BMJ Open Sport Exerc Med: first published as 10.1136/bmjsem-2018-000505 on 15 October 2019. Downloaded from http://bmjopensem.bmj.

com/ on March 4, 2020 at Universita degli Studi

Open access Consensus statement

Italian consensus statement (2020) on

return to play after lower limb muscle
injury in football (soccer)
Gian Nicola Bisciotti,1 Piero Volpi,2,3 Giampietro Alberti,4 Alessandro Aprato,5
Matteo Artina,6 Alessio Auci,7 Corrado Bait,8 Andrea Belli,3 Giuseppe Bellistri,3
Pierfrancesco Bettinsoli,9 Alessandro Bisciotti,10 Andrea Bisciotti,10 Stefano Bona,2
Marco Bresciani,11 Andrea Bruzzone,12 Roberto Buda,13 Michele Buffoli,14
Matteo Callini,15 Gianluigi Canata,16,17 Davide Cardinali,10 Gabriella Cassaghi,10
Lara Castagnetti,2 Sebastiano Clerici,18 Barbara Corradini,10
Alessandro Corsini ‍ ‍ ,3 Cristina D'Agostino,2 Enrico Dellasette,3
Francesco Di Pietto,19 Drapchind Enrica,10 Cristiano Eirale,1,20 Andrea Foglia,21
Francesco Franceschi,22 Antonio Frizziero,23 Alberto Galbiati,3 Carlo Giammatei,24
Philippe Landreau,25 Claudio Mazzola,26 Biagio Moretti,27 Marcello Muratore,3
Gianni Nanni,28,29 Roberto Niccolai,3 Claudio Orizio,30 Andrea Pantalone,31,32
Federica Parra,10 Giulio Pasta,33,34 Paolo Patroni,35 Davide Pelella,3
Luca Pulici ‍ ‍ ,3 Alessandro Quaglia,2,3 Stefano Respizzi,2 Luca Ricciotti,10
Arianna Rispoli,10 Francesco Rosa,2 Alberto Rossato,36 Italo Sannicandro,37

di Milano. Protected by copyright.

Claudio Sprenger,3 Chiara Tarantola,10 Fabio Gianpaolo Tenconi,38
Giuseppe Tognini,39 Fabio Tosi,3 Giovanni Felice Trinchese,40 Paola Vago,41
Marcello Zappia,42 Zarko Vuckovich,1 Raul Zini,43 Michele Trainini,44
Karim Chamari1,45

To cite: Bisciotti GN, Volpi P, Abstract

Alberti G, et al. Italian How might it impact on clinical practice in the
Return to play (RTP) decisions in football are currently
consensus statement (2020)
based on expert opinion. No consensus guideline has been future?
on return to play after
lower limb muscle injury in published to demonstrate an evidence-based decision-
►► Our findings represent a reference from Italian ex-
football (soccer). BMJ Open making process in football (soccer). Our aim was to provide
perts and may help inform practitioners looking for
Sport & Exercise Medicine a framework for evidence-based decision-making in RTP
guidance when making RTT and RTP decisions fol-
2019;5:e000505. doi:10.1136/ following lower limb muscle injuries sustained in football. A
bmjsem-2018-000505 lowing lower limb muscle injury in football.
1-day consensus meeting was held in Milan, on 31 August
►► Further research is required to determine the reli-
2018, involving 66 national and international experts from
ability and validity of the tests recommended due to
various academic backgrounds. A narrative review of
Accepted 27 July 2019 a lack of available evidence.
the current evidence for RTP decision-making in football
►► We acknowledge that our consensus, despite en-
was provided to delegates. Assembled experts came
gaging a large number of experts, provides ‘level 4’
to a consensus on the best practice for managing RTP
evidence.
following lower limb muscle injuries via the Delphi process.
►► We both anticipate and welcome constructive dis-
Consensus was reached on (1) the definitions of ‘return
cussion on areas where others may have data we
to training’ and ‘return to play’ in football. We agreed on
have missed, opinions that diverge from ours and
‘return to training’ and RTP in football, the appropriate use
suggestions for new investigations.
of clinical and imaging assessments, and laboratory and
►► We appreciate that the overarching goal of sports
© Author(s) (or their field tests for return to training following lower limb muscle
and exercise medicine research is to improve RTT
employer(s)) 2019. Re-use injury, and identified objective criteria for RTP based on
permitted under CC BY-NC. No and RTP for football players and all sportsmen and
global positioning system technology. Level of evidence IV,
commercial re-use. See rights sportswomen.
grade of recommendation D.
and permissions. Published by
BMJ.
For numbered affiliations see
end of article. that minimise time-loss injuries often achieve
Introduction greater league success.4–7 The return to play
In professional football (soccer), injuries to (RTP) decision-making process in profes-
Correspondence to
Dr Alessandro Corsini,F.C.
the hamstring, quadriceps femoris, adduc- sional football involves multiple stakeholders,
Internazionale Milano, Milano, tors and soleus-gastrocnemius account for including the individual player, the sports
Milano, Italy; s​ irconi@​gmail.​com 80%–90% of all muscle injuries.1–3 Teams medicine team, the coaching staff and the

