Managing the return to sport of the elite footballer following semimembranosus reconstruction

Abstract

Hamstring strains are the most common injury in elite football and typically occur during high-speed running. Despite its important contribution to power production in the late swing phase, injury to the semimembranosus (SM) is less common than to the biceps femoris, but may involve the free tendon and depending on the degree of retraction, warrant surgical repair. Few case reports detail clinical reasoning, supported by objective data during rehabilitation in elite footballers, and none have described the return to sport (RTS) process following this type of hamstring injury. In this article, we outline the management and RTS of an English Premier League (EPL) footballer who suffered a high-grade SM proximal tendon tear during training. Due to the degree of retraction of the free tendon, the player underwent surgical reconstruction at the recommendation of an orthopaedic surgeon. Early physiotherapy care, nutritional support, on- and off-pitch injury-specific reconditioning and global athletic development are outlined, alongside strength and power diagnostic and global positioning systems data, assessment of pain, player feedback and MRI informed clinical reasoning and shared decision-making during the RTS process. 18 weeks post-surgery the player returned to team training, transferring to a new club 3 weeks later. 2.5 years post RTS, the player remains free of re-injury playing regularly in the EPL.

Keywords: Elite performance; Football; Hamstring; Rehabilitation; Surgery.

Figure 1

Overview of the return to sport (RTS) of an elite male football player following semimembranosus free tendon reconstruction. Early rehabilitation is divided into two phases: physiotherapy care (Weeks 1–7) and transition into gym-based physical preparation (Weeks 8–12) including isometrics (ISO), dynamic strength (DYN) and jump-landing preparation (J-L Prep) and progression from stationary bike to anti-gravity treadmill running (A-GR) (Alter-G, Fremont, CA, USA). Return to participation phase (Weeks 13–17); on-pitch sports-specific reconditioning using the ‘control–chaos continuum’ (weeks displayed on-pitch) plus progression (+) of gym-based physical preparation; ISO+, DYN+ and J-L Prep+. RTS decision=return to team training (Weeks 18–20; return to train) and continued progressive optimal loading with reduced volume (sets) of ISO+, DYN+ and J-L Prep+. Arrows indicate timepoints of isometric posterior chain (IPC), eccentric knee flexor (ENF) and countermovement jump (CMJ) assessments. Data from these strength and power diagnostic tests, quantifying neuromuscular deficits relative to his healthy preseason (PS) values, and his response to on- and off-pitch reconditioning, informed exercise and phase progression decisions.

Figure 2

MRI throughout the return to sport process. Green arrows indicated key prognostic features. (A) 24 hours post-injury: (1) semimembranosus (SM) free tendon laxity and muscle retraction, (2) longitudinal split tearing at SM tendon origin. (B) 7 weeks post-surgery: (1) normal SM tendon/myotendinous junction tension, (2) maturing granulation tissue in SM tendon repair site. (C) 11 weeks post-surgery: (1) segmental tendon thickening and restoration of tension, (2) intratendinous maturing fibrous scar tissue. (D) 17 weeks post-surgery: (1) continued maturation of scar tissue throughout the site of surgical repair of the free proximal extra muscular portion of the SM tendon, (2) long segment of tendon repair shows relatively uniform low signal intensity scarring and maintains normal tension throughout the extra muscular portion and the proximal intramuscular portions of the tendon.

Figure 3

Isometric posterior chain (IPC) test performed using a portable force platform at 1000 Hz (PS-2141, Pasco, Roseville, CA, USA) with proprietary software (ForceDecks, Vald Performance, Brisbane, Australia). Test performed with the player lying supine position, the heel of the testing limb placed on the force platform resting on a firm plinth with the testing angle set at 90° hip and knee flexion using a goniometer (Physio Parts, Twickenham, UK) and the non-testing limb relaxed and fully extended. The player was instructed to push the heel of the testing limb into the force platform exerting as much force as fast as possible while keeping the buttocks, hips and head on the mat and hands crossed on chest. External pressure was applied to the non-tested pelvis/hip to prevent hip extension. The player was familiar with the test, but standardised instructions were given before the assessment, a verbal command of ‘3, 2, 1 GO’ countdown before the initiation of a maximal effort contraction which was held for 3 s during which consistent verbal encouragement was given ‘PUSH, PUSH, PUSH, RELAX’. Three maximal voluntary contractions were performed with 10 s rest between repetitions.

