Management of anterior thigh injuries in soccer players: practical guide.

Most of the anterior thigh injuries are contusions or strains, however, some of these injuries can be career ending. Early diagnosis and correct treatment are key to successful outcome. Analyzing injury mechanism and adding both clinical and imaging findings, clinicians can make the right treatment decisions already often in the acute phase of the injury. Low grade contusions and muscle strains are treated well with planned rehabilitation, but complete tendon injuries or avulsions can require operative treatment. Also, neglected minor injuries could lead to chronic disabilities and time lost from play. Typical clinical presentation of anterior thigh injury is swelling and pain during hip flexion or knee extension. In more severe cases a clear gap can be palpated. Imaging methods used are ultrasound and magnetic resonance imaging (MRI) which are helpful for clinicians to determine more exact the extent of injury. MRI can identify possible tendon retractions which may need surgery. Clinicians should also be aware of other traumatic lesions affecting anterior thigh area such as myositis ossificans formation. Optimal treatment should be coordinated including acute phase treatment with rest, ice, and compression together with designed return-to-play protocol. The anatomical structure involved lines the treatment pathway. This narrative review describes these more common reasons for outpatient clinical visits for anterior thigh pain and injuries among soccer players.

Chronic and Recurrent Rectus Femoris Central Tendon Ruptures in Athletes: Clinical Picture, MRI Findings, and Results of Surgical Treatment.

BACKGROUND: Severe rectus femoris central tendon rupture is an uncommon sports-related injury. Most rectus femoris central tendon injuries can be treated by nonoperative means, but some tend to reinjure, resulting in chronic symptoms. Physicians treating athletes with rectus femoris injuries should be aware of this clinical condition and know that surgical treatment could be beneficial to the athlete if the rectus femoris central tendon rupture becomes chronic. PURPOSE: To describe the clinical picture, magnetic resonance imaging (MRI) findings, and surgical treatment results of rectus femoris central tendon injuries. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: This study included 12 patients who underwent successful repair of recurrent rectus femoris central tendon rupture. Presurgical MRI scans were obtained and compared with the surgical findings. The time of return to play was recorded, and the outcome of surgical treatment was evaluated with validated Subjective Patient Outcome for Return to Sports (SPORTS) criteria: good = full return to preinjury level of sports without any symptoms; moderate = return to preinjury level of sports with some residual symptoms (mild discomfort during sports); and poor = did not return to preinjury level of sports. RESULTS: Overall, 10 patients had a good outcome (83%), and 2 had a moderate outcome (17%). All athletes included in the study were able to return to sport at their preinjury levels 2.5 to 4 months postoperatively. Presurgical MRI scans correlated well with the surgical findings. CONCLUSION: The surgical treatment of rectus femoris central tendon rupture seems to be a good option in chronic and recurrent cases. After surgery and successful rehabilitation, the athlete is expected to continue sports at the preinjury level.

Tears of biceps femoris, semimembranosus, and semitendinosus are not equal-a new individual muscle-tendon concept in athletes.

OBJECTIVES: Hamstring injuries are common and can now be accurately diagnosed. In addition, novel surgical indications have been introduced. However, evidence-based guidelines on the hamstring injuries in management of top-level athletes are missing. METHODS: The management methods and outcomes of treatment are classically based on relatively small case series. We discuss a novel concept based on the fact that each tendon of the hamstrings muscle should be managed in an individual fashion. Furthermore, suitable indications for hamstring surgery in athletes are introduced. RESULTS: The present study introduces modern treatment principles for hamstring injury management. Typical clinical and imagining findings as well as surgical treatment are presented based on a critical review of the available literature and personal experience. CONCLUSIONS: Hamstring injuries should not be considered to be all equal given the complexity of this anatomical region: The three separate tendons are different, and this impacts greatly on the decision-making process and outcomes in athletes.

Periodization in Anterior Cruciate Ligament Rehabilitation: A Novel Framework.

More than 250,000 anterior cruciate ligament (ACL) injuries occur each year in the USA, and approximately 65% of these injuries undergo reconstructive surgery. Appropriate rehabilitation after ACL reconstruction can yield predictably good outcomes, with return to previous levels of activity and high knee function. At present, periodization is used at all levels of sports training. Whether conceptualized and directed by coaches, or by athletes themselves, competitors structure their training in a cyclic fashion, enabling athletes to best realize their performance goals. In practical application, sport physical therapists use periodization: postoperative "protocols" serve as rudimentary forms of periodization, albeit implemented over shorter time frames than that typically employed in preparation for competition. An ACL injury should not be considered a "simple" musculoskeletal pathology with only local mechanical or motor dysfunctions. Together with the psychological trauma and reduction in physical capacity, there is a cascade of events, including neurological insult to the central nervous system and reduction in afferences to the sensorimotor system. Rehabilitation should consider all these issues, and periodization would allow to better define and to plan aims and objectives to return athletes to their sport. Technological resources including advanced neuroimaging methods, virtual reality for injury risk screening and return to sport assessment, and interactive artificial reality-based neuromuscular training methods offer new approaches and tools to address this important biomedical problem. The cost and availability of many of these technologies will continue to decrease, providing greater availability, scientific rigor, and ultimately, utility for cost-effective and data-driven assessments.