Bisciotti GN, et al. BMJ Open Sp Ex Med 2019;5:e000505. doi:10.1136/bmjsem-2018-000505 1

 BMJ Open Sport Exerc Med: first published as 10.1136/bmjsem-2018-000505 on 15 October 2019. Downloaded from http://bmjopensem.bmj.com/ on March 4, 2020 at Universita degli Studi
Open access

technical/performance teams. All must combine effec-

tively to facilitate a successful RTP.8–12 Box 1 Inclusion and exclusion criteria
There is very little research evidence to support RTP
Inclusion criteria
decision-making in football, so RTP decision-making ►► Patient and problem: randomised controlled trials, cases series
process has been based on expert advice (level IV studies and consensus statement investigating lower muscle in-
evidence, grade D, using the Grading of Recommenda- juries in sport.
tions Assessment, Development and Evaluation [GRADE] ►► Intervention: conservative treatment of lower muscle injuries.
framework).13 Today there is no consensus conference ►► Comparator: comparison between different types of muscle injury
specifically focused only on RTP decision-making for classification and different types of conservative treatments.
lower limb muscle injuries in football. Muscle injuries ►► Outcome: time lost to injury, level of return to play, complications
represent a heterogeneous group including several and sequelae.
muscle groups with varying anatomical location, size and Exclusion criteria
biological responses (eg, healing time).1 14 15 RTP deci- ►► Patient and problem: randomised controlled trials, case series and
sion should be based on the specific muscle injured. We consensus statements that investigated lower muscle injuries in a
propose clinical guidelines, imaging protocols, and labo- non-sporting population.
ratory and field tests for clinicians to consider for each ►► Intervention: surgical treatment of lower muscle injuries.
muscle group. ►► Comparison: comparison between conservative and surgical
treatments.
Italian Consensus Conference on RTP after lower ►► Outcome: unspecified outcome of time lost to injury, level of return
to play, complications and sequelae.
limb muscle injury in football
The Italian Consensus Conference (CC) (referred to
here as ‘Conference’) on RTP after lower limb muscle
injury in football was organised by the Italian Society of ►► An independent search was performed by both
Arthroscopy in Milan. The meeting was held on 31 August authors, with no language limitation applied.

di Milano. Protected by copyright.

2018, with the participation of 66 national and interna- ►► The databases searched were Medline, EMBASE,
tional experts covering several disciplines, including the Excerpta Medica, Cochrane Central Register of
following: Controlled Trials and the Cochrane Database of
►► Orthopaedic surgeons (19). Systematic Reviews. Grey literature (ie, conferences,
►► Sports physicians (7). abstracts, thesis and unpublished reports) was not
►► Radiologists (5). considered.
►► Rehabilitation physicians (3). ►► Studies that did not meet our inclusion criteria were
►► Sport physiologists (2). excluded. The inclusion and exclusion criteria are
►► General surgeons (2). shown in box 1.
►► Family physicians (2). The authors provided a summary document divided
►► Physiotherapists (10). into two sections:
►► Physical trainers (15). 1. RTP decision general principles (in sport, not only in
►► Psychologist (1). football; see inclusion criteria in box 1).
The selection of experts was based on pre-eminence 2. RTT and RTP decision-making following lower limb
in at least one of three criteria: (1) Hirsch Index, (2) muscle injuries in football.
number of publications concerning muscle injuries in The document was presented to each expert a
football, and (3) clinical evaluation, medical treatment week ahead of the Conference and was considered
and rehabilitation of muscle injuries in football. The the starting point for our discussion. The two senior
experts did not represent any commercial organisations authors facilitated (GNB) and chaired (PV) the Confer-
at the time of the consensus meeting. All those who ence.
participated in the CC are included as authors of this
report. Two authors (KC and ZV), although not present
at CC, provided intellectual contributions to the study. Consensus Conference statement
This paper represents the synthesis of the Italian Having outlined the background to the consensus state-
Conference on RTP following lower limb muscle injury ment and the methods, we now share our key findings in
in football. The complete document (90 pages in Italian) two sections.
can be found on the official website of the Italian Society Section 1 of our consensus reports the general princi-
of Arthroscopy (​www.​siaonline.​net). ples of RTP decision under five subheadings:
►► Terminology relating to RTP.
Consensus Conference narrative review process ►► Return to training (RTT): decision-making process.
Prior to the Conference, two senior authors (GNB and ►► RTP: decision-making process.
PV) performed a narrative review of RTP decision-making ►► Imaging: what role should it play when clinicians
literature in sport and in football specifically. The review make RTT and RTP decisions.
process was conducted as follows: ►► The biopsychosocial model and RTP decisions.

