogspot.com

Symptoms : pain in the region of the tibial tuberosity in the anterior aspect of the knee (increases after sports effort and with local pressure), increased local volume of the tibial tuberosity, and epiphyseal fragmentation of the tibial tuberosity in some cases.

Mechanism of production : The exact cause of the disease is not yet known, since mechanical, traumatic and growth-related factors have been involved. The most accepted theory is the one that describes apophysitis as a traction of the tibial tuberosity in the growth period. Repeated microtrauma to the tibial tuberosity through contraction of the quadriceps and patellar tendon has been shown to cause loss of tendon-bone continuity with the consequent fragmentation of the tibial tuberosity, which triggers an inflammatory process around it. (Galván and Martínes, 2007)

Treatment : the treatment of these patients is aimed at controlling the disease by modifying physical activity (temporary sports relative rest: movements such as climbing stairs, deep bending of the knees or jumping and kicking), the use of analgesics- non-steroidal anti-inflammatory drugs and immobilization during periods of intense pain (Galván and Martínez, 2007). The use of cold in the area

Image Source: fixmyfeet.co.za

When the irritated area is irritated, stretching of the anterior and posterior thigh muscles, the use of an infrapatellar orthopedic strap for stress relief, low-frequency interference currents and the application of laser therapy are measures that help in the recovery of this injury. In exceptional cases, surgery can be used and perforations of the tibial ossification nucleus can be performed to improve vascularization. (Pérez and Moro, 2004). The moment the pain subsides, begin a physical therapy program aimed at improving the elasticity and strength of the quadriceps, as well as the hamstrings.

Prevention : although it is a growth disease whose causes are not clearly known, it is advisable to follow knee strengthening programs (mainly quadriceps and hamstrings) with their respective stretching, balance training and proprioception, neuromuscular coordination between agonist and antagonist muscles , pitch in perfect condition and use of suitable boots according to the surface (studs).

6.3.4. Leg

6.3.4.1. Tibial periostitis

Diagnosis : pain in the posteromedial region of the tibia, originating from acute or chronic inflammation of the periosteum, specifically at the distal two-thirds, caused by stress with exercise (Moen et al, 2010).

Symptoms : pain in the anterior medial aspect of the leg that appears when starting physical activity and that decreases after a short period of warm-up, but that appears again and with more intensity when you have been exercising for a while.

Production mechanism : Currently, it is believed that tibial periostitis is a bone overload injury, that is, the tibia bends during weight-bearing activities, causing tension and deformation of the tibia, generating traction on the tibia. (Gaeta et al, 2006). Some of the specific factors or mechanisms that favor this injury are the following. The vibrations caused by repetitive training, by the impact of the foot on the ground, on hard ground and sometimes coinciding with the use of inappropriate or too worn shoes. Excessive traction on the areas of insertion of the muscles on the periosteum, originating from muscle stiffness or incorrect support. Excessive hip rotation, increased external tibial torsion, hyperpronation or exaggerated heel eversion (during plantar stance phase), hindfoot valgus. Repetitive trauma directly to the periosteum on the anterior aspect of the tibia. And finally the use of inadequate shoes or biomechanical deficiencies in the tread.

Treatment : according to the literature, studies examining the use of tibial orthoses (Allen et al, 2004), compression stockings, and stretching and strengthening exercises (Moen et al, 2012) do not show an additional effect in the treatment of periostitis tibial. On the contrary, there are studies that suggest that phonophoresis (Wandashisha, 2010), low intensity laser (Wandashisha, 2010) and the use of shock waves (Rompe et al, 2010) are effective and beneficial treatments.

Image Source: juaneduardohv.wordpress.com

Prevention : avoid trauma to the tibial area, carry out a progressive warm-up, control the training load and use suitable footwear as well as a correct tread technique.

6.3.5. Ankle

6.3.5.1. Ankle sprain

Diagnosis : strain (grade I), partial tear (grade II), or total tear (grade II) of one or more ligaments that stabilize the ankle joint.

Symptoms : intense pain, inflammation of the affected area, bruising, local heat and alteration of localized sensitivity in the area of the injured ligament / os.

Mechanism of production : normally an ankle sprain is an injury that occurs fortuitously due to a bad movement or an accident when stepping on the ground. The essence of an ankle sprain is the stretching of the ligament beyond its elasticity limit, which causes it to strain, tear or break, depending on how violently that limit is exceeded.

Treatment : First, it is important to perform rest and elevation of the damaged joint. Then perform physiotherapy work (cryotherapy, compression, ultrasounds, drains, acupuncture). In the most severe cases, surgical treatment may be needed. As soon as the inflammation or pain does not exist or is minimal, rehabilitation work can begin, starting with joint mobility exercises and isometric strengthening, to later move on to concentric strength work, proprioception exercises in unstable situations and re-education of the sporting gesture.

Prevention : ankle strengthening programs, balance and proprioception training, playing field in perfect condition, use of suitable boots for the surface function (studs), proper tread technique and correct warm-up before practicing sports with specific exercises. ankle.

6.3.5.2. Fractures

Diagnosis : partial or complete breakage of one or more of the ankle bones. They usually affect the far or distal ends of the tibia (medial malleolus), fibula (lateral malleolus), or both bones. (Pinzur and Villas, 2014).

Symptoms : pain at the site of the fracture, which can extend from the foot to the knee; swelling that may appear along the leg or be more localized to the ankle; blisters may appear over the fractured area; bruising, decreased functionality when walking; bones that protrude through the skin.

Mechanism of production : indirect (torsion, varus or valgus trauma, leading to tibial and peroneal malleolar fractures; and axial compression trauma, such as tibial pilon fractures or calcaneal fractures), or direct (trauma ).

Treatment : elevation and cold placement, anatomical reduction, splinting, rest, immobilization with a cast / orthopedic boot and surgery.

Prevention : ankle strengthening programs, balance and proprioception training, playing field in perfect condition, use of suitable boots for the surface function (studs), proper tread technique and correct warm-up before practicing sports with specific exercises. ankle.

6.3.5.3. Footballer's ankle or anterior impingement

Diagnosis: formation of an osteophyte in the anterior capsule of the tibiotalar joint caused by repeated plantar flexions

Symptoms: pain in the front of the ankle that worsens when you hit the ball with the instep or in moments of acceleration or sudden stop during the race. Pain is awakened by the physician by flexing or extending the ankle, and a joint cracking sensation is sometimes noted.

Production mechanism: At the moment of hitting the ball, the forced plantar flexion of the foot causes a tension in the anterior part of the joint capsule. These repeated tractions on the insertion of the capsule produce inflammation, painful and, sometimes, small bone tears with the appearance of bone spurs (osteophytes) and decreased mobility of the ankle.

Treatment: physiotherapy that allows the joint capsule to be stretched to maintain movement, adding an anti-inflammatory medication if there is an effusion. Some authors advise applying a functional bandage during sports practice to limit ankle movements to their extreme degrees and avoid collision between the articular surfaces. When the painful condition becomes intolerable, does not respond to analgesics or when the limitation in ankle mobility is evident, removal of the osteophytes is recommended. This gesture is carried out with arthroscopic methods that, with less aggression and morbidity, add the possibility of seeing and washing the inside of the joint and achieving greater pain relief.