Figure 4

High-speed running, maximal speed exposure and posterior chain strength (isometric posterior chain (IPC) and eccentric knee flexor (ENF) during the return to sport after semimembranosus free tendon reconstruction. Session HSR (>5.5 ms^-1; dwell time 0.5 s) distance (m) represented by colour-coded bars (left y-axis) and relative values (fraction of pre-injury gameload) in the table. The % max speed (right y-axis) is % of pre-injury maximal speed (8.95 ms^-1) achieved within session, table shows absolute values. Global positioning systems; augmented 10 Hz Apex (StatSports, Belfast, UK). Absolute force (N, left y-axis) in Inv (involved limb) and Un-inv (uninvolved limb) at each assessment of unilateral IPC test (IPC-PF=peak force; IPC-F at 100 ms=force produced in first 100 ms of contraction) and in bilateral Nordic hamstring eccentric knee flexion (ENF; Avg-F=average force from 3 trials performed with 1 min rest between each). % ILA for each measure shown in the table. IPC values measured during 3 s maximal voluntary contraction performed in a supine position at 90° hip and knee flexion on a portable force platform at 1000 Hz (PS-2141, Pasco, Roseville, CA, USA) with proprietary software (ForceDecks, Vald Performance, Brisbane, Australia); bilateral Nordic hamstring ENF exercise using ‘NordBord^TM’ at 50 Hz (Vald Performance, Brisbane, Australia).

Figure 5

Optimal loading approach following semimembranosus free tendon reconstruction during the early rehabilitation phase onwards; gym-based physical preparation (Weeks 8–20). Running mechanics prior to anti-gravity treadmill running and implemented during on-pitch rehabilitation warm-ups. Dark grey=exercise, Light grey=exercise derivative. Strength (strain/stress) and (intermuscular emphasis)=dynamic strength training. w/=with, ↑=increase, ↓=decrease, ~=circa, > progression/onto. DB, dumbbell; early, early-stage; end, end-stage; GCT, ground contact-time; mid, mid-stage; Nb., note; reps=repetitions; RFD, rate of force development; ROM, range of motion; S-E, strength-endurance.; SL, single-leg.

Figure 6

Return to chronic running loads following semimembranosus free tendon reconstruction using the ‘control–chaos continuum’ as a framework for return to sport. Tables show the player’s pre-injury ‘gameload’ running load metrics from season 2016/2017. Total distance (TD), high-speed running (HSR)=>5.5 ms^-1, explosive distance (Exp-D)=accelerating/decelerating from 2 ms to 4 ms^-1 <1 s, high metabolic load distance=distance above 25 w•kg^-1; HSR plus Exp-D). Gold box are absolute values. Light blue and dark blue boxes show relative (multiples of) gameload (ie, 2×=2 games worth) and absolute, mean and max training and concurrent (training plus game), respectively. Weekly absolute (left y-axis) and relative (right y-axis) TD, high metabolic load distance, HSR and Exp-D are shown for each week of on-pitch rehabilitation in graphs. Session rate of perceived exertion (session-RPE) (y-axis=arbitrary units) shows weekly accumulated session-RPE (training session duration (min)×RPE). % max speed=(maximum speed achieved in session/player’s pre-injury maximal speed (8.95 ms^-1)×100). Control–chaos continuum: Control; high influence on behaviour/actions/movement—controlled situations. Chaos; behaviour/actions/movement, unpredictable/random/reactive—chaotic situations. Green=high control, pale green=moderate control, yellow=control to chaos, orange=moderate chaos, red=high chaos and grey=return to team training (RTT). Global positioning systems; augmented 10 Hz Apex (StatSports, Belfast, UK).

Figure 7

Player countermovement jump (CMJ) bilateral kinetics (A), force–velocity loops (B), bilateral kinetic variables (C), individual limb outputs and asymmetries (D) in preseason testing (pre-injury), and at two timepoints during rehabilitation: 13 weeks and 17 weeks post-surgery. See figure 1 for timing of tests relative to on- and off-pitch conditioning and phases. (A) Take-off phase force, velocity, power, (centre of mass) displacement–time profiles for a single jump at each timepoint—the jump trial with highest flight time:contraction time (FT:CT). Horizontal colour-coded lines show total contraction time (start of movement at 0 s to take-off). (B) Force–velocity loops are derived from same trial shown in (A). (C) Mean of three trials for selected bilateral CMJ variables; % change relative to pre-injury shown in graph, absolute values for same timepoints in table, and in grey mean (±SD) for first team (n=15 outfield players) in preseason assessments (same timepoint as player pre-injury). Decel=Deceleration, Dev=development, RFD=Rate of force development, Lower limb stiffness=(Eccentric peak force–Minimum eccentric force)/Eccentric displacement). CMJ bilateral variables=variables derived from the total vertical ground reaction force data (combined individual limb outputs during bilateral CMJ performed on dual force platforms). (D) Individual limb force and impulse absolute values (left y-axis) and % asymmetries (right y-axis) for selected take-off and landing variables. Light grey=involved, dark grey=uninvolved. Call-out box shows asymmetry (%); +ve=inv>uninv, −ve=uninv>inv. At each time point, three CMJs were performed on floor-embedded force platforms at 1000 Hz (FD4000, Vald Performance, Brisbane, Australia).