The challenge of thigh tendon reinjuries: an expert opinion.

This review critically examines the issue of thigh tendon reinjury in athletes, drawing on recent advancements and diverse perspectives in sports medicine. The findings underscore the paramount importance of an early and accurate diagnosis, which significantly influences treatment efficacy and rehabilitation outcomes. We explore the intricacies of tendon anatomy and the mechanisms underlying injuries, highlighting how these factors interplay with athlete-specific risk profiles to affect reinjury rates. A major finding from the review is the necessity for individualized rehabilitation approaches that integrate both traditional methods and emerging technologies. These technologies show promise in enhancing monitoring and facilitating precise adjustments to rehabilitation protocols, thus improving recovery trajectories. Additionally, the review identifies a common shortfall in current practices - premature to play (RTP) - which often results from inadequate adherence to tailored rehabilitation strategies or underestimation of the injury's severity. Such premature RTP significantly heightens the risk of further injury. Through this synthesis of contemporary research and expert opinion, the review advocates for a multidisciplinary approach in managing thigh tendon injuries, emphasizing the need for ongoing research to refine RTP criteria and optimize rehabilitation techniques. The ultimate goal is to support athletes in achieving safer and more effective recoveries, thereby reducing the likelihood of tendon reinjury.

Magnetic Resonance Imaging With a Novel Hip Flexion Scanning Position for Diagnosing Proximal Hamstring Tendinopathy.

Background: Making a diagnosis of proximal hamstring tendinopathy (PHT) may be challenging, as patients with correlating clinical symptoms may have normal or minimal findings on magnetic resonance imaging (MRI) scans. Purpose/Hypothesis: The purpose of this study was to assess the effect of a novel hip flexion (HF) scanning position on the MRI diagnosis of PHT. It was hypothesized that the HF position, which simulates the symptom-provoking sitting position, would reveal PHT pathology more accurately than the standard scanning position. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: Patients with chronic PHT symptoms were included. Chronicity was defined as symptoms that were present for >3 months. Each patient underwent an MRI in 2 parts: (1) the standard pelvic examination in the supine position and (2) the novel HF position in which the patient lays on his or her side with the hip at 90° of flexion. Tendon insertion areas of the semimembranosus and the biceps femoris were analyzed independently by 2 experienced musculoskeletal radiologists, and the findings were classified as normal, tendinosis, or rupture. The MRI findings for both the standard and HF positions were compared in every patient, and the percentage of different diagnoses between the 2 MRI positions was reported. Results: In total, 38 patients (67 tendons) were analyzed. In 71% of the patients, the HF position revealed more severe injury than the standard position. The HF position showed a rupture in 16% of the tendons, with findings classified as tendinosis in the standard position. Of the tendons diagnosed as normal in the standard position, 6% were classified as rupture and 11% as tendinosis in the HF position. Conclusion: The novel HF scanning position offered additional value in the diagnosis of PHT in symptomatic patients when compared with the standard hip-in-neutral position. This position can improve the diagnostics of PHT, especially if an athlete or an active patient with gluteal area pain has normal or minimal MRI findings in the standard position.

Muscle Healing in Sports Injuries: MRI Findings and Proposed Classification Based on a Single Institutional Experience and Clinical Observation.

MRI plays a crucial role in assessment of patients with muscle injuries. The healing process of these injuries has been studied in depth from the pathophysiologic and histologic points of view and divided into destruction, repair, and remodeling phases, but the MRI findings of these phases have not been fully described, to our knowledge. On the basis of results from 310 MRI studies, including both basal and follow-up studies, in 128 athletes with muscle tears including their clinical evolution, the authors review MRI findings in muscle healing and propose a practical imaging classification based on morphology and signal intensity that correlates with histologic changes. The proposed phases, which can overlap, are destruction (phase 1), showing myoconnective tissue discontinuity and featherlike edema; repair (phase 2), showing filling in of the connective tissue gaps by a hypertrophic immature scar; and remodeling (phase 3), showing scar maturation and regression of the edema. A final healed stage can be identified with MRI, which is characterized by persistence of a slight fusiform thickening of the connective tissue. This information can be obtained from a truncated MRI protocol with three acquisitions, preferably performed with a 3-T magnet. During MRI follow-up of muscle injuries, other important features to be assessed are changes in muscle edema and specific warning signs, such as persistent intermuscular edema, new connective tear, and scar rupture. An understanding of the MRI appearance of normal and abnormal muscle healing and warning signs, along with cooperation with a multidisciplinary team, enable optimization of return to play for the injured athlete. ©RSNA, 2024 See the invited commentary by Flores in this issue.