Prevention: In early stages when there is only an overload of the ankle, with pain in its anterior part, action should be taken by decompressing the joint, releasing excess pressure and thus preventing the bone-forming reaction, which in the long run leads to formation of the osteophyte.

6.3.5.4. Tenosynovitis

Diagnosis : inflammation of the sheath lining that surrounds the tendon, the cord that connects muscle to bone. The wrists, hands and feet are frequently affected, because the tendons are long along these joints. However, the condition can present with any tendon sheath.

Symptoms : Difficulty moving a joint. Joint swelling in the affected area. Pain and tenderness around the joint, especially in the wrist, ankle, foot, or hand. Pain when moving a joint. Redness along the tendon.

Production mechanism : excessive repetitive movements, overloads on the tendon, diseases that cause inflammation, infections, inadequate postural hygiene or incorrect sports technique.

Treatment : The goal of treatment is to relieve pain and reduce inflammation. Resting or keeping the affected tendons still is essential for recovery. The use of a removable brace or splint may be needed to help keep the tendons immobile. Also, applying cold to the affected area should help reduce pain and inflammation. Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, can relieve pain and reduce inflammation. Similarly, local injections of corticosteroids may be helpful. Some patients require surgery to relieve the inflammation surrounding the tendon, but this is not common. Once recovered, perform strengthening exercises using the muscles that surround the affected tendon in order to help prevent the reappearance of the injury.

Prevention : avoid repetitive movements or exercises that excessively overload the tendons, strengthen the nearby muscles with eccentric exercises, carry out an adequate warm-up as well as the correct stretches in the return to calm.

6.3.5.5. Achilles tendinopathy

Diagnosis : Chronic achilles tendinopathy of the middle portion of the Achilles tendon is the clinical entity that presents with pain in the intermediate area of the tendon (corresponding to the part of the tendon located 2-6 cm above its distal insertion in the posterior calcaneal tuberosity), its thickening and morning stiffness lasting more than 3 months. (Alfredson and Lorentzon, 2000)

Symptoms : pain in the Achilles tendon area that initially appears with physical activity but over time can even occur with normal gait and prevent sports practice (Gu et al, 2008). Occasionally, a palpable nodule can be seen in the medial tendon, and the ankle dorsiflexion path is sometimes limited and the strength and endurance of the plantar flexors is decreased (Silbernagel et al, 2001). Ultrasound generally shows alterations consisting of thickening of the tendon, with hypoechoic areas inside, increased vascularity and disorganization of the normal fibrillar pattern. In these cases, the magnetic resonance imaging (MRI) also usually shows tendon thickening, with an increase in the intensity of the intratendinous signal (Alfredson and Lorentzon, 2000).

Production mechanism : In chronic cases, factors such as advanced age, sports overload or training errors (tension forces that exceed their physiological extensibility, causing tissue damage), excessive pronation of the foot, previous injuries, inflammatory rheumatic conditions, hypercholesterolemia have been invoked , kinematic alterations in the knee and decreased muscle activity 27. (Leung and Griffith, 2008)

Treatment : pharmacological (orally and / or locally), relative rest and / or activity modification, orthosis, cryotherapy, electrotherapy (ultrasound, low intensity laser, extracorporeal shock waves ...), manual therapies and programs of exercises (stretching and / or strengthening). Classically, the most common recommendation has been to indicate stretching exercises in the initial phases together with other therapies with analgesic purposes (Paavola and Kannus, 2000) and, when the pain improved, strengthening exercises were added, usually concentric (Flórez et al, 2003 ). Eccentric training programs have been, in recent years, the most relevant change in the treatment of chronic forms of this clinical entity since they seem to reduce pain and improve muscle strength. Surgery is reserved for rebellious cases, where non-surgical treatment performed for at least 6 months has failed, or for patients with significant functional limitation (Alfredson and Lorentzon, 2000).

Prevention : strengthening programs (eccentric) and stretching, especially in the soleus and calves, but also taking care of all the muscles of the leg so as not to suffer from muscular imbalances, proprioception exercises, playing field in perfect condition, use of suitable functional boots of the surface (studs), proper tread technique and correct warm-up before practicing sports with specific ankle exercises.

6.3.6. Foot

6.3.6.1. Stress fracture

Diagnosis : partial or complete bone fracture resulting from the application of repeated stress (microtrauma) less than the stress required to fracture the bone with a simple load (trauma). The Tibia (anterior cortical and tibial malleolus), the Astragalus, the Scaphoid tarsal, the 5th Metatarsal (metaphysis), the 2nd Metatarsal (base) and the Sesamoid are at high risk of suffering this injury. (Torrengo et al, 2010).

Symptoms : diffuse localized bone pain in the initial stages of a mechanical nature and whose intensity increases if the effort is resumed, leading to authentic functional impotence. Detectable in superficial bones by means of palpation and bone percussion with the reflex hammer.

Production mechanism : Extrinsic factors: abrupt increase in duration; intensity or frequency of activity; inadequate rest period between stimuli; not respecting a stage of gradual adaptation to loads when returning to activity; sudden changes in the surface of the activity (the move to harder surfaces) and changes in sports gestures. Intrinsic factors: tissue ischemia, repeated capillary compression, misalignment of the lower limbs; postural and support alterations; muscle imbalances; Metabolic clinical pathologies and female triad (menstrual disorders, eating disorders and bone mineral deficiency) (Torrengo et al, 2010).

Treatment : Phase I: give time to the regenerative biological process, mainly by the periosteum and the vessels, since the greater the vascularization, the greater the osteoforming power. Use of casts or pneumatic splints to reduce the abnormal load on the fracture, ice massage or contrast baths, transcutaneous electrical stimulation, high-frequency currents, and shock waves. Extracorporeal shock wave lithotripsy decreases recovery time, recurrences, and pain during the recovery period for stress fractures in high-performance athletes (Herrera et al, 2005). Phase II: apply suitable plantar supports to avoid biomechanical alterations of the foot. Continue with the application of ice and high frequency currents after the exercises. Phase III: exercise program with rest phases in order to consolidate the fracture and promote bone remodeling.

Prevention : Use appropriate footwear, avoid overtraining, avoid sudden changes in surfaces, improve sports technique, strengthen and have a good muscular balance and an adequate diet.

6.3.6.2. Plantar fasciitis

Diagnosis : acute inflammation of the aponeurosis or plantar fascia, which limits function due to pain in the lower part of the heel. It is suggested that it represents a type of “tennis elbow” on the heel, caused by repeated microtraumas at the insertion point. (Karagounis et al, 2011).

Symptoms : Pain in the sole of the foot and the lower part of the heel, specifically in the anteromedial prominence of the calcaneus. It is usually more intense in the first at the beginning of the activity, then it tends to decrease, but does not disappear and is increased with long periods of standing, walking or exercising (especially on hard surfaces) and with activities that require weight bearing . Pain increases with forced dorsiflexion of the foot and toes, with knee extension (due to increased tension in the plantar aponeurosis), when climbing stairs, when walking barefoot and / or on the tips of the fingers . Pain associated with PF can be described as throbbing, sharp, or stabbing. (Digiovanni et al, 2011)

Production mechanism : it is considered to be a self-limiting process, although of long evolution, caused by repeated microtraumas in the place of insertion of the plantar fascia in the heel, producing a degeneration of collagen in the area of origin of the fascia (medial tubercle calcaneus) (James et al, 2011).

