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JORNADA MONOGRÁFICA SOBRE LA LESIÓN MUSCULAR
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Definición del return-to-play (RTP) 2010:
“ certificación médica de un atleta para la plena participación en el deporte sin restricciones ( fuerza y acondicionamiento, entrenamiento y competición “
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Step 2Evaluación
Riesgo de participación
Step 1Evaluación estado
de salud
Step 3Modificación
decisión
Decisión de Return-to-play ( vuelta a la competición )
edad , sexo etc..
Síntomas: dolor..
Antecedentes: recurrencias…
Examen físico: derrame..
Tests Lab : Rx, RM
Tests funcionales : isocineticos..
Estado psicológico
Gravedad potencial : concussion ..
Factores Médicos
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Step 2Evaluación
Riesgo de participación
Step 1Evaluación estado
de salud
Decisión de Return–to-play ( vuelta a la competición )
edad , sexo etc..
Síntomas: dolor..
Antecedentes: recurrencias…
Examen físico: derrame..
Tests Lab : Rx, RM
Tests funcionales : isocineticos..
Estado psicológico
Gravedad potencial : concussion ..
Factoresdeporte
Step 3Modificación
decisión
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Step 2Evaluación
Riesgo de participación
Step 1Evaluación estado
de salud
Step 3Modificación
decisión
Decisión de Return-to-play ( vuelta a la competición )
momento de la temporada
Presión del jugador..
Presión externa: coach, familia
Enmascarar la lesión : analgesia
Conflicto de intereses
Miedo a los litigios
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Gestión de cuando podrávolver a competir un jugador o atleta con una determinada lesión muscular.
El “return to play” en las lesiones musculares
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Lesión muscular
Gestión del “Return-to-play” en les lesiones musculares:
Tiempo de convalecenciaTiempo de convalecenciahasta que el jugadorhasta que el jugadorpuede volver a jugarpuede volver a jugar
Condiciona el riesgo de reCondiciona el riesgo de re--lesilesióónnen la misma temporadaen la misma temporada
ImportantImportantíísimo la decisisimo la decisióón final deln final delmomento de volver a competirmomento de volver a competir
En las prEn las próóximas temporadas !!ximas temporadas !!
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Porcentaje de jugadores según el return-to-play
Ekstrand y cols,, 2007
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Croisier, 2004; Woods, 2004; Hägglund 2009; Werner 2009
¿Por que es importante conocer bien el return-to-play de las lesiones musculares ??
• Las lesiones musculares siguen siendo la causa más
frecuente de lesiones deportivas
• La incidencia casi no ha variado en los últimos 30 años
• Sigue existiendo una tasa de re-lesión muy alta !!
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Futbol Australiano, Orchard 2005
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22%
17,6
6,3
34,8
2004
16%
19,9
6,4
34,1
2006
36,634,437,440,3Incidencia (nuevas lesiones por equipo y temporada)
30%
15,7
4,5
2002
37%
22,9
5,8
2000
25%36%Ratio de recurrencia
21,721Prevalencia (partidos perdios per equipo)
6,66,8Incidencia n. Lesiones de m . isquiotibiales por equipo y temporada)
20081998Temporada
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Porcentajes de re-lesión muscularDatos Liga fútbol australiana :1992-98
Lesióncuadriceps
Lesión isquiosurales
Semanas después return-to-play
30%
3%
6%
8 %
13 %
22 %
2%
3%
5 %
9%
Acumulado por temporada
6th o + semanas
3-5th semana de volver
2th semana de volver
Primera semana
Orchard y Seward Clin J Sport Med 2002
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• 31 % de todas las lesiones• 16 % relesiones
51 equipos; 2200 futbolistas; temporadas 2001-2009
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92 % afectan a 4 grupos musculares !!!!!!
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20 %
17 %8 %
26 %
20 %
4 %
4 %
4%
Primer equipo de Basket FCB. Epidemiología lesional 4 temporadas
32%lesiones
musculares
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• ¿Por que es tan frecuente ??
• ¿Porque hay tanta recurrencia ??�30 % al primer año �18 % a los 4 años
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Normal
Post ejercicioLesión
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11w
12w
13w
14w
DegenerationDegenerationRegenerationRegeneration
FibrosisFibrosis
InflammationInflammation
Weeks after muscle injury
Johnny Huard, Yong Li, Freddie Fu. J Bone Joint Surg, 2002
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M
MM
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??
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• Persistencia de “weakness” en los músculos lesionados
• Reducción extensibilidad de la unión miotendinosa por la
fibrosis o cicatriz residual
• Cambios adaptativos en el patrón biomecánico después de
la lesión.