Managing Lower Limb Muscle Reinjuries in Athletes: From Risk Factors to Return-to-Play Strategies.

Muscle injuries and subsequent reinjuries significantly impact athletes, especially in football. These injuries lead to time loss, performance impairment, and long-term health concerns. This review aims to provide a comprehensive overview of the current understanding of muscle reinjuries, delving into their epidemiology, risk factors, clinical management, and prevention strategies. Despite advancements in rehabilitation programs and return-to-play criteria, reinjury rates remain alarmingly high. Age and previous muscle injuries are nonmodifiable risk factors contributing to a high reinjury rate. Clinical management, which involves accurate diagnosis, individualized rehabilitation plans, and the establishment of return-to-training and return-to-play criteria, plays a pivotal role during the sports season. Eccentric exercises, optimal loading, and training load monitoring are key elements in preventing reinjuries. The potential of artificial intelligence (AI) in predicting and preventing reinjuries offers a promising avenue, emphasizing the need for a multidisciplinary approach to managing these injuries. While current strategies offer some mitigation, there is a pressing need for innovative solutions, possibly leveraging AI, to reduce the incidence of muscle reinjuries in football players. Future research should focus on this direction, aiming to enhance athletes' well-being and performance.

Effectiveness of Exercise Treatments with or without Adjuncts for Common Lower Limb Tendinopathies: A Living Systematic Review and Network Meta-analysis.

INTRODUCTION: Exercise therapy is usually prescribed as first-line treatment for lower limb tendinopathies. The multitude of exercise- and non-exercise-based management options can be overwhelming for the treating sports professional and patient alike. We chose to investigate the comparative effectiveness of exercise therapy with or without adjuncts for managing the commonest lower limb tendinopathies. METHODS: Through an extensive systematic literature search using multiple databases, we aimed to identify eligible randomised controlled trials (RCTs) on Achilles tendinopathy, patellar tendinopathy or greater trochanteric pain syndrome (GTPS) that included at least one exercise intervention in their treatment arms. Our primary outcomes were patient-reported pain and function (Victorian Institute of Sport Assessment; VISA). Follow-up was defined as short-term (≤ 12 weeks), mid-term (> 12 weeks to < 12 months) and long-term (≥ 12 months). The risk of bias and strength of evidence were assessed with the Cochrane Collaboration and GRADE-NMA tools, respectively. Analyses were performed separately for each one of the three tendinopathies. RESULTS: A total of 68 RCTs were included in the systematic review. All pairwise comparisons that demonstrated statistically and clinically significant differences between interventions were based on low or very low strength of evidence. Based on evidence of moderate strength, the addition of extracorporeal shockwave therapy to eccentric exercise in patellar tendinopathy was associated with no short-term benefit in pain or VISA-P. From the network meta-analyses, promising interventions such as slow resistance exercise and therapies administered alongside eccentric exercise, such as topical glyceryl trinitrate for patellar tendinopathy and high-volume injection with corticosteroid for Achilles tendinopathy were based on low/very low strength of evidence. CONCLUSION: In this network meta-analysis, we found no convincing evidence that any adjuncts administered on their own or alongside exercise are more effective than exercise alone. Therefore, we recommend that exercise monotherapy continues to be offered as first-line treatment for patients with Achilles and patellar tendinopathies and GTPS for at least 3 months before an adjunct is considered. We provide treatment recommendations for each tendinopathy. PROSPERO registration number CRD42021289534.

