The Role of MRI in Groin Pain Syndrome in Athletes.

Groin pain syndrome (GPS) is one of the most frequent injuries in competitive sports. Stresses generated in the lower limbs by quick turns and accelerations, such as in soccer, basketball or hockey, can produce localized regions of increased forces, resulting in anatomical lesions. The differential diagnoses are numerous and comprise articular, extra-articular, muscular, tendinous and visceral clinical conditions and a correct diagnosis is crucial if treatment is to be efficient. MRI is the gold standard of diagnostic techniques, especially when an alternative pathology needs to be excluded and/or other imaging techniques such as ultrasound or radiography do not lead to a diagnosis. This paper, based on the current literature, gives a comprehensive review of the anatomy of the pubic region and of the typical MRI findings in those affected by GPS. Many clinical conditions causing GPS can be investigated by MRI within appropriate protocols. However, MRI shows limits in reliability in the investigation of inguinal and femoral hernias and therefore is not the imaging technique of choice for studying these clinical conditions.

Achilles Tendon Repair after Tenorraphy Imaging and the Doughnut Metaphor.

After Achilles tendon tenorraphy, tendon tissue undergoes a long period of biological healing. During this period, tissue turnover shows heterogeneity between its peripheral and central regions. This case report concerns the description of the tendon healing process of an athlete who underwent an Achilles tendon tenorraphy. As the reparative processes progressed, magnetic resonance imaging (MRI) showed centralization of the hyperintensity area and the tendon assumed a doughnut-like appearance. At the same time, ultrasound (US) assessment showed a progressive reorganization of the tendon fibrillar structure. Therefore, for the athlete, MRI and US assessment together represent a useful tool for the decision-making process after Achilles tendon tenorraphy.

The conservative treatment of longstanding adductor-related groin pain syndrome: a critical and systematic review.

Longstanding (chronic) adductor-related groin pain syndrome is a widely common problem for athletes in many sports activities which often drastically reduces player activity and performance. The first choice in therapeutic treatment is conservative therapy. The objective of this study is to provide a systematic review regarding conservative treatment for longstanding adductor-related groin pain syndrome present in literature today. Furthermore, this study aims to give a critical vision of the current state of the art of the considered topic. After screening 234 articles, 19 studies following the inclusion criteria were included and summarized in this current systematic review and seven different types of therapeutic interventions were described. Compression clothing therapy, manual therapy together with strengthening exercise and prolotherapy were the therapeutic interventions which showed both the greatest level of strength of evidence (Moderate) and grade of recommendation (D). The remaining four types of therapeutic interventions i.e.: corticoid injection, platelet rich plasma therapy, intra-tissue percutaneous electrolysis and pulse-dose radiofrequency, showed both lower levels of strength of evidence (Conflicting) and grade of recommendation (C). In conclusion the literature available on the conservative treatment for longstanding adductor-related groin pain syndrome is limited and characterized by a low level of evidence. Therefore, our recommendation is to refer only to the few studies with higher level of evidence and at the same time to encourage further research in this area. The intervention showing the greater level of strength of evidence, and the greater grade of recommendation are compression clothing therapy, manual therapy and strengthening exercise, and prolotherapy. Other therapeutic interventions such as intra-tissue percutaneous electrolysis and pulse-dose radiofrequency seem promising but require further studies to confirm their efficacy.

Return to football training and competition after lockdown caused by the COVID-19 pandemic: medical recommendations.

The lockdown caused by the COVID-19 pandemic represents a great unknown regarding the physiological changes induced in elite football players. Although it will differ from country to country, the return to sport for professional football players will follow a forced lockdown never experienced and longer than the normal annual season break. Moreover, in addition to an obvious decrease in performance, the lockdown will possibly lead to an increase of the injury risk. In fact, preseason is always a period with a specific football injury epidemiology, with an increase in the incidence and prevalence of overuse injuries. Therefore, it seems appropriate to recommend that specific training and injury prevention programmes be developed, with careful load monitoring. Training sessions should include specific aerobic, resistance, speed and flexibility training programmes. The aerobic, resistance and speed training should respect some specific phases based on the progressiveness of the training load and the consequent physiological adaptation response. These different phases, based on the current evidence found in the literature, are described in their practical details. Moreover, injury prevention exercises should be incorporated, especially focusing on overuse injuries such as tendon and muscle lesions. The aim of this paper is to provide practical recommendations for the preparation of training sessions for professional footballers returning to sport after the lockdown.