ACTN3 single nucleotide polymorphism is associated with non-contact musculoskeletal soft-tissue injury incidence in elite professional football players.

PURPOSE: Muscle injuries are common in professional football, even though prevention protocols are being implemented. Genetics constitutes a novel field for studying intrinsic injury risks and performance. Since previous studies involving single nucleotide polymorphisms (SNPs) have shown that SNPs influence muscle injury rate, injury severity and recovery time, the aim was to study the association the SNP of ACTN3 has with those parameters in professional football players. METHODS: The medical staff team recorded non-contact musculoskeletal soft-tissue injuries in 43 professional football players in 7 different seasons (2007-2012 and 2015-2016). Injury rate, injury severity and injury recovery times were established. Players were genotyped by extracting DNA from a blood sample and using a polymerase chain reaction. RESULTS: Injury rate was associated with the SNP of ACTN3 (p = 0.003). The 577R allele was more frequent in subjects than in a normal population by showing presence in 93% of the subjects and suggesting that it could influence football performance. No statistically significant differences in injury severity and recovery time were associated with the SNP of ACTN3. CONCLUSIONS: Genetics is gaining in importance when assessing injury risk and performance in professional football. ACTN3 can be regarded as a biomarker of injury susceptibility in this discipline. Identifying those players with the highest injury susceptibility through genetics could lead football teams to individualise workloads and prevention protocols. LEVEL OF EVIDENCE: III.

Operative Treatment of Proximal Rectus Femoris Injuries in Professional Soccer Players: A Series of 19 Cases.

BACKGROUND: Proximal rectus femoris (PRF) tears are relatively rare injuries among top-level athletes. PRF injuries can be avulsions of both tendon heads (direct and reflected heads) or of a single head, and some have a tendency to progress to recurrent injuries. PURPOSE: To describe a series of operatively treated PRF ruptures in professional soccer players. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Nineteen cases of PRF injuries (18 patients, 1 bilateral) in professional soccer players who were treated surgically were retrospectively reviewed. Perioperative findings with return-to-play data were recorded. RESULTS: Of the PRF injuries, 10 total avulsions (both heads) and 9 single-head tears were seen on magnetic resonance imaging and were later confirmed during surgery. All 18 patients returned to their preinjury level of play (mean follow-up, 2.8 years [range, 1-11 years]). CONCLUSION: The repair of PRF tears in professional soccer players yielded good results and allowed all patients to return to their preinjury level of play.

Central Tendon Injuries of Hamstring Muscles: Case Series of Operative Treatment.

BACKGROUND: As compared with injuries involving muscle only, those involving the central hamstring tendon have a worse prognosis. Limited information is available regarding the surgical treatment of central tendon injuries of the hamstrings. PURPOSE: To describe the operative treatment and outcomes of central tendon injuries of the hamstrings among athletes. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Eight athletes (6 top level, 2 recreational) with central hamstring tendon injuries underwent magnetic resonance imaging and surgical treatment. The indication for surgery was recurrent (n = 6) or acute (n = 2) central hamstring tendon injury. All patients followed the same postoperative rehabilitation protocol, and return to play was monitored. RESULTS: Magnetic resonance imaging found a central tendon injury in all 3 hamstring muscles (long head of the biceps femoris, semimembranosus, and semitendinosus) with disrupted tendon ends. In acute and recurrent central tendon injuries, full return to play was achieved at 2.5 to 4 months. There were no adverse events during follow-up. CONCLUSION: Central tendon injuries of the hamstrings can be successfully repaired surgically after acute and recurrent ruptures.

Genetic biomarkers in non-contact muscle injuries in elite soccer players.

PURPOSE: Damage to skeletal muscle necessitates regeneration to maintain proper muscle form and function. Interindividual differences in injury severity, recovery time, and injury rate could be explained by the presence of single nucleotide polymorphisms (SNPs) in genes involved in the reparation and regeneration of connective tissue . We wished to identify new genetic biomarkers that could help to prevent or minimize the risk of non-contact muscle injuries and are associated with a predisposition to developing muscle injuries. METHODS: Using allelic discrimination techniques, we analysed 12 SNPs in selected genes from the genomic DNA of 74 elite soccer players. RESULTS: SNPs in the hepatocyte growth factor (HGF) gene showed evidence of a statistically significant association with injury incidence, severity, and recovery time. SNPs in the SOX15 gene showed evidence of a statistically significant association with injury incidence. SNPs in the GEFT and LIF genes showed evidence of a statistically significant association with recovery time. CONCLUSIONS: Genetic profile could explain why some elite soccer players are predisposed to suffer more injuries than others and why they need more time to recover from a particular injury. SNPs in HGF genes have an important role as biomarkers of biological processes fragility within muscle injuries related to injury rate, severity, and long recovery time.