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Open access

Table 1 Mean (SD) of voting rounds for section 1 (RTP Table 2 Mean (SD) of voting rounds for section 2 (RTT and
decisions general principles) RTP decision-making following lower limb muscle injuries in
Voting Voting Voting Voting Voting football)
1 2 3 4 5 Voting
Voting 1 Voting 2 Voting 3 4
Average score 9.76 9.76 9.80 9.72 9.96
SD 0.33 0.33 0.30 0.35 0.32 Average score 9.24 9.64 9.54 9.72
SD 0.49 0.39 0.43 0.35
RTP, return to play; RTT, return to training.
RTP, return to play.

may be subjected to constraints concerning both the

Our consensus ‘decision-making process’ refers to the
intensity and amount of training load performed.24 25
evidence-based criteria outlined to support decisions on
The CC considered it necessary to introduce a clarifica-
both RTT and RTP.16 17
tion, in accordance with the 2016 consensus statement on
Section 2 of our consensus provides guidance on RTT
the return to sport.8 We define the term ‘return-to-training’
and RTP decision following four specific lower limb
as beginning when the player is partially reintegrated
muscle injuries in football. We cover decisions on both
into the team, and define the term ‘return to play’ as begin-
RTT and RTP following:
ning when a player has made a full return to unrestricted
►► Hamstring injuries.
availability in training and competition.
►► Quadriceps injuries.
In summary, the concept of RTT is linked to ‘return to
►► Adductor injuries.
sports practice/training with possible restrictions’, while RTP is
►► Soleus-gastrocnemius injuries.
linked to the concept of ‘return to training and competition
The agreements and guidance presented were the
without restriction’. We underline that RTT and RTP are
result of a Delphi process. A written outline for each
based on different decision-making criteria. RTT is based

di Milano. Protected by copyright.

section was presented by the facilitator (GNB), followed
on clinical-functional criteria, whereas RTP is based on
by a plenary discussion conducted by the chairman (PV).
functional-performance criteria. The RTP criteria have
Acceptance of a consensus statement was approved by a
an added layer of complexity as decision-making crosses
majority vote.
from the responsibility of medical team to the perfor-
The Conference participants voted using a Likert scale
mance team.24
of 0–10, where 0 reflected complete disagreement, 5
neither agreement nor disagreement, and 10 complete The RTT decision-making process
agreement. Clarification and debate continued until RTT decisions must be supported by clinical assessment
a mean score of >7.5 was reached.15 18–20 For section 1, and imaging and functional tests based on ‘injury-depen-
we required five rounds of votes, while for section 2 four dent criteria’. The following points must be identified
rounds to reach consensus. Amendments were made and followed for each type of muscle injury:
between each voting round following discussion among ►► Identification of appropriate clinical tests dependent
the Conference group. Consensus was reached in all on the type of muscle injury.8
cases (ie, for each voting round, a mean score of >7.5 was ►► Identification of appropriate imaging protocols
reached). The voting results are shown in tables 1 and 2. dependent on the type of muscle injury.15 24 25
►► Identification of appropriate laboratory tests specific
Section 1: RTP decision general principles to the functional deficit for the type of muscle
Terminology of RTP injury.26 27
The term RTP was defined by the consensus statement ►► Identification of appropriate field tests specific to the
developed by the American Academy of Orthopaedic functional deficit for the type of muscle injury.26 27
Surgeons and the American College of Sports Medicine The test battery must account for the performance and
as follows: related physiological demands of each player’s field posi-
The decision-making process of returning an tion. RTT decision-making process may need to be altered
injured or ill athlete to practice or competition. This for primary time-loss or recurrent time-loss injury.8–10 16 17
ultimately leads to medical clearance of an athlete
The concept of ‘tolerable risk’ in RTT decision-making process
for full participation in sports.21–23
Tolerable risk (TR) represents the maximum level
This definition implicitly means a return to ‘full training of risk acceptable for different short-term and long-
and competition availability’. However, in football, RTP is term outcomes associated with RTT.8–10 28 29 TR is
complex and often involves a period of progressive reinte- attributed equally to medical and technical staff, team
gration, where a player is not necessarily a full participant management, and the player. TR is shared except in
in all team activities. This period varies on factors such as life-threatening situations (eg, concussion in which
the type of injury and the overall amount of time out of the player has a reduced level of consciousness/deci-
full training. During the reintegration period, the player sion-making ability). Under such circumstances, the

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Open access

di Milano. Protected by copyright.