Effects of in Season Multi-Directional Plyometric Training on Vertical Jump Performance, Change of Direction Speed and Dynamic Postural Control in U-21 Soccer Players.

The aim of the study was to assess the effects of multi-directional plyometric training (MPT) on vertical jump height, change of direction speed (CODS), and dynamic postural control (DPC) of soccer players under 21 year (U-21). Twenty-seven male soccer players were randomly allocated to either an experimental group (EG; n = 14; age: 19.0 ± 0.9 years) or a control group (CG; n = 13; age: 19.0 ± 0.7 years). The EG introduced 6 weeks MPT, 2 days per week into their in-season training, while CG continued training without change. Measurements of vertical jump height, CODS and DPC were completed at the beginning and end of the 6 week MPT. ANOVA demonstrated a significant group × time interaction for SJ (F = 6.03, p = 0.021), CMJ (F = 9.10, p = 0.006), and T-Test (F = 10.46, p = 0.002). The Bonferroni Post Hoc test demonstrated significant increase for the three tests in both group (EG and CG). For SJ (EG: p < 0.001; CG: p < 0.001), CMJ (EG: p < 0.001; CG: p = 0.005) and T-Test (EG: p < 0.001; CG: p = 0.02). For DPC on the dominant leg, there was a significant group × time interaction for four axes [anterior (F = 5.48, p = 0.028), antero-lateral (F = 4.82, p = 0.038), postero-lateral (F = 4.82, p = 0.038), and medial (F = 6.77, p = 0.015)]. The Bonferroni Post Hoc test demonstrated significant increase in EG (p < 0.001), but no significant change in CG in four axes (anterior, antero-lateral, postero-lateral and medial). Furthermore DPC on the non-dominant leg, there was a significant group × time interaction for three axes [lateral (F = 8.09, p = 0.009), postero-lateral (F = 11.92, p = 0.002), and medial (F = 5.84, p = 0.023)]. The Bonferroni Post Hoc test demonstrated significant increase in EG (p < 0.001), but no significant change in CG in three axes (lateral, postero-lateral, and medial). In conclusion, incorporating MPT into the in-season regimen of under 21 soccer players improved performance of various indices related to soccer activity (i.e., CMJ, CODS, and DPC). MPT has the potential to be appealing to coaches, as it requires little time while yielding valuable results in the physical preparation of soccer players.

Italian consensus statement (2020) on return to play after lower limb muscle injury in football (soccer).

Return to play (RTP) decisions in football are currently based on expert opinion. No consensus guideline has been published to demonstrate an evidence-based decision-making process in football (soccer). Our aim was to provide a framework for evidence-based decision-making in RTP following lower limb muscle injuries sustained in football. A 1-day consensus meeting was held in Milan, on 31 August 2018, involving 66 national and international experts from various academic backgrounds. A narrative review of the current evidence for RTP decision-making in football was provided to delegates. Assembled experts came to a consensus on the best practice for managing RTP following lower limb muscle injuries via the Delphi process. Consensus was reached on (1) the definitions of 'return to training' and 'return to play' in football. We agreed on 'return to training' and RTP in football, the appropriate use of clinical and imaging assessments, and laboratory and field tests for return to training following lower limb muscle injury, and identified objective criteria for RTP based on global positioning system technology. Level of evidence IV, grade of recommendation D.

Anterior cruciate ligament injury risk factors in football.