Isolated Adductor Magnus Injuries in Athletes: A Case Series.

Background: Little is known about injuries to the adductor magnus (AM) muscle and how to manage them. Purpose: To describe the injury mechanisms of the AM and its histoarchitecture, clinical characteristics, and imaging features in elite athletes. Study Design: Case series; Level of evidence, 4. Methods: A total of 11 competitive athletes with an AM injury were included in the study. Each case was clinically assessed, and the diagnosis and classification were made by magnetic resonance imaging (MRI) according to the British Athletics Muscle Injury Classification (BAMIC) and mechanism, location, grade, and reinjury (MLG-R) classification. A 1-year follow-up was performed, and return-to-play (RTP) time was recorded. Results: Different mechanisms of injury were found; most of the athletes (10/11) had flexion and internal rotation of the hip with extension or slight flexion of the knee. Symptoms consisted of pain in the posteromedial (7/11) or medial (4/11) thigh during adduction and flexion of the knee. Clinically, there was a suspicion of an injury to the AM in only 3 athletes. According to MRI, 5 lesions were located in the ischiocondylar portion (3 in the proximal and 2 in the distal myoconnective junction) and 6 in the pubofemoral portion (4 in the distal and 2 in the proximal myoconnective junction). Most of the ischiocondylar lesions were myotendinous (3/5), and most of the pubofemoral lesions were myofascial (5/6). The BAMIC and MLG-R classification coincided in distinguishing injuries of moderate and mild severity. The management was nonoperative in all cases. The mean RTP time was 14 days (range, 0-35 days) and was longer in the ischiocondylar cases than in the pubofemoral cases (21 vs 8 days, respectively). Only 1 recurrence, at <10 months, was recorded. Conclusion: Posteromedial thigh pain after an eccentric contraction during forced adduction of the thigh from hip internal rotation should raise a suspicion of AM lesions. The identification of the affected portion was possible on MRI. An injury in the ischiocondylar portion entailed a longer RTP time than an injury in the pubofemoral portion.

Self-reported bio-psycho-social factors partially distinguish rotator cuff tendinopathy from other shoulder problems and explain shoulder severity: A case-control study.

OBJECTIVE: Examine how rotator cuff (RC) tendinopathy differed from other shoulder problems (OSP) by measuring a variety of self-reported bio-psycho-social factors, and establish which explain severity. METHODS: A validated online survey battery was used to collect self-reported biopsychosocial variables in an international population. Diagnostic group and severity were the dependent variables. Multiple logistic and linear regression analyses were utilised to generate explanatory models for group differences and severity after group comparison and univariate regression analysis. RESULTS: 82 people with RC tendinopathy (50 female, 42.8 ± 13.9 years) and 54 with OSP (33 female, 40.2 ± 14.1 years) were recruited. Both groups had comparable severity results (Shoulder Pain and Disability Index = 37.3 ± 24.5 vs. 33.7 ± 22.5). Seven factors individually differentiated RC tendinopathy from OSP. The multivariable model included 4 factors: activity effect on pain (OR(95%CI) = 2.24(1.02-4.90)), previous injury in the shoulder (OR(95% CI) = 0.30(0.13-0.69)), activity level (moderate OR(95% CI) = 3.97(1.29-12.18), high OR(95% CI) = 3.66(1.41-9.48)) and self-efficacy (OR(95%CI) = 1.12(1.02-1.22)) demonstrating acceptable accuracy. The second multivariable model for RC tendinopathy severity included one demographic, three psychological and two biomedical variables (ß(range) = 0.19-0.38) and explained 68% of the variance. CONCLUSION: Self-reported bio-psycho-social variables may be beneficial for further detailed clinical assessment as they partially distinguish RC tendinopathy from OSP, even when the groups have comparable overall pain and functional problems. Moreover, these variables were shown to be substantially associated with RC tendinopathy severity variance, implying that the clinical evaluation might be improved, perhaps by pre-consultation online data collection. The models should be validated in the future and considered alongside data from physical and imaging examinations.