Image source: cronicajalisco.com

Treatment : Triceps sural (gastronemius and soleus - Achilles tendon) and specific stretching of the plantar fascia to increase length, extensibility and optimize the tension of the affected soft tissues, modifying their properties through mechanical and neurological effects. (Kavros, 2005). Myofascial Trigger Point Therapy to decrease plantar stiffness. Concentric strengthening exercises for the plantar flexor muscles of the foot, the tibialis anterior muscle and the intrinsic muscles of the foot (roll up a towel with the fingers, pick up marbles, coins, etc.). (Cole et al, 2005). Relative rest, avoiding mechanical overload and activities that aggravate pain. Use of templates adapted by a specialist. Reduce body weight. Apply ice after exercise (Lafuente et al, 2007). Physiotherapy: Ultrasonic therapy (Chien-Tsung et al, 2012), acupuncture (Kumnerddee and Pattapong, 2012), shock waves and corticosteroid injections. In the last case surgery (Lafuente et al, 2007).

Prevention : programs for strengthening and stretching the muscles of the leg and foot, playing field in perfect condition, use of suitable boots that function on the surface (studs) and adjusted to the foot (using insoles if necessary) and proper training technique. tread.

6.3.6.2. Séver's disease

Diagnosis : painful inflammation of the growth plate of the heel. Also called calcaneal apophysitis.

Symptoms : pain of varying intensity in one or both heels, especially after exercise. The pain usually subsides with rest, and can usually leave the area sore for a few days after playing sports.

Production mechanism : In ages between 9 and 13 years, a significant percentage of the calcaneus (heel bone) has ossified, however, the posterior part, which is in contact with the ground, still presents a growth cartilage of considerable size ( softer and more elastic). Even when children are increasing in height and size at these ages, their bones are still “children's”, causing overload in the weakest tissues. In addition to impact with the ground, the process (cartilage) is subject to constant traction by the Achilles tendon. Other complementary theories postulate a possible alteration in the blood supply of the calcaneal process.

Treatment : The treatment is clearly symptomatic. There is no cure for this condition, except for the term of calcaneal development. While this process occurs, the following measures can be performed: apply local ice after sports, use of footwear with cushioning the heel, gel heel pads, anti-inflammatories, sports rest, in very extreme cases temporary immobilization may be recommended.

Image source: damas17podologia.es

Prevention : avoid obesity, use suitable footwear, avoid overtraining, avoid sudden changes of surfaces.

7. Analysis of a case. Biceps femoris muscle tear

7.1. Definition

Muscle tear is defined as the complex of anatomical and functional alterations, caused by an unexpected and violent increase in the physiological tension of the muscle fiber (usually during an eccentric contraction, in which the muscle contracts but the external force forces it to stretch), which overcomes its elastic resistance and causes its rupture. This rupture affects the entire thickness of the muscle and the fascia, and manifests with the appearance of syncope pain and characteristic clicking. In addition, the depression of the area that has suffered the rupture is observed, producing the sign of the "ax" and the retraction of the belly of the broken muscle, forming a muscle herniation above the "ax". Functional disability is instantaneous and lasting and prevents the performance of any exercise. (Jiménez et al, 2010)

Ultrasonic exploration allows images to be observed where the muscle appears retracted and hyperechoic, with the presence of a large muscle hematoma (see image). Sloughs appear inside the broken muscle, giving the appearance of a bell clapper (Jiménez et al, 2010). The dynamic study and the compression maneuvers allow to demonstrate the mobility of the broken muscular stump, as well as the floating character of the sloughs and fibrin remnants, which supernate inside the blood collection. This test also demonstrates a complete loss of function of the broken muscle (Lee and Healy, 2004)

Image source: Jiménez et al, 2010

7.2. Anatomy

The biceps femoris is a muscle found in the back of the thigh, the most lateral of the hamstring muscles.

It is located in the superficial plane and in the deep plane since it is made up of 2 portions and therefore has 2 origins (long portion, in the ischial tuberosity through a common tendon with the semitendinosus; and short portion, on the external side of the linea aspera), and a single insertion, in the head of the fibula.

Its function is related to 3 very important movements, the external rotation of the knee, the extension of the hip and the flexion of the knee.

Image source: osteopatiamadrid.com

7.3. Injury incidence in soccer

Among muscle injuries, the muscles that have the greatest incidence are the hamstrings. According to Hawkins (1999), there were 27.7 injuries per 1000 hours of competition in these muscles, in a study on four English soccer teams. Arnason (2004) found a similar injury incidence (24.6 injuries / 1000 hours of competition) in 306 soccer players in Iceland. Walden (2005) observed 30.5 injuries / 1,000 hours of competition in 266 players from eleven European elite teams. Recently, Hagglund (2013) reported that 42% of the injuries that affected the lower limbs of 26 European teams between 2001 and 2010 were hamstring injuries, and that it was more frequent in the dominant lower limb (D). According to Woods et al. (2004) and Ekstrand et al. (2011) of all injuries to a soccer team, 12% occur to the hamstrings and constitute an average of five injuries per season. Among all of them, the femoral biceps is the one with the highest incidence (Heiderscheit et al., 2010; Goldman and Jones, 2011), as also stated by Mallo et al. 2011, saying that 1.0 injuries occur in these muscles per 1000 hours.

Image source: albertartasona.es

1.4. Production mechanisms and risk factors

This muscle group has the ability to generate high levels of force, which has a great impact in sports situations that involve high intensity actions: accelerations, jumps, changes of direction (De Hoyo et al, 2013). Several authors have studied the elongations and internal forces of the hamstring muscles during a sprint using the Inverse Dynamic Analysis methodology (Schache et al, 2013; Chumanov et al, 2007, 2011, 2012; Drezner, 2003; Thelen et al, 2005 ; Yu et al, 2008), showing that the maximum tension is reached at the end of the swing phase and the beginning of the stance phase, where the muscle contracts eccentrically to stop hip flexion and knee extension (Chumanov , 2011). Woods (2004) found that 57% of hamstring injuries occur during this phase of the career, which can largely justify the prevalence of this injury in soccer players, due to the high number of this type of actions throughout of a game, one every two minutes on average per player (Waldron and Murphy, 2013). The greatest muscle-tendon stretch occurs on the femoral biceps (Thelen et al, 2005), which may make it the muscle with the greatest tendency to be injured (Askling et al, 2007).

Image source: Relationship between the tension supported in the hamstring and the phase of the run.

Image source: De Hoyo et al, 2013

Focusing on the critical moment of injury in a sprint, mentioned above, Navarro et al (2015) explain, using a mechanical model, why the injury occurs in one of the hamstring muscles, specifically in the femoral biceps. To do this, let's look at the figure and the forces represented in it.

Fib: Internal force in the femoral biceps

Fst: Force of the Semitendinosus

Fsm: Force of the Semimembranosus

Fgm: Gluteus Maximus Strength

Fc: Quadriceps Strength

Fj: Joint force in the tibia

Ff: Limit of mechanical failure

The mechanical model is summarized by the following equations:

Fib + (Fst + Fsm + Fgm) - (Fc + Fj)> 0 -> Fib <Ff = No lesion

Fib + (Fst + Fsm + Fgm) - (Fc + Fj) <0 -> Fib> Ff = Yes lesion

The first equation indicates that if the total force applied to the BF, resulting from the vector sum of the muscular force of the BF itself, together with the forces of the other three muscles involved in its shortening (semitendinosus, semimembranosus and gluteus medius ), and of those that do it in the opposite direction trying to stretch it (quadriceps and joint force) is greater than 0, no injury occurs. This is due to the fact that the internal force in the BF is greater than the resistance force to breakage of the muscle fiber. Conversely, if the total force on the BF is less than 0, the internal force on the BF is less than the breaking strength force and injury occurs.