Figure 1 Tolerance risk flow chart. The first step is the ‘individual risk assessment’, while the second step is the ‘activity
risk factors’. The first and second steps represent the ‘risk assessment process’. The third step (tolerance risk assessment)
influences the risk assessment process in the return to play decision-making process. BW, body weight.

sole and final decision of RTT depends entirely on the (ie, transfer). The tolerance risk flow chart is shown in
medical team assessment. TR is variable and depen- figure 1. In any case, it is important to underline that
dent on the presenting situation. For example, TR may the medical staff has the responsibility to act in the best
be considered greater in a cup final than in a friendly interests of the player’s long-term health regardless of
match. Furthermore, TR can be influenced by several any contractual negotiation.
factors, such as whether an injury is acute or an overuse For player suffering from a muscle injury, TR is repre-
injury; a first time injury or recurrence; by its degree of
sented by the objective quantification of the maximum
severity and anatomical location; by its type (ie, monoar-
mechanical load that can be tolerated by the injured
ticular muscle, biarticular muscle, myotendinous
junction, in proximity to the central tendon and so on); muscular tissues. TR must be based on the following:
and by biological, endocrine-metabolic and gender-re- ►► Clinical examination.
lated factors. TR may also need to take into account ►► Imaging.
for economic evaluations; a typical example is when ►► Functional tests.
the player is directly involved in a market negotiation The clinical examination is illustrated in section 2.

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Open access

The basic principles of functional tests used in the RTT decision- parameters recorded in the postinjury period to make an
making process RTP judgement.
Functional tests must attempt to simulate real-time game For each of the six categories of speed listed, the
situations that replicate the following28: recorded data should account for the time spent and
►► Forces required during muscle contraction. distance covered at the indicated velocity. Recordings
►► Speed required during movement. should be taken in similar training environments (ie, do
►► Power expressed during movement. not compare possession-based play with shuttle runs).
►► Type of movement required (ie, specific or non-spe- The categories are presented below.
cific to the football model; eg, straight line running is ►► Walking (range 0–<5.4 km/hour).
a non-specific movement, while cutting during a run ►► Jogging (range 5.5–<10.8 km/hour).
is a specific movement). ►► Low speed running (range 10.9–<14.4 km/hour).
►► Specificity of the required movement (ie, specific ►► Intermediate speed running (range 14.5–<19.8 km/
or non-specific in comparison with the movement/ hour).
movements that can cause a reinjury in the previously ►► High-speed running (range 19.9–<25.2 km/hour).
injured muscles; eg, a sprint is a specific risk move- ►► Maximum speed running (≥25.2 km/hour).
ment for biceps femoris muscle injury, and kicking
is a specific risk movement for rectus femoris muscle Qualitative evaluation
injury). QLE is based on the analysis of metabolic power (MP)
calculated with GPS technology. MP (expressed in W/
Objective criteria in the RTP decision-making process kg−1) represents the product of speed and acceleration in
Decisions for RTT and RTP should be based on objective determining the intensity of running.57–59
criteria. The only subjective criteria that may be taken into The MP value can be calculated using the following
account are the individual profiles (ie, the psychological formula57:
state) of players. Clinical and functional investigations

di Milano. Protected by copyright.

that are numerically quantifiable are preferred when MP=CE•v
making decision. In this context, a reported pain value,
such as the Visual Analogue Scale, is acceptable. Indeed, where CE represents the energy cost of running at
pain is an essential parameter in the decision-making a constant speed (equal to 1 kcal/kg/km)59 and v is
process.30–48 The presence of pain in the injured tissue the athlete’s instantaneous speed. Below is the division
area strongly suggests that healing is incomplete. For of MP into six progressively greater categories. MP is
this reason, many authors underline the notion that RTT calculated by quantifying time spent in each MP cate-
should be granted only on complete resolution of the gory.
presenting symptoms.36 48–54 −1
►► Low power (0–<5 W.kg ).
−1
►► Intermediate power (5.1–<10 W.kg ).
The RTP decision-making process ►► High power (10.1–<20 W.kg ).
−1

The RTP decision-making process is a judgement of ►► Higher power (20.1–<25 W.kg ).

−1

whether the athlete is fit enough to resume full training ►► Very high power (25.1–<50 W.kg ).
−1

without restriction, as well as ready to take part in competi- ►► Maximum power (≥50 W.kg ).
−1

tion. The decision-making process for RTP, which follows MP time values recorded in the last period of prein-
that of RTT, is an assessment based on a judgement of jury training are compared with the same parameters
‘functionality’ and ‘performance capacity’ rather than recorded postinjury to formulate the RTP judgement.
‘clinical-functional suitability’.
We considered the use of global positioning system
Parameter analysis
(GPS) technology55 56 sufficient to inform objective
PA is based on a number of parameters recorded prein-
criteria. Therefore, these recommendations are limited
to teams who have access to GPS information. We jury, including the following57–59:
►► Total distance covered during training (regardless of
encourage all professional teams to adopt GPS data
collection. the run speed).
►► Equivalent distance (ED). In football, energy expend-
We subdivided the fundamental points of the RTP deci-
sion into three evaluation categories: iture is influenced by the accelerating and deceler-
►► Quantitative evaluation (QNE). ating components of the activity.58 ED corresponds
►► Qualitative evaluation (QLE). to the distance that the athlete could theoretically
►► Parameter analysis (PA). cover if he ran, at constant speed, using the same total
energy expenditure as that used during the game.
Quantitative evaluation The ED value can be calculated using the following
QNE25 57–59 requires the analysis of speed (divided into formula57:
six progressively increasing speed categories) recorded
in the last period of preinjury training versus the same ED=W/Ecc

