From broken metatarsals to muscle strains, physiotherapy helps with a host of sports injuries. Physios are present on the touchline and in the medical room – they are part of a player’s journey, assessing the injury, rehabilitation and return to play. Here, The Chartered Society of Physiotherapy offer an expert view on rugby and football injuries, particularly how they happen and how to treat them.

Physios incorporate sports-specific skills into a player’s rehabilitation and are best placed to understand the functional demands of the sport and to analyse individuals for potential areas of risk. They assess posture and biomechanics, as well as movement mechanics, to look at how all the joints work together in unison, and perform tests to assess individual joints, muscles, tendons, ligaments and the functionality of the nervous system. For safety and to reduce the risk of re-injury, players should complete rehabilitation under the guidance of a chartered physiotherapist.

Common Football Injuries

Hamstring Strain

The hamstrings are a group of four muscles found at the back of the thigh that bend the knee. When they are overstretched the muscle fibres can tear, leading to a strain. This happens during explosive or rapid movements such as sprinting. Immediate physiotherapy will involve the ‘PRICE’ protocol to reduce bleeding, swelling and pain. Rehabilitation will include gentle stretching, soft tissue work and muscle strengthening. The player will move onto football-specific drills, including jumping, running and sprinting.

A grade one hamstring strain involves around five-to-10 per cent of the muscle fibres and requires one-to-two weeks’ rest before a player can return. A grade two strain is more extensive, including a greater number of muscle fibres, and players will tend to be out for three-to-six weeks. A grade three muscle strain is a severe tear involving most or all (rupture) of the muscle fibres. Players may require surgery and could be out for three-to-four months.

Sprained Ankle

This is where there is soft tissue damage to the ligaments in the ankle joint. Around 70-to-85 per cent of ankle sprains are ‘inversion’ sprains. This occurs when you roll the ankle outward and the sole of the foot faces in and up. This can happen during a tackle, by running on uneven ground or landing awkwardly.

Initial treatment will involve the ‘PRICE’ protocol. As the ligaments start to heal, the player will be encouraged to put more weight through the ankle joint. The physio will then work with the player on their balance, co-ordination and muscle strength.

Grade one ankle sprains are a mild sprain of the ligaments. Grade two is a partial tear of the ligament(s) and may result in some ‘looseness’ at the joint. Grade three is a complete tear of the ligament which results in gross instability at the ankle joint and may require surgery. Dependent on the grade, a player may be out for three-to-six months.

Anterior Cruciate Ligament (ACL) Injury

This is the supporting ligament in the knee joint that enables twisting and turning movements. It can tear or completely rupture during an awkward landing or fall, or under the impact of a tackle.

This injury is more common in women. Rehabilitation is an intensive and staged process to work on fitness and strength, and to ensure that the repair (graft) does not fail from early stressors. Initial treatment could include electrical muscle stimulation, hydrotherapy, anti-gravity treadmill work and exercises for flexibility.

Football-specific drills will be introduced later, starting with straight line running. Pivoting and quick turns will be introduced towards the latter stages of rehab, as these put the newly-repaired ligament under the most stress.

Medial Collateral Ligament (MCL) Sprain

This is the ligament that joins the thigh bone and the shin bone and is found on the inner side of the knee joint. As with the ACL, it can be torn through twisting or impact. Immediate treatment will involve the ‘PRICE’ protocol.

As the ligaments start to heal, the player will be encouraged to put more weight through the ankle joint. The physio will then work with the player on their balance, co-ordination and muscle strength to get them back to match fitness. They may use bracing techniques to support the joint during rehabilitation.

MCL sprains can be categorised into three types. A grade one sprain is a mild sprain of the ligaments. Grade two is a partial tear and may result in some ‘looseness’ at the joint. Grade three is a complete tear of the ligament which results in gross instability and may require surgery.

Thigh (Quadriceps) and Calf Strains

A tear can occur in the quadriceps group of muscles found on the front of the thigh that are responsible for straightening the leg, i.e. when kicking a ball. The calf is at the back of the lower leg and is made up of two key muscles which enable players to push off and run. Like other muscles, the calf can be torn and strained when stretched beyond its limits.