Several authors have shown through prospective studies with soccer players that having previously suffered an injury increases the risk of injury (Árnason et al, 2004; Hagglund, 2013). Other retrospective studies (Opar, 2013, Lee, 2009, Askling, 2010), by comparing players with and without previous injuries, conclude that after having had the injury the eccentric strength of the hamstrings decreases, the length of the Hamstrings at which maximum eccentric force occurs, the Hamstrings: Quadriceps ratio (I: C) and flexibility. In addition, the scar that forms during recovery can produce an increase in the stiffness of the fiber at that level and, therefore, a lower capacity to deform (Orchard, 2002)

With the previous model, Navarro et al (2015) explain how these risk factors affect the injury mechanism, following the example of the BF:

Decreased threshold of rupture due to having had a previous injury . If the scar that forms after the injury causes the rupture threshold (Ff) in that area to be lower than in the rest of the muscle, it is easier for the internal force (Fib) that the muscle supports to exceed this threshold, and injury occurs.

Lack of eccentric force . When a soccer player is sprinting, the angular velocity of knee extension is very large, requiring greater force from the hamstrings to stop it. If the hamstrings, due to lack of eccentric force, fail to slow down the speed of the leg sufficiently, the muscle is elongated more than desired, increasing the muscle-tendon tension and, therefore, the risk of injury. (Lee, 2009, Opar, 2013)

Lack of flexibility . Several authors have linked the lack of flexibility and the risk of injury. (Witvrouw, 2003, Arnasson, 2004, Henderson, 2010, Engebretsen, 2010, Askling, 2010, Fousekis, 2011). Witvrouw (2003), in a follow-up study of 146 Belgian league players, found that the group of players who were injured had less flexibility. When flexibility is low due to a lack of elasticity of the muscle, its stiffness increases, which means that the internal elastic stresses are greater at smaller elongations. This fact reveals why the tears occur near the junction between the muscle and the tendon, especially in the proximal part of the biceps (Heiderscheit, 2010), a portion of the muscle that acts on both joints.

Lack of synchronization of the lumbopelvic muscles . Gluteus maximus and hamstring function is influenced by the position of the pelvis (Kapandji, 1977). If an anteversion of the pelvis occurs, either due to a lack of abdominal tone or due to a shortening of the iliac psoas, the strength of the gluteus maximus is reduced, which leads to excess elongation of the hamstrings. An activation of the abdominals during the swing phase of running reduces the anteversion of the pelvis and prevents excess tension in the hamstrings (Oh, et al. 2007, Kuszewski et al., 2009, Frank, et al. 2009 , Mendiguchia et al. 2012). Ultimately, proper timing between the hamstrings, gluteus maximus, and abdominals can prevent hamstring muscle injury.

Insufficient Hamstring Ratio: Quadriceps . If the extensor forces of the leg (quadriceps and joint forces) are very high, the force of the hamstrings has to be increased to be able to brake the leg. When this occurs, the risk of hamstring muscle strength exceeding the breaking limit is greater, increasing the risk of injury (Croisier, 2004; Lee, 2009; Sugiura et al, 2008). The literature establishes an optimal ratio of 0.8 (Cooms and Garbutt, 2002; Croisier et al, 2008). New alternatives have recently appeared to replace or support this method used so far, such as Surface Electromyography (Navarro et al, 2015).

Image source: kinesiologiaula.wordpress.com

7.5. Treatment

In this section we will present an example of a treatment protocol carried out on an injured hamstring player.

First phase or approach phase (first 5 days approx.):

  • Immobilization Prevent future retractions of the tear and make the hematoma smaller.

  • Cryotherapy. To make the hematoma smaller, decrease inflammation and speed up repair.

  • Understanding. It seems to have a very powerful anti-inflammatory effect.

  • Elevation.

  • Electrotherapy and drainage type massage.

  • Upper body strength work can be performed without involving injured muscles

Combine compression and cryotherapy repeating intervals of 15 to 20 min (the time depends on the size of the muscle) lasting approximately every 3 to 4 hours. Be very careful with the application of cryotherapy, with respect to the proposed intervals, and control individual susceptibility, to avoid skin lesions.

Second phase or orientation phase (from day 6 to 12 approx.)

  • Physiotherapy:

    • Electrotherapy with an analgesic and decontracting effect to promote muscle refunctionalization.

    • Temperature: ultrasound (it is advisable to do it with stretching without passing the pain point), hyperthermia (the depth of the lesion must be taken into account and therefore the previous ultrasound study is very important) or diathermy.

    • Home isometrics manuals

    • Cryotherapy at the end of the week

  • Muscle activation. Early and progressive mobilization is very important, starting to do the following exercises gradually, taking into account the degree of tolerance to pain. External electrostimulation can be added to strength exercises:

    • from day 6 to 9 approx .: Isometric exercises progressively and taking into account that they have to be of maximum intensity until the appearance of pain (discomfort). It will also be important to progressively use different amplitudes and perform them in different positions and angles. The protocol that we propose with this guide is to perform isometric exercises in 3 different amplitudes and with a time schedule that can start with 6 s of contraction and 2 s of relaxation.

    • from day 10 to 12 approx .: Concentric exercises (controlled and with low loads 30-50% RM) and controlled unstable bipodal proprioception work

  • Stretching. The stretching of the muscle in this phase has to be painless, following the premise of bearable discomfort. We recommend starting with guidelines of 12 seconds of stretching and 12 seconds of rest. The least risky and advisable stretch is active stretching by the method of active contraction of the antagonist muscles in axial rotation, to stretch the injured muscle and improve its viscoelastic conditions and reduce the risk of fibrous scars and re-injuries.

  • Complementary work.

    • Work on the stabilization and mobilization of the lumbopelvic waist or core, without involving the injured muscles.

    • Upper Body Strength Exercises Using Resistance Strength (50% RM)

  • Cardiovascular maintenance in the form of aerobic capacity:

    • from day 6 to 9 approx .: exercise bike

    • from day 10 to 12 approx .: elliptical, or walking (in or out of the water)

Third phase or pre-optimization phase (from day 13 to 21 approx.)

  • Physiotherapy:

    • Electrotherapy with an analgesic and decontracting effect to promote muscle refunctionalization.

    • Temperature: ultrasound (it is advisable to do it with stretching without passing the pain point) and diamine.

    • Stick with isometric manuals

    • Cryotherapy at the end of the week

  • Muscle activation.

    • from days 13 to 16 approx .: Concentric exercises with medium load (50-60% RM). Begin with varied unstable monopodal proprioception work and continue to the end of recovery. Also start with exercises in the field to work on basic skills: running, movements in different directions and low-impact plyometrics

    • from day 17 to 21 approx .: Concentric exercises with medium load (50-60% RM) and start with controlled eccentrics. Continue with the exercises in the basic skills field: running, movements in different directions and medium impact plyometrics. You can introduce basic technical soccer actions: control, driving and a very short and smooth pass.