INTRODUCTION: Anterior cruciate ligament (ACL) lesion represents one of the most dramatic injuries in a football (soccer) player's career. There are many injury risk factors related to intrinsic (non-modifiable) and/or extrinsic (modifiable) factors of ACL injury. EVIDENCE ACQUISITION: Research of the studies was conducted until September 2018 without publication data limitation or language restriction on the following databases: PubMed/MEDLINE, Scopus, ISI, EXCERPTA. EVIDENCE SYNTHESIS: To date, evidence from the literature suggests that the risk of ACL injury is multifactorial and involves biomechanical, anatomical, hormonal, and neuromuscular factors. Despite this relative complexity, the mechanisms of injury are well known and rationally classified into two categories: mechanisms of injury based on contact or on non-contact with another player, with the non-contact injury mechanisms clearly prevailing over the mechanisms of contact injury. One of the most frequent biomechanical risk factors, associated with ACL non-contact injury, is represented by the valgus knee in the pivoting and cutting movements and in the landing phase after jumping. Gender-related risk factors show female populations to have a higher predisposition to ACL injury than males However, there are still some theoretical and practical aspects that need further investigation such as; genetic risks together with the role of estrogen and progesterone receptors in female populations, and the in-vivo interaction shoe-playing surface. In particular, the genetic risk factors of ACL lesion seem to be an interesting and promising field of investigation, where considerable progress has still to be made. CONCLUSIONS: This narrative review provides an insight into the risk factors of ACL injury that could be used by practitioners for preventing injury in football (soccer).

Hamstring Injuries Prevention in Soccer: A Narrative Review of Current Literature.

Hamstring injuries and reinjuries are one of the most important sport lesions in several sport activities including soccer, Australian football, track and field, rugby, and in general in all sport activities requiring sprinting and acceleration. However, it is important to distinguish between the lesions of the biceps femoris and semitendinosus and semimembranosus. Indeed, three muscles representing the hamstring complex have a very different injury etiology and consequently require different prevention strategies. This fact may explain, at least in part, the high incidence of reinjuries. In soccer, hamstring injuries cause an important rate of time loss (i.e., in average 15-21 matches missed per club per season). The hamstring injury risk factors may be subdivided in three categories: "primary injury risk factors" (i.e., the risk factors mainly causing a first lesion), "recurrent injury risk factors" (i.e., the risk that can cause a reinjury), and bivalent injury risk factors" (i.e., the risk factors that can cause both primary injuries and reinjuries). The high incidence of hamstring lesions caused consequently an important increase in hamstring injury research. However, although the prevention has increased paradoxically, epidemiological data do not show a loss in injuries and/or reinjuries but, on the contrary, they show an increase in hamstring injuries. This apparent paradox highlights the importance both of the improvement in the prevention programs quality and the criteria for return to play after hamstring injury.

Multidirectional Plyometric Training: Very Efficient Way to Improve Vertical Jump Performance, Change of Direction Performance and Dynamic Postural Control in Young Soccer Players.

The aim of the study was to assess the effects of multidirectional plyometric training (MPT) on vertical jump height, change of direction performance (CODP), and dynamic postural control (DPC) in young soccer players. Twenty-eight young male soccer players were randomly assigned to an experimental group (EG, n = 14; age: 11.8 ± 0.4 years) and a control group (CG, n = 14; age: 11.6 ± 0.5 years). The EG introduced 8-week MPT, two days per week into their in-season training, while CG continued training without change. Measurements of vertical jump height, CODP, and DPC were completed at the beginning and end of the 8-week MPT. A significant group × time interaction was observed for Squat-Jump (p < 0.05), for Counter-Movement Jump (p < 0.05), and for CODP test (p < 0.05). In addition, a significant group × time interaction was observed for DPC in seven axes for the dominant- (anterior, lateral, postero-lateral, posterior, postero-medial, medial, and antero-medial; p < 0.05 for all) and in seven axes for the non-dominant- (anterior, antero-lateral, lateral, posterior, postero-medial, medial and antero-medial; p < 0.05 for all) legs. The rest of the axes of both legs did not show any significant group × time interaction (p > 0.05). In conclusion, incorporating MPT into the in-season regimen of young male soccer players improved performance of various indices related to soccer activity (i.e., vertical jump height, CODP, and DPC). MPT has the potential to be appealing to coaches, as it requires little time while yielding valuable results in the physical preparation of young soccer players.