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Open access

where W represents the energy cost expressed in J/kg, (US) signal may be obtained in 32% of examinations.84
and Ecc is the energy cost of running in a straight line at On average, the area under the anomalous MRI signal,
constant speed on compact grassland (ie, 4.6 J/kg). at the time of RTP, ranged from 20% to 28% of the
►► Equivalent distance index (EDI). EDI represents area measured at the baseline, that is, at the time of the
the ratio between the value of ED and the distance injury.86 Both the MRI and the US signals normalised
actually covered by the player (RD) according to the after an average of 6 months.84–86 Several studies of
following formula57: postlesion tissue at the time of RTP demonstrate that
34% of athletes exhibit a low-intensity MRI signal, indica-
EDI=ED/RD tive of the formation of fibrotic scar tissue.84 87 88 Despite
persistent alteration, the percentage of reinjuries was less
►► Anaerobic index (AI). AI represents the ratio between than 2%.84–86 The presence of abnormalities on MRI and
the energy cost beyond a certain metabolic threshold US during this period may be explained by the greater
(ie, anaerobic threshold value or maximal aerobic number of the ionic interactions of immature collagen
speed value) and is calculated as follows57: formed during the early stage of muscle healing. The
conversion of these weaker bonds to stronger covalent
AI=Wtp/W bonds, during post-translational modifications of the
constituent amino acids, may require longer periods of
where Wtp represents the energy consumed beyond the up to 6 months depending on the extent of the injury.84
metabolic threshold considered (anaerobic threshold or Therefore, in respect of imaging, this consensus speci-
maximal aerobic speed) expressed in J/kg, and W is the fies the following:
total energy expenditure, also expressed in J/kg. ►► RTT decision-making process does not necessarily
require a total resolution of MRI and US area of
The evaluation of aerobic fitness in RTP decision-making process signal alteration.84–86
Many studies suggest a correlation between low aerobic ►► In MRI, a signal alteration (hyperintensity zone in

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fitness and increased risk of muscle injury.60–66 Injuries fluid-sensitive sequences) decreased by at least 70%
with greater time loss characterised by low-intensity phys- in comparison with the baseline signal alteration is
ical activity are accompanied by a decrease in aerobic acceptable for RTT.85 86 89
fitness.6 Suspension of high-intensity aerobic activity ►► The presence of an extensive area of low signal inten-
for 20 days or greater results in a significant decrease sity, indicative of fibrotic scar tissue, must be inter-
in VO2max.67 68 Therefore, 20 days or greater of reduced preted as a risk factor for reinjury.83 86 87 However,
aerobic activity should include an evaluation of VO2max attention must be paid to the fact that a haemosid-
and/or the corresponding aerobic speed value69 assessed erin deposition, following haemorrhage, can mimic
by an incremental speed run test. We suggest evaluating the formation of fibrotic tissue.89
aerobic fitness during the RTP period by a valid test for ►► Given its greater sensitivity and the greater tissue
determining VO2max.70–74 contrast gradient, MRI is preferable to US when
making RTT decisions.84 89
The monitoring of acute and chronic load in the RTP decision-
making process The biopsychosocial model
The over-riding priority of RTP period is to avoid rein- RTT and RTP decision-making processes are heavily
jury.8–10 Monitoring of the training load, that is, the influenced by the psychosocial context within which they
‘acute load’, in relation to the preceding four training occur.80–93 Not taking psychosocial factors into account
loads, that is, the so-called ‘chronic load’, allows the can lead to the loss of valuable objective information
‘acute versus chronic workload’ ratio (ACWR) to be being missed. Psychological factors include apprehen-
calculated.75 Use of ACWR is still debated and therefore sion, fear or anxiety. In addition to negatively interfering
it may be necessary to update load calculations based on with performance, these parameters represent a risk
future best practice guidelines.76 77 However, we consider factor for reinjury.37 54 94–97 Therefore, we specified the
the calculation of ACWR useful in managing progressive following:
increases in training load, which may reduce the risk ►► During RTT and RTP decisions should take into
of reinjury. We strongly advise that ACWR assessment account the psychological state of the athlete.37 94–96
becomes an integral part of RTP decisions. ►► Individuals such as the coach, technical staff and
others may exert pressure on the RTT and RTP
The role of imaging in the RTT and RTP decision-making decision-making process.29 43 44 94 98–103 A potential
process conflict of interest exists between the athlete’s needs
The value of imaging during decision to return a player and wishes of the coach, technical staff and/or the
to sport is debated.16 78–83 In RTP cases 29–49 days after management team of the club.100 104 105 We recom-
a muscle injury, between 50% and 90% of athletes still mend all stakeholders avoid external pressures to
show an abnormal MRI signal (ie, hyperintensity of the maintain maximum objectivity during RTT and RTP
injured area).84–86 Furthermore, an abnormal ultrasound decisions.