  • Stretching. Continue stretching the muscle without pain, following the premise of bearable discomfort.

  • Complementary work.

    • Work on the stabilization and mobilization of the lumbopelvic waist or core, which may involve the injured muscles.

    • Increase the load in upper body strength exercises (60-80% RM).

  • Cardiovascular maintenance in the form of aerobic power:

    • from day 6 to 9 approx .: extensive intervals on exercise bike

    • from day 10 to 12 approx .: extensive intervals on a stationary bike

Fourth phase or optimization phase (from approx. 21)

  • Physiotherapy:

    • Post-work massage therapy when needed

    • Cryotherapy at the end of the week

  • Muscle activation.

    • Concentric exercises with high loads (+ 70% RM) eccentric. Progression of soccer specific skills and high impact plyometrics.

  • Stretching. Continue muscle stretching without pain

  • Complementary work.

    • Get on with core work

    • upper body explosive strength exercises

  • Cardiovascular maintenance in the form of aerobic power:

    • Intensive intervals on a stationary bike or running.

* Once the player is discharged, he goes on to injury prevention work.

7.6. Prevention

In addition to the injury prevention guidelines set forth in previous chapters, in this section we will present an example of an injury prevention protocol, especially in hamstring or hamstring injuries, described in the literature by Estévez and Paredes (2015).

We will divide the prevention work into three phases during each training day:

  • Individual pre-training training : set of guidelines and exercises that each player must follow individually before training with the group based on their characteristics and history of previous injuries.

  • Group training or field session : exercises to be carried out by the group together during the training session and aimed at preventing injuries. (Here we must emphasize that not only the exercises that can be performed with force or "without the ball" are aimed at preventing injuries, but that the session in its entirety must have that principle among others, controlling work and recovery times for example.)

  • Individual recovery training : set of guidelines and exercises that each player must follow individually after training with the group based on their characteristics and history of previous injuries.

Below we will detail some exercises or individual pre-activation work protocols based on eccentric force, lumbopelvic stability work, proprioception work and neuromuscular control work.

Eccentric strength exercises

Image source: Estévez and Paredes, 2015

Strength exercises or

core stability

Image source: Estévez and Paredes, 2015

Balance exercises

and proprioception

Image source: Estévez and Paredes, 2015

Control exercises

neuromuscular

Image source: Estévez and Paredes, 2015

8. Bibliography

Adamczyk, G. and Luboiñski, F. (2002). Epidemiology of football related injuries part I, Jesien, 3 (2), 236-260.

Aichroth, P. (1971) Osteochondritis dissecans of the knee: a clinical survey. J Bone Joint Surg (Br). 53B: 440-7.

Alfredson, H. and Lorentzon, R. (2000). Chronic achilles tendinosis. Recommendations for treatment and prevention. Sports Med. 29: 135-46.

Allen, CS., Flynn, TW., Kardouni, JR., Hemphill, MH., Schneider, CA. and Pritchard, AE. (2004) The use of a pneumatic leg brace in soldiers with tibial stress

fractures - a randomized clinical trial. Mil Med. 169 (11): 880-4.

Andersen, TE, Larsen, O., Tenga, A., Engebretsen, L. and Bahr, R. (2003). Football incident analysis: a new video based method to describe injury mechanisms

in professional football. British Journal of Sports Medicine, 37 (3), 226-32.

Arendt, E. and Dick, R. (1995). Knee injury patterns among men and women in collegiate basketball and soccer: NCAA data and review of literature. Am J Sports

Med. 23 (6): 694-701

Arnason, A., Gudmundsson, A. and Dahl, HA. (nineteen ninety six). Soccer injuries in Iceland. Scand J Med Sci Sports. 6 (1): 40-5

Árnason, A., Sigurdsson, SB, Gudmundsson, A., Holme, I., Engebretsen, L. and Bahr, R. (2004) Risk factors for injuries in football. American Journal of Sports

Medicine 32 (Suppl. 1), S5-S16.

Arundale, A., Silvers, H., Logerstedt, D., Rojas, J., and Snyder-Mackler. (2015). An interval kicking progression for return to soccer following lower extremity injury.

International journal of sports physical therapy 10 (1): 114-127.

Askling, CM., Tengvar, M., Saartok, T. and Thorstensson, A. (2007) Acute first-time hamstring strains during slow-speed stretching: clinical, magnetic resonance imaging, and recovery characteristics. Am J Sports Med. 2007: 35: 1716-24.

Askling, CM., Nilsson, J. and Thorstensson, A. (2010). A new hamstring test to complement the common clinical examination before return to sport after injury.

Knee Surg Sports Traumatol Arthrosc, 18, 1798–803.

Bannister, GC., Wallace, WA., Stableforth, PG. and Hutson, MA. (1992) A classification of acute acromioclavicular dislocation: A clinical radiological and anatomical

study. lnjury. 23 (3): 194-196.

Beijsterveldt, AMC., Port, IGL., Vereijken, AJ. and Backx, FJG. (2014). Risk Factors for Hamstring Injuries in Male Soccer Players: A Systematic Review of

Prospective Studies. Scandinavian Journal of Medicine & Science in Sports, 23: 253-262.

Birch, JG., Guidera, KJ. and Heinrich, SD. (2001). Knee and leg: pediatric aspects. Orthopedic Knowledge Update 6 (Spanish Edition). Extremities

Inferiores, Medical Trends, Barcelona. 123-41.

Busto, JM., Liberato, I. and Vargas, G. (2009). Meniscal injuries. Ortho-tips. Vol.5 n.1.

Call, A., Carling, C., Nedelec, M., Davison, M., Le Gall, F., Berthoin, S. and Dupont, G. (2014) Risk factors, testing and preventative strategies for non-contact

injuries in professional football: current perceptions and practices of 44 teams from various premier league. Br J Sports Med. 48: 1352-1357

Casals, A. and Castells, M (2007) Latest advances in stress fractures. National Congress of Podiatry. BilbaoChomiak, J, Junge, A., Peterson, L., Dvorak,

J. (2000). Severe Injuries in Football Players. The American Journal of Sports Medicine, 28.

Cole, C., Seto, C. and Gazewood, J. (2005). Plantar Fasciitis: Evidence-Based Review of Diagnosis and Therapy. Am Fam Physician. 1; 72 (11).

Chien-Tsung, MD., Chang, W. and Jen-Pei, MD. (2012). Effects of Short-term Treatment with Kinesiotaping for Plantar Fasciitis. Journal of Musculoskeletal Pain,

Vol. 18 (1),

Chumanov, ES., Heiderscheit, BC. and Thelen, DG. (2007). The effect of speed and influence of individual muscles on hamstring mechanics during the swing

phase of sprinting. J Biomech, 40, 3555-62.

Chumanov, ES., Heiderscheit, BC. and Thelen, DG, (2011). Hamstring musculotendon dynamics during stance and swing phases of high speed running. Med Sei

Sports Exerc, 43 (3), 525-32.

Chumanov, E., Wille, CM., Michalski, MP. and Heiderscheit, BC. (2012). Changes in muscle activation patterns when running step rate is increased. Gait & posture.

Vol 36 (2): 231-5.

Croisier, JL., Ganteaume, S., Binet, J., Genty, M., and Ferret, JM. (2008). Strength imbalances and prevention of hamstring injury in professional soccer players: a

prospective study. Am J Sports Med. 36 (8): 1469–75.