• Otros factores coadyuvantes, estabilidad lumbopèlvica etc..
Verrall, 2009; Heiderscheit , 2010
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Circulation 2011
=?
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2007 2008
Jugador de futbol
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4 cm
Jugador de baloncesto, lesión muscular primer partido play-offs
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Lesión muscular de 4 cm
¿4 semanas para volver a competir ??
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Caudo-craneal
Área = 3,2 cm2
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Return-to-play a los 3 días
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Futbolista profesional, RTP 3 días
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Lesión m. oblicuos del abdomen por contusión
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m. Oblicuointerno
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RTP6 días
RTP10 días
RTP15 días
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Ejemplo 1 :
• min. 8 4/4 : me noto algo …..
• min. 9 4/4 : creo que me roto …
• Mecanismo lesional: en la frenada - salida !!
• Siguió jugando …
• Al día siguiente molestias importantes
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RM 3 TESLAS24 h de la lesión
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Jugo a los 15 días juega partido sin problemas
RM a las 24 horas previasal Return-to-play
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1era 2nda 9na8ta3era 4rta 5ta 6ta 7ta
“Return-to-play” de una lesión de grado II de bíceps femoral
en distintos deportes
semanas
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Entonces , es suficiente con nuestra experiencia ???
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RTP
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Orchard, Clin J Sports Med, 2005
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Orchard y cols Clin J Sports Med 2005
• Test de fuerza y flexibilidad
• Criterios de imagen
• Test funcional de campo
• Control de factores de riesgos
Principales factores determinantes del “return-to-play”
en las lesiones musculares:
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Orchard y cols Clin J Sports Med 2005
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Croisier, 2002; 2005
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Brockett,C, 2004; Proske, 2004
Jugador normal
60% max torque
30- 40°
N
pierna con antecedentes
Jugador con antecedentes
suggests it is a change in optimum angle maybe a risk factor for recurrent injury.
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25
o
500Tiempo (ms)
BBííceps F. normal ceps F. normal
BBííceps F. lesionadoceps F. lesionadoDm (mm)
TMG Tensiomiógráfo
BBííceps F. RTP ceps F. RTP
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Ole Olsen (1998)
Mediante un “encoder” lineal determinamos el desplazamiento del peso recorrido en función del tiempo
Muscle lab
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Muscle lab
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Orchard y cols ; Clin J Sports Med 2005
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Slavotinek J et al. AJR. 2002; 179: 1621-1628.
Abnormal cross-sectional area greater than 50% were associated with longer recoverytimes.
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Verrall G et al. J Orthop Sports Phys Ther. 2006
• MRI volume > 20 cm3 were 2,3 times more likely to be reinjured than those with a volume < 20 cm3.
• MRI injury size > 55% were 2,2 times more likely to be reinjured than those with a size < 55%.
Volume size (cm3) = �/6 x (length x depth x wide)
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Verrall y cols ,J OrthopS PhysTher, 2006
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Askling y cols, Am J Sports Med, 2007
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Askling y cols, Am J Sports Med, 2007
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Koulouris G et al. AJSM. 2007.
MRI length (>60mm) of a strain has the strongest correlation association with a repeat hamstring injury
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Ramon Balius, Xavier Alomar, Mari Cármen Dobado. Carles Pedret, Gil Rodas
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MUSCLETECH NETWORK PROJECT .MEASUREMENTS:
Length of injuryLesion areaVolume of the lesionCalculation of the hematomaRegister prior hamstring injuriesAssessment the gap or fibrillar defect
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RTP after 5 weeks
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Hasselman, AMJS, 1995
Peor pronósticoRTP 45 días
RTP 33 días
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Orchard y cols, Clin J Sports Med 2005
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Orchard y cols, Clin J Sports Med 2005
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Principales Factores de riesgo en las lesiones musculares:
Evidencia clara
Evidencia bastante clara
Controvertida
Inadecuada evidencia
Difícil de demostrar pero parece clara
Poca evidencia, al revés seguro
Muy controvertido
Antecedentes lesionales
Edad
Baja fuerza
Flexibilidad
Fatiga
Calentamiento
Estiramientos
Evidencia científicaFactor de riesgo
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��Es importante el mecanismo lesional como factor determinante del RTP ??