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Open access

►► The decision-making process must be based on ►► Subjective feelings of the player taken into account
a continual exchange of information, between (ie, assess levels of anxiety, apprehension, fear of
all stakeholders. This should allow for reformu- failure and/or fear of reinjury).37 54 94–97
lation/revision of the rehabilitation plan where
necessary.8–10 Specific assessment
►► The RTT and RTP decision-making process must ►► Passive straight leg raise test.54 108–110
be based on a continuum that runs parallel to the ►► Dynamic flexibility H test.111
rehabilitation process. Isolated decisions regarding Laboratory tests for RTT
RTT and RTP that are not part of the rehabilitation The following are the laboratory tests recommended
process are to be avoided.8–10 prior to RTT:
►► The RTT and RTP decision-making process must be
►► Evaluation of hamstring muscle strength by dynamo-
player-centred. The central role of the player/patient metric tests (isometric, isotonic and isokinetic
is to be respected by taking the following into account: tests).54 85 112 113 The basic principles for the admin-
1. The short-term, medium-term and long-term health istration of dynamometric tests are shown in table 3.
risks associated with RTT and RTP.
2. The role of player/patient as an active ‘decision mak- Field tests for RTT
er’ when deciding whether to RTT or RTP. The following are the field tests we recommended to
determine readiness to RTT after hamstring strain:
24 25 114–116
►► Illinois Agility Test.
Section 2: RTT and RTP decision-making following 24 25
►► Braking test.
lower limb muscle injuries in football 117
►► Backward running.
Hamstrings, quadriceps, adductors and soleus-gastrocne-
No previous validation studies were identified on
mius muscles account for 80%–90% of all football muscle
the use of field tests to inform RTT and RTP. However,
injuries.1–3 Each muscle group was reviewed and reported
we considered an RTP test checklist for athletes who

di Milano. Protected by copyright.

under five subheadings:
suffered a lower extremity injury set out in a 2013 Delphi
►► Epidemiology.
study.118 The tests were recommended based on expert
►► Clinical and imaging assessments for RTT.
opinions (GRADE evidence level V). Furthermore, the
►► Laboratory tests for RTT.
Illinois Agility Test is an asymmetric test24 25 114–116; thus,
►► Field tests for RTT.
we recommend execution in its modified format formu-
►► RTP tests.
lated by Rouissi et al.119
RTT and RTP decisions following hamstring injuries
RTP tests
Epidemiology
The RTP decisions are based on performance evaluation,
Hamstring injuries are the most frequent injury in foot-
and therefore chronologically follow the RTT deci-
ball and represent about 17% of all football injuries.106
sion-making process. We recommend the following RTP
A professional football team incurs an average of 10
specific guidelines:
hamstring injuries per season.6 7 This results in an average
►► The data acquisition period must start from the first
of 90 days of time lost to injury, and on average between
day of RTT and include a period of at least 7–10 days.
15 and 21 matches lost per team per season. The inci-
►► During this period, the training sessions should be
dence of hamstring injuries ranges from 0.87 to 0.96 per
systematically recorded via GPS technology.
1000 hours of exposure (training and match).6 ►► It is necessary to identify several ‘typical’ sessions from
the last preinjury week and from the period following
Clinical and imaging assessments for RTT the RTT on which to base a return to normal function.
The following are our recommendations for clinical and The three evaluation categories are mentioned in the
imaging assessments for RTT following hamstring injury: ‘The RTP decision-making process’ section.57–59
The reference value, below which the positive judge-
General assessment ment for RTP is postponed, is arbitrarily set at a maximum
►► Absence of clinical symptoms.49 53 54 difference of 10% between preinjury data and the data
►► Absence of pain or tenderness during muscle palpa- recorded during the acquisition period following RTT.
tion.15 49 54 86 107 Furthermore, regarding aerobic fitness, we advise the
15 108
►► Absence of pain on passive and active stretching. player regains a VO2max value equal to at least 90% of
►► Absence of pain on isometric, concentric and eccen- their preinjury level.
tric contraction.15
►► Completion of the prescribed rehabilitation RTT and RTP decisions following quadriceps injuries
programme.86 Epidemiology
►► MRI and US imaging assessment respecting points In soccer, the majority (~88%) of quadriceps femoris
specified in ‘The role of imaging in the RTT and RTP injuries involve the rectus femoris.6 7 The risk of suffering
decision-making process’ section.84–89 from this type of injury is higher during competition than

Bisciotti GN, et al. BMJ Open Sp Ex Med 2019;5:e000505. doi:10.1136/bmjsem-2018-000505 7