Cunningham, C. and Cunningham, S. (1996). Injury surveillance at a national multi-sport event. Aust J Sci Med Sport. 28 (2): 50-6.

Da Silva, R., Nevado, F. and Paredes, V. (2014). Proposal for the distribution of preventive work within the micro-cycle of competition in a soccer team

professional. Soccer-Tactical Magazine (92).

De Loes, M., Dahlstedt, LJ. and Thomee, R. (2000) A 7-year study on risks and costs of knee injuries in male and female youth participants in 12 sports. Scand J

Med Sci Sports. 10: 90–7.

De Hoyo, M., Naranjo-Orellana, J., Carrasco, L., Sañudo, B., Jiménez-Barroca, J. and Domínguez-Cobo, S. (2013). "Review of injury to the musculature

Hamstring in sport: risk factors and strategies for their prevention. "Andalusian Journal of Sports Medicine 06 (01): 30-37.

De Smet, AA., Ilahi, OA. and Graf, BK. (nineteen ninety six). Reassessment of MR criteria for stability of osteochondritis dissecans in the knee and ankle. Skeletal Radiol. 25: 159-

63.

Digiovanni, BF., Nawoczenski, DA., Malay, DP., Graci, PA., Williams, TT., Wilding, GE. and Baumhauer, JF. (2006). Plantar fascia-specific stretching exercise

improves outcomes in patients with chronic plantar fasciitis. A prospective clinical trial with two-year follow-up. J Bone Joint Surg Am. 88 (8).

Domínguez, J. and López, MJ. (2010). Scientific bases for the design of an exercise program for patellofemoral pain syndrome. www.sermef-

exercises.org

Drezner JA. (2003). Practical management: hamstring muscle injuries. Clin J Sport Med. 13: 48-52.

Dvorak, J. and Junge, A. (2000). Football Injuries and Physical Symptoms. The American Journal of Sports Medicine, 28.

Eils, E., Streyl, M., Linnenbecker, S., Thorwesten, L., Völker, K. and Rosenbaum, D. (2004). Characteristic plantar pressure distribution patterns during soccer-

specific movements. The American Journal of Sports Medicine, 32 (1), 140-145.

Ekstrand, J., Hägglund, M. and Waldén M. (2011) Epidemiology of muscle injuries in professional football (soccer). American Journal of Sports Medicine. 39 (6):

1226-1232.

Ekstrand, J., Timpka, T. and Hägglund, M. (2006). Risk of injury in elite football played on artificial turf versus natural grass: a prospective two-cohort study.

British Journal of Sports Medicine, 40 (12), 975-80.

Ekstrand, J., Waldén, M. and Hägglund, M. (2004). A congested football calendar and the wellbeing of players: correlation between match exposure of European

footballers before the World Cup 2002 and their injuries and performances during that World Cup. British Journal of Sports Medicine, 38 (4), 493-497

Engebretsen, AH., Myklebust, G., Holme, I., Engebretsen, L. and Bahr, R. (2010). Intrinsic risk factors for hamstring injuries among male soccer players: a

prospective cohort study. Am J Sports Med, 38 (6), 1147–1153.

Estévez, JL. and Paredes, V. (2015). Proposal of a preventive protocol for hamstring injury in soccer: emphasizing neuromuscular training.

Journal of Physical Preparation in Soccer. ISSN: 1889-5050

Flórez, MT., Echávarri, C. and Pavón, M. (2003). Exercise program in tendinopathies. Rehabilitation (Madr). 37: 354-62.

Fousekis, K., Tsepis, E., Poulmedis, P., Athanasopoulos, S. and Vagenas, G. (2011). Intrinsic risk factors of non-contact quadriceps and hamstring strains in

soccer: a prospective study of 100 professional players. Br J Sports Med. 45: 709–714.

Franz, JR., Paylo, KW., Dicharry, J., Riley, PO and Kerrigan, DC (2009). Changes in the coordination of hip and pelvis kinematics with mode of locomotion. Gait

Posture, 29, 494-8.

Gaeta, M., Minutoli, F., Vinci, S., Salamone, I., D'Andrea, L. and Bitto, L. (2006). High-resolution CT grading of tibial stress reactions in distance runners. AJR Am J

Roentgenol. 187 (3): 789-93.

Gal, C. (2001). Pubalgia: prevention and treatment. PAIDOTRIBO

Galván, R. and Martínez, M. (2007). Osgood-Schlatter disease. Ortho-tips. Vol. 3 No. 2

García, M. and LLopis, R. (2010). Survey on sports habits in Spain. Higher Sports Council. Madrid

Goldman, EF. and Jones, DE. (2011). Interventions for preventing hamstring injuries: a systematic review. Physiotherapy. 97 (2): 91–99.

Green, A., Smith, J., Redding, M., and Akelman, E. (1992). Acute open reduction and rigid internal-fixation of proximal interphalangeal joint fracture dislocation.

Journal of Hand Surgery-American Volume, 17A (3), 512-517.

Gu, YD., Li, JS., Lake, MJ., Ren, XJ. and Zeng, YJ. (2008). The mechanical response of Achilles tendon during different kinds of sports. Commun Num Meth Engng.

24: 2077-85.

Hägglund, M. (2007) Epidemiology and prevention of football injuries. U-Tryck, Linköping, Sweden.

Hägglund, M., Waiden, M. and Ekstrand, J. (2006). Previous injury as a risk factor for injury in elite football: a prospective study over two consecutive seasons. Br

J Sports Med, 40 (9), 767-72.

Hägglund, M., Waldén, M. and Ekstrand, J. (2013). Risk factors for lower extremity muscle injury in professional soccer: The UEFA injury study. The American

Journal of Sports Medicine, 41 (2), 327-335.

Harmon, KG. and Dick, R. (1998). The relationship of skill level to previous cruciate ligament injury. Clin J Sport Med. 8 (4): 260-5

Hawkins, RD. and Fuller, CW. (1999). A prospective epidemiological study of injuries in four English professional football clubs. British Journal of Sports Medicine,

33 (3), 196-203

Hawkins, R., Hulse, M., Wilkinson, C., Hodson, A., & Gibson, M. (2001). The association football medical research program: an audit of injuries in

professional football. British Journal of Sports Medicine, 35 (1), 43-47.

Heckmann, TP., Barber-Westin, SD. and Noyes, FR. (2006) Meniscal repair and transplantation: indications, techniques, rehabilitation, and clinical outcome. J

Orthop Sports Phys The. 36 (10): 795-814.

Heiderscheit, BC, Sherry, MA, Silder, A., Chumanov, ES and Thelen, DG (2010). Hamstring strain injuries: recommendations for diagnosis, rehabilitation, and

injury prevention. J Orthop Sports Phys Ther. 40 (2): 67–81.

Henderson, G., Barnes, CA. and Portas, MD. (2010). Factors associated with increased propensity for hamstring injury in English Premier League soccer players. J

Sci Med Sport, 13 (4), 397–402.

Herrera, M., Leal, CA., Murillo, M., Duran, R Carlos, J. and Eduardo, O. (2005). Treatment of stress fractures of the tibia in tall athletes

performance by extracorporeal shock wave lithotripsy. Colombian Journal of Orthopedics and Traumatology. Vol. 19 - No. 1.

