Methods
This is a retrospective study based on isokinetic data and clinical records from Brazilian professional elite-level soccer players between the years 2009 and 2019. This study followed the recommendations of The Strengthening the Reporting of Observational Studies in Epidemiology Statement12 and its design followed the recommendations of the Improving Healthcare Decisions Task Force (Professional Society for Health Economics and Outcomes Research (ISPOR) Retrospective Database Recommendations).13 ,14 The purpose, experimental procedures, possible risks and benefits of the study were explained to the athletes, who provided a written informed consent form to confirm participation in the study. For players younger than 18 years, their parents or legal guardians were informed of the risks and signed an informed consent before investigation enrolment.
It included 570 elite professional soccer players who had been playing for at least 5 years on first or second Brazilian divisions, training regularly one to two sessions per day, six times per week.
To be included in this study, players had to be able to fully participate in team training sessions and matches. Players who had a hamstrings or quadriceps muscle injury in the past 3 months, a knee surgery in the past 12 months, or were under treatment from other painful musculoskeletal injuries were excluded from our sample. Players with tendon or muscle injury grade I and without symptoms at rest were allowed to participate in the study. Only players who had played in their usual positions for the last year were included in the study.
Participants were requested to eat according to their team’s nutritionist diet 48 hours preceding the assessment and then refrain from eating and drinking substances other than water 1 hour before testing. All tests were carried out in January, few weeks before Brazil Regional Championships’ season starts. Players were also instructed to refrain from strenuous activities 48 hours before testing.
For evaluation of the PT an isokinetic dynamometer (Cybex-CSMI (Computer Sports Medicine Inc), model HumacNorm 2009, Stoughton, Massachusetts, USA) with signal acquisition rate of 500 Hz was used. To improve patient’s understanding of the test, we used a modified 10-points Borg scale for strength effort15; and a 10 cm Visual Analogue pain Scale (VAS), where ‘0 cm’ indicated ‘no pain’ and ‘10 cm’ indicated ‘worst imaginable pain’.16 For data storage and processing was used a Macbook Pro Notebook (Cupertino, California, USA) equipped with Microsoft Office software package for Mac (V.2011, Redmond, Washington, USA) and SPSS (V.20.1) from IBM.
On arrival, participants were provided with appropriate explanation and demonstration of all procedures. Participants informed their playing position, as the most frequently played in the past year. Positional groupings were goalkeepers (G), defenders (D), sidebacks (S), midfielders (M) and forwards (F). Dominant leg was defined as their preferred kicking leg for a penalty kick. Anthropometric information was recorded by team’s medical staff before the participants completed a standardised warm-up on the isokinetic machine.
All subjects were submitted to a testing protocol following the guidelines of American Physical Therapy Association17–20 and soccer-specific studies using isokinetic machines.5 7 21 The same physiotherapist, with 10 years of experience, performed all tests. The isokinetic machine was calibrated followed manufacturer’s manual instructions.
Participants seated on the isokinetic machine chair with lumbar spine fully supported and hip in 85° of flexion. The knee joint axis of rotation was aligned with the axis of the arm attached to the isokinetic machine. The dominant leg was tested first. The isokinetic machine lever arm length was adjusted so the contact point (Pad) was positioned one centimetre above the lateral malleolus; allowing free ankle flexion and extension during the test. The participant executed 10 concentric repetitions of knee’s extensor (Ext) and flexor (Flx) muscles at 90° per second (100° arc of motion) for familiarisation and warming up (Borg up to 5, VAS up to 1); following by a rest period of 120 s. The warm-up on the isokinetic machine was chosen to improve specificity and familiarisation with the following test (ref). The participant performed five concentric repetitions of knee’s Ext and Flx muscles at 60° per second during a second familiarisation and warm up session, following by another rest period of 120 s. Immediately after, the subjects performed three concentric repetitions of knee’s Ext and Flx muscles at 60° per second (100° arc of motion) with maximum effort (Borg 10), receiving constantly the standardised verbal encouragement: ‘Faster’. The presence of pain equal or superior to 4 on VAS interrupted the test (excluding the participant from study). The repetition with higher torque value (PT) among all the three repetitions was used for statistical analysis. The eccentric testing was performed at 60° per second (100° arc of motion). The subject executed five repetitions of warm-up and familiarisation followed by three repetitions at maximum effort (Borg 10), constantly receiving the standardised verbal encouragement: ‘Hold it’. The presence of pain equal or superior to 4 on VAS interrupted the test, excluding the participant from the study. Between each set of exercises, subjects had 90 s to rest. Between each limb’s test, subjects had 120 s to rest.
Demographic data as age, age category, height, body mass, dominance, field playing position (position) were recorded for descriptive analysis (mean±SD). Position was divided as: goalkeepers, defenders, sidebacks, midfielders and forwards. Age categories were also divided as: G1 (17–20 years old), G2 (21–24 years old), G3 (25–28 years old), G4 (29–32 years old) and G5 (33 years old or more).
Concentric peak torque (CPT) and eccentric peak torque (EPT) of right and left knee Ext and Flx were extracted from the isokinetic machine in Newtons (N/m). From these data, variables were organised as means of right and left leg in: Ext.CPT and Ext.EPT, Flx.CPT, Flx.EPT. All data were normalised by body mass in kilograms.
Data’s normality was confirmed using visual inspection (Q-Q plots) and the Kolmogorov-Smirnov tests. Homogeneity of variance was assessed via Levene’s Test. Data with normal distribution were subjected to a two-way analysis of variance (ANOVA). Data with non-normal distribution were subjected to Kruskal-Wallis analysis. Post hoc analysis used Bonferroni test, adjusted for multiple comparisons for non-normalised data. Size effects was measured through between subjects partial-eta square (η2). The magnitude was categorised as small (0.01), moderate (0.06) and large (0.14), respectively.22 23 All data were processed using a SPSS V.20 (IBM) with statistical significance set at alpha level p=0.05.
Patient and public involvement
Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.