Pathways driving tendinopathy and enthesitis: siblings or distant cousins in musculoskeletal medicine?

Tendinopathy and enthesitis share clinical, anatomical, and molecular parallels. However, their relationship is complex, presenting challenges in diagnosis and treatment. The biomechanics underlying these pathologies, together with relative immune and stromal contributions to pathology, are characterised by crucial comparative elements. However, methodologies used to study enthesitis and tendinopathy have been divergent, which could account for discrepancies in how these conditions are perceived and treated. In this Review, we summarise key clinical parallels between these two common presentations in musculoskeletal medicine and address factors that currently preclude development of more effective therapeutics. Furthermore, we describe molecular similarities and disparities that govern pathological mechanisms in tendinopathy and enthesitis, thus informing translational studies and treatment strategies.

MRI findings prior to return to play as predictors of reinjury in professional athletes: a novel decision-making tool.

BACKGROUND: Because MRI has shown great accuracy in assessing acute muscle injuries, identification of risk factors for reinjury before return to play (RTP) in professional athletes during the healing process could be very relevant. We assessed the value of MRI findings prior to RTP as predictors of reinjury. METHODS: Retrospective observational study of 59 professional athletes, mean age 26 years, with first-time acute muscle injury and successful rehabilitation ready to RTP. They underwent MRI within 6 days of the injury and within 7 days prior to RTP. The primary outcome was reinjury. Risk of reinjury was assessed using radiological signs in control MRI scans before RTP. The risk was classified as low, medium or high when none, one or two radiological signs were observed, respectively. RESULTS: Reinjury occurred in 9 participants, with a rate of 15.2%. None of the baseline MRI-related variables was significantly associated with reinjury. In the control MRI scan performed within 7 days prior to RTP, three independent findings were significantly associated with reinjury. These included transversal and/or mixed connective tissue gap (p = 0.002), intermuscular oedema (p = 0.015) and callus gap (p = 0.046). In the predictive model of the risk of reinjury, the presence of two of these radiological signs, together with interstitial feathery oedema, was associated with a high risk of recurrence (OR 29.58, 95% CI 3.86-226.64; p = 0.001). CONCLUSIONS: In professional athletes with acute muscle injuries of the lower limbs successfully rehabilitated, some radiological signs on MRI performed shortly before RTP were associated with a high risk of reinjury.

Overview of Thigh and Leg Anatomical and Sonographic Landmarks in Rheumatic Patients.

Musculoskeletal ultrasound has become a practical and accessible diagnostic tool for musculoskeletal diseases. It is used to examine joints, tendons, vessels, and nerves due to its wide availability in rheumatology practice. Ultrasound has also been applied for years in other areas such as muscular injuries in sports activities and rheumatic diseases with inflammation such as myositis. The knowledge among rheumatologists about muscle ultrasound is increasingly growing taking into account it is not the main target of their ultrasound activity but mainly based on the evaluation of joint, synovitis, tenosynovitis, vasculitis in giant cell arteritis, and parotid gland evaluation in Sjögren´s syndrome. Thus, the present review describes anatomical and ultrasound findings including all muscles of the thigh (anterior, posterior, medial aspects) and leg (anterior, lateral, posterior superficial, deep posterior compartments) of lower limb structures to ease a comprehensive clinical and sonographic evaluation.

Biopsychosocial approach to tendinopathy.

Tendinopathy describes a spectrum of changes that occur in damaged tendons, leading to pain and reduced function that remains extremely challenging for all clinicians. There is an increasing awareness of the influence that psychological and psychosocial components, such as self-efficacy and fear-avoidance, have on rehabilitation outcomes in musculoskeletal medicine. Although it is widely accepted that psychological/psychosocial factors exist in tendinopathy, there is currently a distinct lack of trials measuring how these factors affect clinical outcomes. Biopsychosocial treatments acknowledge and address the biological, psychological and social contributions to pain and disability are currently seen as the most efficacious approach to chronic pain. Addressing and modulating these factors are crucial in the pathway of personalised treatments in tendinopathy and offer a real opportunity to drive positive outcomes in patients. In this education review, we also provide the current evidence-based guidance on psychological and psychosocial developments in musculoskeletal medicine and how these may be translated to treating tendinopathy using a biopsychosocial model.

