Infographic

Br J Sports Med: first published as 10.1136/bjsports-2020-102119 on 7 April 2020. Downloaded from http://bjsm.bmj.com/ on April 9, 2020 at Universite Paris Sud. Protected by copyright.
Infographic. Diagnosis, prevention and treatment of common
lower extremity muscle injuries in sport—grading the
evidence: a statement paper commissioned by the Danish
Society of Sports Physical Therapy (DSSF)
Lasse Ishøi  ‍ ‍,1 Kasper Krommes,1 Rasmus Skov Husted,2 Carsten B Juhl,3 Adam Virgile,4
Kristian Thorborg  ‍ ‍1,2

Muscle strain injuries are a significant

problem in multidirectional sports, such
as football, with most injuries located in
the hamstrings, adductors, rectus femoris/
quadriceps and calf muscles.1 These inju-
ries may not only cause absence from
football for the individual player, but
also negatively affect overall team perfor-
mance.2 The incidence of muscle strain
injury has remained constant during the
last decades in football3 and Australian
rules football4 with slightly increased
incidence for hamstring5 and calf muscle
strain injuries,4 which highlights the
ongoing challenge of muscle strain injuries
in sport.
Reduction of the burden of muscle strain
injuries in sports is most likely achieved
by adoption of evidence-­ based preven-
tion programmes. Several prevention
programmes and their associated effect
on muscle injuries have been published,
including the FIFA 11+ warm  up
programme for overall injury preven-
tion,6 the Nordic Hamstring protocol
for hamstring injury prevention7 and the
Adductor Strengthening Programme for
groin injury prevention.8
Figure 1  The preventive effect is assessed as risk ratios assessed as trivial (RR >0.78), small
(0.78≥ RR >0.61), medium (0.61≥ RR >0.47) and large (RR ≤0.47). Evidence quality is based on
the Grading of Recommendations Assessment Development and Evaluation (GRADE) framework.
Figure 2  The preventive effect is assessed as risk ratios assessed as trivial (RR >0.78), small
(0.78≥ RR >0.61), medium (0.61≥ RR >0.47) and large (RR ≤0.47). Evidence quqlity is based on
the Grading of Recommendations Assessment Development and Evaluation (GRADE) framework.
To aid clinical management and preven-
tion of common lower extremity muscle
injuries in sport, we recently published
a statement paper commissioned by the
Danish Society of Sports Physical Therapy
regarding diagnosis, prevention and
treatment of muscle injuries in sport.9
In this letter, we summarise the findings
of prevention for hamstring, groin and
rectus femoris/quadriceps muscle injuries
(figures 1–3).
We systematically searched electronic
databases, and included studies based on
the highest available evidence, that is,
meta-­analyses of randomised controlled
trials (RCTs) supplemented with addi-
tional RCTs. Subsequently, we evaluated
the quality of evidence using the Grading
of Recommendations Assessment Devel-
opment and Evaluation framework,
grading the quality of evidence from high
to very low.10
For prevention of hamstring injuries,
we included three systematic reviews and
12 RCTs. In addition, we performed a
post hoc meta-­analysis to investigate the
preventive effect of the Nordic Hamstring
exercise Protocol, since this was not
available in the existing literature. We
found that programmes that included the
Nordic hamstring exercise resulted in a
45%–65% reduction in hamstring injuries
(moderate to high quality of evidence)
(figure 1). Furthermore, the FIFA 11+

Ishøi L, et al. Br J Sports Med Month 2020 Vol 0 No 0    1

 Infographic

Br J Sports Med: first published as 10.1136/bjsports-2020-102119 on 7 April 2020. Downloaded from http://bjsm.bmj.com/ on April 9, 2020 at Universite Paris Sud. Protected by copyright.
To cite Ishøi L, Krommes K, Husted RS, et al.
Br J Sports Med Epub ahead of print: [please include
Day Month Year]. doi:10.1136/bjsports-2020-102119
Accepted 25 March 2020
Br J Sports Med 2020;0:1–2.
doi:10.1136/bjsports-2020-102119

ORCID iDs
Lasse Ishøi http://​orcid.​org/​0000-​0002-​2716-​6567
Kristian Thorborg http://​orcid.​org/​0000-​0001-​9102-​
4515

Figure 3  The preventive effect is assessed as risk ratios assessed as trivial (RR >0.78), small
(0.78≥ RR >0.61), medium (0.61≥ RR >0.47) and large (RR ≤0.47). Evidence quality is based on
the Grading of Recommendations Assessment Development and Evaluation (GRADE) framework.
warm up programme resulted in a 61%
reduction in hamstring injuries (moderate
quality of evidence; figure 1).
For prevention of groin injuries, we
included two systematic reviews and
13 RCTs. We found that both the FIFA
11+programme  and the Copenhagen
Adductor strengthening programme
resulted in a 40% reduction in groin inju-
ries compared with usual care (low to
moderate quality of evidence; figure 2).
For rectus femoris/quadriceps injuries,
we included five RCTs, and pooled data
from two RCTs. Based on that analysis, we
found that the FIFA 11+programme indi-
cated a 27% reduction in rectus femoris/
quadriceps injuries compared with usual
care (low quality of evidence; figure 3).
In summary, we found that the risk of
two most common muscle injuries, namely
hamstring and groin injuries, can be effec-
tively reduced by 40%–65% by using
specific exercise interventions. However,
the available evidence for prevention is
mainly conducted in football, and thus
may not be extrapolated to other sports.
1
Department of Orthopedic Surgery, Copenhagen
University Hospital, Sports Orthopedic Research Center
- Copenhagen (SORC-­C), Hvidovre, Denmark
References
2 injuries and severe injuries: an 11-­year follow-­up of
Department of Orthopedic Surgery and Physical
Therapy, Copenhagen University Hospital, Physical
Medicine & Rehabilitation Research – Copenhagen
(PMR-­C), Hvidovre, Denmark
3
Department of Sports Science and Clinical
Biomechanics, University of Southern Denmark, Odense
M, Denmark
4
College of Nursing and Health Sciences, University of
Vermont, Burlington, Vermont, USA
Correspondence to Lasse Ishøi, Department of
Orthopedic Surgery, Copenhagen University Hospital,
Amager-­Hvidovre, Sports Orthopedic Research Center -
Copenhagen (SORC-­C), Hvidovre 2650, Denmark;
​lasse.​ishoei@​regionh.​dk
Twitter Lasse Ishøi @LasseIshoei, Kasper Krommes @
krommes and Kristian Thorborg @KThorborg
Contributors  LI, KK, RSH, CBJ and KT wrote the
original paper of which this text and infographics are
based upon. AV designed the infographics contained in
this paper.
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.
Patient consent for publication  Not required.
Provenance and peer review  Not commissioned;
externally peer reviewed.
© Author(s) (or their employer(s)) 2020. No
commercial re-­use. See rights and permissions.
Published by BMJ.
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