Hontoria, L., González, V., Alvarez, M., Calvo, J., Chamorro, P., Juanes, MA. and Montoya, JJ. (1997) Manual of Sports Injuries. BOOTS HEALTHCARE.

Madrid

Hrysomallis, C. (2013). Injury Incidence, Risk Factors and Prevention in Australian Rules Football. Sports Med. 43: 339–354

Inklaar, H. (1994). Soccer injuries I: incidence and severity. Sports Medicine, 18 (1), 55-73.

Inklaar, H., Bol, E. and Schmikli, SL. (1996) Injuries in male soccer players: team risk analysis. Int J Sports Med. 17 (3): 229-34

James, D., Goff, D. and Crawford, R. (2011). Diagnosis and Treatment of Plantar Fasciitis. Am Fam Physician. 15; 84 (6).

Jiménez, F., Goits, H. and Bouffard, A. (2010). Clinical and ultrasound diagnosis of muscle injuries. Archives of Sports Medicine. Vol 27. N. 138. 465-

476.

Junge, A., Chomiak, J. and Dvorak, J. (2000). Incidence of Football Injuries in Youth Players. The American Journal of Sports Medicine, 28.

Junge, A. and Dvorak, J. (2000). Influence of Definition and Data Collection on the Incidence of Injuries in Football. The American Journal of Sports Medicine, 28.

Junge, A., Dvorak, J. and Graf-Baumann, T. (2004). Football injuries during FIFA tournaments and the Olympic Games, 1998-2001: development and

implementation of an injury-reporting system. Am J Sports Med. 32 (1 Suppl.): 80S-9S

Junge, A. and Dvorak, J. (2004). Soccer injuries: a review on incidence and prevention. Sports Med. 34 (13): 929–938.

Kapandji, IA (1977). Articular Physiology Notebooks. Barcelona, Toray-Masson.

Karagounis, P., Tsironi, M., Prionas, G., Tsiganos, G. and Baltopoulos, P. (2011). Treatment of plantar fasciitis in recreational athletes: two different therapeutic

protocols. Foot Ankle Spec. 4 (4).

Kavros, SJ. (2005). The efficacy of a pneumatic compression device in the treatment of plantar fasciitis. J Appl Biomech. 21 (4).

Kumnerddee, W. and Pattapong, N. (2012). Efficacy of electro-acupuncture in chronic plantar fasciitis: a randomized controlled trial. Am J Chin Med. 40 (6).

Kuszewski, M., Gnat, R. and Saulicz, E. (2009). Stability training of the lumbo-pelvo-hip complex infl uence stiffness of the hamstrings: a preliminary study. Scand J

Med Sci Sports, 19, 260-6.

Lafuente, A., O'Mullony, I., Escribá de La Fuente, M. and Cura-Ituartea, P. (2007). Plantar fasciitis: review of evidence-based treatment. Reumatol Clin.

3 (4).

Lee, JC. and Healy, J. (2004). Sonography of Lower Limb Muscle Injury. AJR. 182: 341-351.

Lee, MJ., Reid, SL., Elliott, BC. and Lloyd, DG. (2009). Running biomechanics and lower limb strength associated with prior hamstring injury. Med Sei Sports Exerc.

41 (10), 1942-1951.

Leung, JLY. and Griffith, JF. (2008). Sonograhy of chronic Achilles tendinopathy: a case control study. Int J Clin Ultrasound. 36: 27-32.

Lilley, K., Gass, E. and Locke, S. (2002). A retrospective injury analysisi of state representative female soccer palyers. Physical Therapy in Sport, 3, 2-9.

Lizaur, A., Marco, L. and Cebrian R (1994). Acute dislocation of the acromioclavicular joint. Traumatic anatomy and the importance of deltoid and trapezius. J Bone

Joint Surg. 76 (4): 602-606.

Llana, S., Pérez, P. and Lledó, E. (2010). The epidemiology of soccer: a systematic review. International Journal of Medicine and Sciences of Physical Activity and

Sport vol. 10 (37) pp. 22-40

Mallo, J., González, P., Veiga, S. and Navarro, E. (2011). Injury incidence in a Spanish sub-elite professional football team: A prospective study during four

consecutive seasons. Journal of Sports Science & Medicine. 10 (4): 731-736.

Mansat, M. v Mansat, CH. (1985). Traumatic lesions of the acromioclavicular joint. In: L'epoule du sportif. Masson, Paris.

Masouros, SD., McDermott, ID., Amis, AA. and Bull, AM. (2008). Biomechanics of the meniscus-meniscal ligament construct of the knee. Knee Surg Sports

Traumatol Arthrosc; 16 (12): 1121-1132.

Mendiguchia, J., Alentorn-Geli, E. and Brughelli, M. (2012). Hamstring strain injuries: are we heading in the right direction? British Journal of Sports Medicine. 46

(2): 81-85.

McGrath, A. and Ozanne, J. (1997). Heading injuries out of soccer: a review of the literature. Monash University Accident Research Center, 125.

Moen, MH., Bongers, T., Bakker, EW., Weir, A., Zimmermann, WO., Werve, M. and Backx, FJ. (2010). The additional value of a pneumatic leg brace in the

treatment of recruits with medial tibial stress syndrome; a randomized study. JR Army Med Corps. 156 (4): 236-40.

Moen, MH., Holtslag, L., Bakker, E., Barten, C., Weir, A., Tol, JL. and Backx, F. (2012). The treatment of medial tibial stress syndrome in athletes; to randomized

clinical trial. Sports Med Arthrosc Rehabil Ther Technol. 30; 4:12.

Morgan, B. and Oberlander, MA (2001). An Examination of Injuries in Major League Soccer. The American Journal of Sports Medicine, 29,426-430.

Morgan, BE. and Oberlander, MA. (2001). An examination of injuries in major league soccer: the inaugural season. Am J Sports Med. 29 (4): 426-30

Navarro, E., Chorro, D., Torres, G., García, C., Navandar, A. and Veiga, S. (2015). A review of risk factors for hamstring injury in soccer: a biomechanical

approach. Motor skills: European Journal of Human Movement 34: 52-74.

Nielsen, AB., And Yde, J. (1989). Epidemiology and traumatology of injuries in soccer. Am J Sports Med. 17 (6): 803-7

Nourissat, G., Parier, J. and Radier, C. (2014). "Chronic Acromioclavicular Pathology." EMC - Locomotive Apparatus 47 (1): 1-7.

Oh, JS., Cynn, HS., Won, JH., Kwon, OY. and Yi, CH. (2007). Effects of performing an abdominal drawing-in maneuver during prone hip extension exercises on hip

and back extensor muscle activity and amount of anterior pelvic tilt. J Orthop Sports Phys Ther; 37, 320-4.

Opar, D., Williams, M., Timmins, R., Dear, N. and Shield, A. (2013). Knee flexor strength and bicep femoris electromyographical activity is lower in previously

strained hamstrings. Journal of Electromyography and Kinesiology. 23: 696–703

Orchard, JW. (2001). Intrinsic and extrinsic risk factors for muscle strains in Australian football. Am J Sports Med, 29, 300-303.

Orchard, J., Walt, S., McIntosh, A. and Garlick, D. (2002). Muscle activity during the drop punt kick. Science and Football IV. W. Sprinks, T. Reilly and A. Murphy,

eds, London: Taylor and Francis. 32–43

Ortin, O. and Medina, S. (1994) Interphalangeal dislocations. Traumatology and Orthopedics in Family Medicine. Jarpo Editores. 296-8.