The effect of exercise on cytokines: implications for musculoskeletal health: a narrative review.

The physiological effects of physical exercise are ubiquitously reported as beneficial to the cardiovascular and musculoskeletal systems. Exercise is widely promoted by medical professionals to aid both physical and emotional wellbeing; however, mechanisms through which this is achieved are less well understood. Despite numerous beneficial attributes, certain types of exercise can inflict significant significant physiological stress. Several studies document a key relationship between exercise and immune activation. Activation of the innate immune system occurs in response to exercise and it is proposed this is largely mediated by cytokine signalling. Cytokines are typically classified according to their inflammatory properties and evidence has shown that cytokines expressed in response to exercise are diverse and may act to propagate, modulate or mitigate inflammation in musculoskeletal health. The review summarizes the existing literature on the relationship between exercise and the immune system with emphasis on how exercise-induced cytokine expression modulates inflammation and the immune response.

Management of patellar tendinopathy: a systematic review and network meta-analysis of randomised studies.

OBJECTIVES: We performed a systematic review and network meta-analysis (NMA) of randomised controlled trials (RCTs) to provide insights into the effectiveness of available treatment modalities in patellar tendinopathy(PT). METHODS: Several databases were searched in May 2021 for RCTs assessing the effectiveness of any intervention compared with any other intervention, placebo or no treatment for pain and/or function in PT. The risk of bias and strength of evidence were assessed with the Cochrane Collaboration and GRADE (Grading of Recommendations, Assessment, Development and Evaluations)/GRADE-NMA tools. RESULTS: A total of 37 RCTs were eligible that assessed 33 different interventions and their combinations, most represented by single studies. Based on pairwise meta-analyses of two RCTs, extracorporeal shockwave therapy (ESWT) does not appear to be superior to sham ESWT (eccentric exercise in both groups) for short-term pain (mean differences (MD) +0.1, 95% CI (-0.8 to 1), p=0.84) or function (MD -1.8, 95% CI (-8 to 4.4), p=0.57). Based on a pairwise meta-analysis of three RCTs, isometric exercise appears as effective as isotonic exercise for immediate postintervention pain relief (MD -1.03, 95% CI (-2.6 to 0.5), p=0.19). Our NMA showed that topical glyceryl trinitrate (GTN) and hyaluronic acid injection, both combined with eccentric exercise and moderate, slow resistance exercise had the highest probability of being the most effective interventions (low/very low strength of evidence). CONCLUSIONS: Promising interventions with inadequate evidence, such as topical GTN, hyaluronic acid injections and isometric and slow resistance exercise, should be further investigated through high-quality RCTs. Meanwhile, eccentric loading with or without adjuncts should remain the first-line treatment for all individuals with patellar tendinopathy.

Heel fat pad syndrome beyond acute plantar fascitis.

Heel pain is a frequent cause of pain and disability in adult active population. In patients with this clinical presentation, several causes must be ruled out, among them plantar fasciitis the most common. Other etiologies of plantar heel pain are the entrapment of muscular branch of the lateral plantar nerve (Baxter nerve) or fat pad atrophy, being the last one the second cause of heel pain after plantar fasciitis. A case series of patients with pathological findings of the heel fat pad area using MRI and US to provide a differential diagnosis of heel pain. Observational case series study. Nine patients visited presented with pain in the plantar aspect of the heel. The plantar aspect of the heel was evaluated in detail with US and MRI. Main inclusion criteria were to present acute or chronic pain on the plantar aspect. In five cases the right heel was affected, in three cases the left heel. One case presented bilateral complaints. All patients presented mechanical pain. Specifically, four of them also described a constant clunk during footstep. Heel fat pad lesion was confirmed with MRI and US in the medial aspect, observed in five patients. In four patients, the heel fat pad was globally affected respectively. This case series tries to put some light on other heel conflicts beside plantar fasciitis that should be ruled out, being one of those, heel fat pad atrophy. Our presentation highlight the role that bed side ultrasound can play in the definition of a specific pattern confirmed with MRI after the US.