 BMJ Open Sport Exerc Med: first published as 10.1136/bmjsem-2018-000505 on 15 October 2019. Downloaded from http://bmjopensem.bmj.com/ on March 4, 2020 at Universita degli Studi
Open access

Table 3 Basic principles for the administration of dynamometric (isometric, isotonic and isokinetic) tests
Isometric tests147–149 Isotonic tests147 150–152 Isokinetic tests42 85 112 113 153
Operate a proper warm-up. Operate a proper warm-up. Operate a proper warm-up.
 Biomechanically isolate the Biomechanically isolate the Biomechanically isolate the muscle group to be tested.
muscle group to be tested. muscle group to be tested.
Standardise the lever arm. Standardise the lever arm and Standardise the lever arm and ROM.
ROM.
Begin the test with the healthy Begin the test with the healthy Begin the test with the healthy limb.
limb. limb.
Apply an isometric contraction Apply the maximal speed Align the centre of rotation of the joint with that of the
of progressive intensity for a during the movement. mechanical device.
duration of between 3 sec and
5 sec.
Encourage the patient during Encourage the patient during Encourage the patient during the test.
the test. the test.
Perform at least three trials Perform at least one set of Subtract the weight of the limb from the calculation of the
with an adequate recovery 6–10 repetitions. force moment (usually done automatically by the device).
between each trial (around 1
min 30 sec).
Consider the peak value. Consider both average and Consider the average value, avoiding the so-called ‘peak
peak value. artifact’.
Check for any pain symptoms Check for any pain symptoms Check for any pain symptoms with VAS.
with VAS. with VAS.

di Milano. Protected by copyright.

Stop the test in the presence Stop the test in the presence of Stop the test in the presence of severe pain (VAS >3).
of severe pain (VAS >3). severe pain (VAS >3).
The dynamometric values The dynamometric values Perform one set of 6–10 repetitions at low speed (30°/
must be ≥90% of the must be ≥90% of the prelesion s−60°/s) and one set at high speed (>300°/s).
prelesion values or ≥90% of values or ≥90% of the
the contralateral limb values. contralateral limb values.
  Perform at least one eccentric test at 60°/s or 30°/s.
Consider the value of the joint angle corresponding to the
peak force production.
Consider the values of the mechanical work.
Consider the shape of the force curve.
Consider the value of the ratio of HS (concentric modality)
to Q (concentric modality), and the value of the ratio HS
(eccentric modality) to Q (concentric modality).
Perform the tests observing an adequate recovery between
the sets (~2−3 min).
The dynamometric values must be ≥>90% of the pre-lesion
values or ≥>90% of the contralateral limb values
ROM, range of motion; VAS, Visual Analogue Scale.

training (1.1 vs 0.3 per 1000 hours of exposure)6–120; 62% General assessment
of rectus femoris lesions are recorded during the first ►► The same conditions specified for hamstring lesions
half of the match, and the peak risk is observed between hold true.
the 16th and 45th minutes of play.6 120 The most common
mechanism of injury is during the kicking motion Specific assessment
(~28% of injuries). The rate of reinjury is approximately ►► Passive quadriceps stretch test.108 124
13%,121–123 and a team of 25 players should expect on
average three lesions of the rectus femoris per season, Laboratory tests for RTT
resulting in a total time loss of around 50 days.6 7 After quadriceps injury, the following are the laboratory
tests for RTT recommended by CC:
Clinical and imaging assessments for RTT ►► Quadriceps muscles strength assessed by dynamo-
We recommend the following clinical and imaging assess- metric tests.54 85 112 113
113
ments for RTT following quadriceps injury: ►► Synchro plates test.

8 Bisciotti GN, et al. BMJ Open Sp Ex Med 2019;5:e000505. doi:10.1136/bmjsem-2018-000505

 BMJ Open Sport Exerc Med: first published as 10.1136/bmjsem-2018-000505 on 15 October 2019. Downloaded from http://bmjopensem.bmj.com/ on March 4, 2020 at Universita degli Studi
Open access

Field tests for RTT fatigued. Football match play incidences of 0.84 per
The following are the field tests recommended prior to 1000 hours of exposure have been recorded.137 138 Calf
RTT following quadriceps injury: injuries cause greater time loss per incident138 and are
24 25 114 115
►► Illinois Agility Test. more likely to occur during critical periods of competi-
►► Braking test.
24 25
tion (eg, end of the season in soccer).139 Older soccer
24 25
►► Kicking test. players (above 25.8±4.5 years) demonstrate an almost
twofold increase in the rate of calf injury (HR, 1.93;
RTP tests 95% CI 1.38 to 2.71).6 Age and a history of calf strain are
►► The same conditions specified for hamstring lesions the strongest risk factors for suffering future calf injury.6 7
hold true.
Clinical and imaging assessments for RTT
RTT and RTP decisions following adductor injuries The following are the clinical and imaging assessments
Epidemiology prior to RTT recommended by CC following calf injury:
Adductor injuries account for 23% of all muscle inju-
ries in soccer.125 126 They occur most frequently in the General assessment
22–30 years age group and reinjury rates are reported ►► The same conditions specified for the hamstrings,
to be as high as 18%.125 126 Previous injury and a history quadriceps and adductor lesions hold true.
of reduced adductor muscle strength have been identi-
fied as risk factors for adductor injury.127 Amateur soccer Specific assessment
players with adductor weakness are four times more ►► Heel-raise test.140 141
prone to adductor injury.126 ►► Ankle flexibility test.142 143