Immediate physiotherapy treatment will involve the ‘PRICE’ protocol to reduce the bleeding, swelling and pain. Rehabilitation will include gentle stretching, soft tissue work and muscle strengthening before the player can start football-specific drills, including jumping, running and sprinting.

Muscle strains are categorised into three grades – grade one will involve around five-to-10 per cent of the muscle fibres. A grade two strain involves a greater number of muscle fibres. A grade three muscle strain is a severe tear or rupture involving most or all of the muscle fibres.

How to Minimise the Risk of Rugby Injuries

James Moore, a former Saracens Physiotherapist, outlines the ways in which players at all levels can minimise their risks of being injured.

Knees

Knee injuries have been shown to result in the largest amount of time lost from sport. It can take up to nine months to return after an ACL injury, for example. The hamstrings have been shown to be the region most frequently injured by the outside backs (full backs and wings) and the most common injury to occur away from contact.

The hamstring works effectively well with the knee in that it supports the ACL by controlling the shin. But while the hamstring can support the knee well the knee also needs to be able to produce huge forces and in particular large amounts of deceleration forces, especially when changing direction. Hamstring injuries predominantly occur during high speed running, which is why the back three are most vulnerable.

Effective eccentric exercise training (slow and controlled) will help with deceleration movements and effective high-speed training will help to minimise hamstring injuries. Examples include any form of pressing movements such as leg presses, squats and deadlifts but done under control and tension through the lowering phase (i.e. lowering slowly).

Train your hamstrings with both complex movements (split squats and lunges) as well as isolated movements (hamstring curls). Strength training in the gym alone will not protect your knees – the hamstrings need to be trained at speed, so effective drills and running sessions will help to condition your hamstrings. Practicing cutting movements and decelerations can condition your knees.

Ankles and Calves

Calf injuries have been shown to be the most frequent injury experienced by the front row. While simple ankle sprains and minor calf strains do not result in a large amount of time lost per injury, they can occur regularly, so through a season their cumulative effect of time lost is significant.

The surface that rugby is played on can vary and this means that your feet and ankles need to adapt constantly and at the same time produce force.

Running alone doesn’t condition the ankles, feet and calves well enough to deal with the demands of the surfaces and the sport. Effective strategies include strength training through calf raises, calf and ankle mobility through range by working uphill, and by maintaining good ankle and calf flexibility (through regular stretching), and working on reactivity through proprioceptive exercises such as single leg balance work.

Spine

Spinal injuries – ranging from simple sprains to catastrophic injuries involving spinal fractures – are becoming more common in rugby. There is an increased use of the head and neck being used as a lever arm to help with ‘clearing out’. Training your neck muscles by maintaining neck flexibility drills and by building the muscles around the neck can help. Exercises that can help include simple shrugs. There are much more complex exercises, but we would advise specialist input being sought before commencing them as the neck is a very sensitive and vulnerable area.

The low back can also be very vulnerable. When you go back to basics the spine is really a large spring that is designed to transfer force around the body. It is not designed to be the primary force producer. This primary force production should come from the shoulders and hips, so effective mobility and flexibility for both your hips and shoulders, coupled with good strength through your available range of motion, can take a lot of pressure off your spine and therefore protect it.

Recovery

The most important part of training is recovery to allow your muscles to adapt and recover effectively. Rugby is a high velocity collision sport that traumatises the muscles and joints with impact. This needs effective recovery to allow the body to be ready for the next session.

Monitoring your nutrition, sleep and the amount of work you have done is key to achieving the right physiological state so that you are ready to play at the weekend. If you turn up to a game fatigued and not completely recovered, your risk of injury goes up significantly.

Schedule in regular breaks where you reduce your rugby training, reduce your running and weight training. This does not need to be done at the same time in the same week but cycling the reduction can be key to making sure that you are not over-cooking it for the weekend.

For more information, visit www.csp.org.uk/public-patient/sports-injuries.