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Semimembranosus
Semitendinosus
Biceps Femoris
SM ST BF
“ El m. bíceps femoral es el que mas trabaja, quien mas se fatiga y mas sufre en las aceleraciones y desaceleraciones por lo tanto el que mas se lesiona “
Verrall, 2010 In: M. Cash Pocket Atlas of the Moving Body, Edbury Press, London (2000)
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Orchard y cols, Clin J Sports Med 2005
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• Deportista de bajo riesgo por su posición en el terreno de
juego (portero, jugador de baloncesto…).
• Deportista joven.
• Lesión en localización anatómica de bajo riesgo (vastos
laterales, SM, gemelo externo, glúteos…).
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Orchard y cols, Clin J Sports Med 2005
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• ¿Qué otros aspectos debemos tener en cuenta, aún con poca o ninguna evidencia científica , sobretodo en el deporte profesional ?
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• Nuevos tratamientos ( ojo PRPs !!!! )• Hábitos tóxicos
• Estado laboral contractual
• Estados psico-emocionales alterados:
ansiedad, hipermotivación, miedos.
• Situación de veterano o novato dentro el
equipo.
• ......
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Update en investigaciones para la reparación del tejido muscular
Huard y cols; J Bone Joint Surg Am 2002
PRPPRP
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• ¿El primer partido que juega es mejor fuera
o en casa ?
• ¿Mejor empezar primera o segunda parte ?
• ¿ Partido oficial o de entrenamiento ?
• ……..
Otros condicionantes a tener en cuenta:
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Día lesión
Día RTP
Desparecen Síntomas
(dolor)
ECONormal
90%
RMNormal
50% (Verrall)
Peak Torkenormal hasta
70% CL ( Croisier)
Flexibilidad 100 %
Test funcionalesde campo 80-90%
Entreno conequipo90%
12-31% Re-lesiones
(Wood,Orchard,Verrall)
Corre con normalidad
RTP de la lesiones musculares::
RMAnormal
36% (Connell)
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• No hacemos las cosas bien ??
• Se es demasiado prematuro en el return-to-play ??
• No se siguen buenos programas de rehabilitación ??
• O hay algo más …
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Tasa de recurrencias lesiones isquiotibiales ;n = 49;
Verrall ,2009
80% RTPLesiones ISQUEFA 2008
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FaseAguda
Fase regeneración
Fase Funcional
Criterios para pasar de fase hasta el return-to-sport
Día RTP
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Criterios para pasar de fase hasta el return-to-sport
• Optimum angle of peak torque
• Strength imbalance
• Hip extension strength
• Leg asymmetries in horizontal force
• Lumbar rotation capabilities
• Imaging techniquesDía RTP
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1. Máxima fuerza sin dolor
a)4 repeticiones consecutivas con máximo esfuerzo en el test
de fuerza en posición prona y flexión de la rodilla (90ºy 15º).
b) déficit de menos de un 5% bilateral en ratio ISQ/EXC ( 30º/s)
/ Con/QUA (240º/s) durante test isocinético
c) Simetría bilateral en el ángulo de flexión optimo en
concéntrico en el torque flexión de la rodilla a 60º/s
2. Rango de movilidad completo sin dolor
3. Ejercicios específicos del deporte cerca de la máxima velocidad
de ejecución
Criterios para el return- to- play lesiones m. isquiotibiales
Heiderscheit, J Orth Sport Phy The, 2010
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y al final ���� � �la última decisión, el día D
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jugador
Toma de decisión final del RTP:
coach Team doctor
fisioterapeuta
Médicos externos
familiares
El Club
Una final
amigos
representante
masajista
Preparador físico
ayudantes
Especialistas colaboradores
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jugador
Toma de decisión final del RTP:
coach Team doctor
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jugador
Toma de decisión final del RTP:
coach
Deportes de equipo !!
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jugador
Toma de decisión final del RTP:
Deportes individuales !!
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Recordad:
1. La curación total es mas lenta que los hallazgos clínicos
2. No existen marcadores claros para asegurar el “return-to-play”
3. Cada lesión muscular tiene un R-T-P diferente pues intervienen muchos factores.
4. Existe una gran variabilidad interindividual en el “return-to-play”
5. Deben identificarse los jugadores de riesgo
6. Debemos gestionar los factores de riesgos y minimizarlos.
7. Debemos seguir planes de rehabilitación contrastados y de forma rigurosa
8. Es imposible eliminar al 100 % el riesgo de re-lesión
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9. Debemos basarnos en el conocimiento científico y en la experiencia clínica.
10. Aun así, debemos ser prudentes pero nunca conservadores
11. La decisión final debe ser compartida
12. Y no dejar de investigar !!!!!
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