Laboratory tests for RTT

Clinical and imaging assessments for RTT
The following are the laboratory tests prior to RTT
The following are the clinical and imaging assessments
recommended by CC following calf injury:
prior to RTT recommended by CC following adductor

di Milano. Protected by copyright.

►► Soleus-gastrocnemius muscles strength assessed by
injury:
dynamometric tests.53 84 111 112
113
General assessment ►► Synchro plates test.
144–146
►► The same conditions specified for hamstrings and ►► Drop jump test.
quadriceps lesions hold true.
Field tests for RTT
Specific assessment The following is the field test for RTT recommended by
►► Pubic stress test.
113 128 129 CC following calf injury:
24 25 114–116
►► Resisted hip adduction test.
112 127 128 ►► Illinois Agility Test.
113 130–133
►► Squeeze test.
108 134 RTP tests
►► Adductor passive stretching test.
►► The same conditions specified for the hamstrings,
Laboratory tests for RTT quadriceps and adductor lesions hold true.
The following are the recommended laboratory tests for Summary and conclusion
RTT following adductor injury: The Italian CC incorporated a cross-professional group
►► Adductor muscles strength assessed by dynamometric of established clinician and academics from various back-
tests.54 85 112 113 grounds. The diversity of the group provided a large
number of experiential-based viewpoints to be taken into
Field tests for RTT
account. The CC recommendations are summarised as
The following are the field tests for RTT recommended
follows:
by CC following adductor injury:
113 1. The appropriateness of the term RTP and the concepts
►► Kicking test.
135 136 of RTT were reformulated as RTT signifying a return
►► Carioca test.
to sports practice with possible restrictions, and RTP a
RTP tests return to training and competition without restriction.
►► The same conditions outlined for hamstrings and 2. The general and specific criteria concerning RTT and
quadriceps lesions hold true. RTP decision were identified, discussed and approved.
3. The four main muscle groups (hamstrings, quadri-
RTT and RTP decisions following soleus-gastrocnemius ceps, adductors and soleus-gastrocnemius) involved in
injuries lower limb football muscle injuries were identified and
Epidemiology discussed. The CC approved recommendations on the
Soleus-gastrocnemius (calf) injuries are common across following areas:
sports involving high-speed running, high total running a. Clinical and imaging assessment for RTT.
loads and high number of accelerations/decelerations. b. Laboratory tests for RTT.
Calf injuries are observed frequently when a player is c. Field tests for RTT.

Bisciotti GN, et al. BMJ Open Sp Ex Med 2019;5:e000505. doi:10.1136/bmjsem-2018-000505 9

 BMJ Open Sport Exerc Med: first published as 10.1136/bmjsem-2018-000505 on 15 October 2019. Downloaded from http://bmjopensem.bmj.com/ on March 4, 2020 at Universita degli Studi
Open access

d. RTP tests. Funding The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Future objectives
Patient consent for publication Not required.
The CC recommends the future development and
Provenance and peer review Not commissioned; externally peer reviewed.
research into efficacy of the following:
►► Field and laboratory tests to objectively inform RTT Data availability statement All data relevant to the study are included in the
article or uploaded as supplementary information.
and RTT decisions.
Open access This is an open access article distributed in accordance with the
►► The role of imaging in the decision-making processes
Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which
for RTT and RTP. permits others to distribute, remix, adapt, build upon this work non-commercially,
and license their derivative works on different terms, provided the original work is
Author affiliations properly cited, appropriate credit is given, any changes made indicated, and the
1
Qatar Orthopaedic and Sports Medicine Hospital, Doha, Qatar use is non-commercial. See: http://​creativecommons.​org/​licenses/​by-​nc/​4.​0/.
2
Humanitas Clinical Institute, Rozzano, , Italy
3
FC Internazionale Milano, Milano, Milano, Italy ORCID iDs
4
Department of Biomedical Sciences for Health, Università degli Studi di Milano, Alessandro Corsini http://​orcid.​org/​0000-​0001-​5793-​3221
Luca Pulici http://​orcid.​org/​0000-​0002-​8911-​1297
Milano, Italy
5
Centro Traumatologico Ortopedico, Torino, , Italy
6
Universita degli Studi di Milano, Milano, Italy
7
UOS Angiografia e Radiologia Interventistica, Ospedale delle Apuane, Massa
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