Paavola, M. and Kannus, P. (2000). Long-term prognosis of patients with achilles tendinopathy. Am J Sports Med. 28: 634-42.

Pérez, AJ. and Moro, JA. (2004). Locomotor system pathology in health sciences. Buenos Aires; Madrid: Panamerican Medical.

Peterson, L., Junge, A. and Chomiak, J. (2000). Incidence of football injuries and complaints in different age groups and skill-level groups. Am J Sports Med. 28 (5

Suppl.): S51-7

Piazza, L., Lisboa, ACA., Libardoni, TC., Vidmar, MF., Oliveira, LFB., Brinhosa, GCS. and Santos, GM. (2014). "Static and dynamic alignment of the retropé não

difference between subjects and sem femoropatellar dor syndrome. / Alignment static and dynamic rearfoot does not differentiate subjects with and without

patellofemoral pain syndrome. "Motricidade 10 (3): 21-30.

Pinzur, M. and Villas, C. (2014). Ankle fractures. Ed. AAOS-SECOT.

Powers, CM (2003). The influence of altered lower-extremity kinematics on patellofemoral joint dysfunction: A theoretical perspective. Journal of Orthopedic

& Sports Physical Therapy, 33 (11), 639-646.

Quesnot, A., Chanussot, JJ. and Danowski, RR. (2010). Rehabilitation of the upper limb. Madrid: Editorial Médica Panamericana.

Rodríguez, EC., Gómez, F. and Ortega, M. (2002). "Dissecting Osteochondritis of the Knee." Spanish Journal of Orthopedic Surgery and Traumatology 46 (05): 428-435.

Romo, R., Fernández, JM., Camacho, J., Tarazona, P. and Quinzaños, J. (2010). Fracture-dislocation of the proximal interphalangeal joint. ABC Medical Center.

Acta Ortopédica Mexicana; 24 (4): Jul.-Aug: 252-259

Rompe, JD., Cacchio, A., Fury, JP. and Maffulli, N. (2010) Low-energy extracorporeal shock wave therapy as a treatment for medial tibial stress syndrome. Am J

Sports Med. 38 (1): 125–32.

Rowe, CR. (1988). Acromioclavicular and sternoclavicular joints. In: The Shoulder. Churchill, Livingston, New York.

Rozas, M., Bilbeny, B. and Giménez, L. (2007) Interphalangeal luxation. ABS El Castell 1. Castelldefels, Barcelona, Spain. FMC. 14 (3): 167-71

Sánchez, A., Navarro, R., Rodríguez, A. Castells, J. García, C. and García, E. (2004) Study of meniscal injuries and associated injuries. Canary Islands Medical and

Surgical: Vol. 1. N.3.

Schache, AG, Kim, H., Morgan, K., and Pandy. (2010). "Hamstring muscle forces prior to and immediately following an acute sprinting-related muscle strain

injury. "Gait & Posture 32 (1): 136-140.)

Schenck, RC. and Goodnight, JM. (nineteen ninety six). Osteochondritis dissecans. J Bone Joint Surg (Am). 78A: 439-56.

Schmidt-Olsen, S., Jorgensen, U. and Kaalund, S. (1991) Injuries among young soccer players. Am J Sports Med. 19 (3): 273-5

Silbernagel, KG., Thomeé, R., Thomeé, P. and Karlsson, J. (2001). Eccentric overload training for patients with chronic Achilles tendon pain- a randomized

controlled study with reliability testing of the evaluation methods. Scand J Med Sci Sports. 11: 197-206.

Stege, JP., Stubbe, JH., Verhagen, EA. and Van Mechelen, W. (2011). "Risk factors for injuries in male professional soccer: a systematic review." British Journal of

Sports Medicine 45 (4): 375.

Sutlive, TG., Mitchell, SD., Maxfield, SN., McLean, CL., Neumann, JC., Swiecki, CR. and Flynn, TW. (2004). Identification of individuals with patellofemoral pain whose symptoms improved after a combined program of foot orthosis use and modified activity: A preliminary investigation. Physical Therapy, 84, 49-61.

Thelen DG., Chumanov, ES., Best, TM., Swanson, SC. and Heiderscheit, BC. (2005) Simulation of biceps femoris musculotendon mechanics during the swing

phase of sprinting. Med Sei Sports Exerc. 37: 1931-8.

Theron, N., Schwellnus, M., Derman, W., and Dvorak, J. (2013). Illness and injuries in elite football players-A prospective cohort study during the FIFA

confederations cup 2009. Clinical Journal of Sport Medicine, 23 (5), 379-383.

Thijs, Y., Van Tiggelen, D., Roosen, P., De Clercq, D., and Witvrouw, E. (2007). A prospective study on gait-related intrinsic risk factors for patellofemoral pain.

Clinical Journal of Sport Medicine, 17 (6), 437-445.

Torrengo, F., Paús, V. and Cédola, J. (2010). Stress fractures in athletes. Updated Complementary Study Algorithm and Staging. Magazine

the Argentine Association of Sports Traumatology. Vol 17, n. 1

Van Mechelen, W., Hlobil, H. and Kemper, HCG. (1992). Incidence, severity, aetiology and prevention of sport injuries. A review concepts. Sports Medicine, 14.82

- 99.

Venturini, C., Morato, F., Michetti, H., Russo, M., and Carvalho, VD. (2006). Study of the association between patellofemoral and retropevarus. Acta Fisiátrica, 13 (2),

70-73.

Waldén, M., Hägglund, M. and Ekstrand, J. (2005). UEFA Champions League Study: A Prospective Study of Injuries in Professional Football during the 2001-2002

Season, British Journal of Sports Medicine 39 (8): 542-546.

Waldron, M. and Murphy, A. (2013). "A Comparison of Physical Abilities and Match Performance Characteristics Among Elite and Subelite Under-14 Soccer

Players. "Pediatric Exercise Science 25 (3): 423-434.

Wandashisha, D. (2010). Effect of phonophoresis versus low level laser in the treatment of type II medial tibial stress syndrome. rajiv gandhi university of

health sciences padmashree institute of physiotherapy nagarbhavi, Bangalore.

Witvrouw E., Danneels, L., Asselman, P., D'Have, T. and Cambier, D. (2003). Muscle flexibility as a risk factor for developing muscle injuries in male professional

soccer players. A prospective study. " Am J Sports Med, 31 (1), 41–46.

Woods, C., Hulse, M. and Hodson, A. (2002). The Football Association Medical Research Program: an audit of injuries in professional footballanalysis of

preseason injuries. British Journal of Sports Medicine, 36 (6), 436-441.

Woods, C., Hawkins, RD., Maltby, S., Hulse, M., Thomas, A., and Hodson, A. (2004). "Football Association Medical Research Program." The Football Association

Medical Research

Yu, B., Queen, RM., Abbey, AN., Liu, V., Moorman, CT. and Garrett, WE. (2008) "Hamstring muscle kinematics and activation during overground sprinting." Journal

of Biomechanics 41 (15): 3121-3126.

Zahínos, JI., González, C. and Salinero, J. (2010). Epidemiological study of the injuries, the processes of readaptation and prevention of the injury of anterior

cruciate ligamento in the professional football. Journal of Sport and Health Research. 2 (2): 139-150.