Hamstring Muscle Injuries: MRI and Ultrasound for Diagnosis and Prognosis.

Hamstring injuries (HSI) are the most frequent muscle injuries in active individuals and professional athletes. Early and accurate diagnosis is key for planning a correct and individualised return to play (RTP). For that diagnosis imaging tests such as Magnetic Resonance Imaging (MRI) and ultrasound (US) are the most useful tests in the initial stages.

Muscle Madness and Making a Case for Muscle-Specific Classification Systems: A Leap from Tissue Injury to Organ Injury and System Dysfunction.

Despite the recent publication and subsequent clinical application of several muscle injury classification systems, none has been able to address the varying and often unique/complex types of injuries that occur in different muscles. Although there are advantages of using a unified classification, there are significant differences between certain muscles and muscle groups. These differences may complicate the clinical effectiveness of using a unified injury classification. This narrative explores the difficulties in using a single classification to describe the heterogeneous nature of muscle injuries. Within that context, the possibility of viewing muscles and muscle injuries in the same manner as other biological tissues, structures, organs, and systems is discussed. Perhaps, in addition to a unified classification, subclassifications or muscle specific classifications should be considered for certain muscles. Having a more specific (granular) approach to some of the more commonly injured muscles may prove beneficial for more accurately and effectively diagnosing and treating muscle injuries. Ideally, this will also lead to more accurate determination of the prognosis of specific muscle injuries.

Ultrasound classification of medial gastrocnemious injuries.

High-resolution ultrasound (US) has helped to characterize the "tennis leg injury" (TL). However, no specific classifications with prognostic value exist. This study proposes a medial head of the gastrocnemius injury classification based on sonographic findings and relates this to the time to return to work (RTW) and return to sports (RTS) to evaluate the prognostic value of the classification. 115 subjects (64 athletes and 51 workers) were retrospectively reviewed to asses specific injury location according to medial head of the gastrocnemius anatomy (myoaponeurotic junction; gastrocnemius aponeurosis (GA), free gastrocnemius aponeurosis (FGA)), presence of intermuscular hematoma, and presence of gastrocnemius-soleus asynchronous movement. Return to play (RTP; athletes) and return to work (RTW; occupational) days were recorded by the treating physician. This study proposes 5 injury types with a significant relation to RTP and RTW (P < .001): Type 1 (myoaponeurotic injury), type 2A (gastrocnemius aponeurosis injury with a <50% affected GA width), type 2B (gastrocnemius aponeurosis with >50% affected GA width), type 3 (free gastrocnemius aponeurosis (FGA) tendinous injury), and type 4 (mixed GA and FGA injury). The longest RTP/RTW periods were associated with injuries with FGA involvement. Intermuscular hematoma and Gastrocnemius-soleus asynchronous motion during dorsiflexion and plantarflexion were observed when the injury affected >50% of the GA width, with or without associated FGA involvement, and this correlated with a worse prognosis. The proposed classification can be readily applied in the clinical setting although further studies on treatment options are required.

A Histoarchitectural Approach to Skeletal Muscle Injury: Searching for a Common Nomenclature.

In recent years, different classifications for muscle injuries have been proposed based on the topographic location of the injury within the bone-tendon-muscle chain. We hereby propose that in addition to the topographic classification of muscle injuries, a histoarchitectonic (description of the damage to connective tissue structures) definition of the injury be included within the nomenclature. Thus, the nomenclature should focus not only on the macroscopic anatomy but also on the histoarchitectonic features of the injury.