High incidence of hip and knee arthroplasty in former professional, male football players.

BACKGROUND: The purpose of this study was to estimate the incidence of hip and knee arthroplasty in Italian male professional football (soccer) players who have played for a minimum 10 years in the Italian major football leagues. METHODS: The study group was formed by 104 male professional football players who were interviewed to evaluate the incidence of hip and knee arthroplasty. The data were collected through a questionnaire and the results collected were compared with a control group of 100 volunteers matched for age, weight and height, who did not present orthopedic diseases but had never practiced sport. RESULTS: In the study group, 26 subjects (25%) underwent hip and knee arthroplasty at an average mean age of 62.1±6 years. The frequency of arthroplasty was: 13.5% for the hip, 5.8% for the knee and 5.8% for both hip and knee. In the control group, the incidence of arthroplasty was 1% for the knee and no subjects presented hip arthroplasty. CONCLUSIONS: Italian male, former professional football players present a higher than normal incidence of hip and knee arthroplasty. Further studies are necessary to understand the pathological pathways underlying the etiology of hip and knee osteoarthritis in male populations of former professional football players in order to develop effective preventive programs to reduce the percentage of arthroplasties.

Italian consensus conference on guidelines for conservative treatment on lower limb muscle injuries in athlete.

Provide the state of the art concerning (1) biology and aetiology, (2) classification, (3) clinical assessment and (4) conservative treatment of lower limb muscle injuries (MI) in athletes. Seventy international experts with different medical backgrounds participated in the consensus conference. They discussed and approved a consensus composed of four sections which are presented in these documents. This paper represents a synthesis of the consensus conference, the following four sections are discussed: (i) The biology and aetiology of MIs. A definition of MI was formulated and some key points concerning physiology and pathogenesis of MIs were discussed. (ii) The MI classification. A classification of MIs was proposed. (iii) The MI clinical assessment, in which were discussed anamnesis, inspection and clinical examination and are provided the relative guidelines. (iv) The MI conservative treatment, in which are provided the guidelines for conservative treatment based on the severity of the lesion. Furthermore, instrumental therapy and pharmacological treatment were discussed. Knowledge of the aetiology and biology of MIs is an essential prerequisite in order to plan and conduct a rehabilitation plan. Another important aspect is the use of a rational MI classification on prognostic values. We propose a classification based on radiological investigations performed by ultrasonography and MRI strongly linked to prognostic factors. Furthermore, the consensus conference results will able to provide fundamental guidelines for diagnostic and rehabilitation practice, also considering instrumental therapy and pharmacological treatment of MI. Expert opinion, level IV.

Risk factors of anterior cruciate ligament injury in football players: a systematic review of the literature.

BACKGROUND: The ACL lesion represents one of the most dramatic injuries in a sportsman's career. There are many injury risk factors related to intrinsic, or non-modifiable, and extrinsic, or modifiable, factors. In literature at today current evidence suggests that ACL injury risk is multifactorial and involves biomechanical, anatomical, hormonal and neuromuscular factors. PURPOSE: To perform a systematic review of the literature concerning the ACL injury risk factors in soccer. CONCLUSION: The injury risk factors show a low level of evidence, further studies in the field are needed. STUDY DESIGN: Systematic review.

ACL injury in football: a literature overview of the prevention programs.

BACKGROUND: The ACL prevention programs are addressed to the control and/or modification of the so-called "modifiable risk factors". All these programs focus on different intervention strategies aimed to decrease the ACL injury risk, particularly in female athletes population. PURPOSE: To furnish an overview of the most used ACL injury prevention program through a narrative review. CONCLUSION: In literature there are many reports on prevention programs whose common denominator is the proper alignment of the lower limb joints and proper motor control during movements that are considered at risk for ACL integrity, as the landing phase after a jump. Nevertheless, some programs would appear more effective than others. In any cases a major problem remains the lack of sufficient compliance in respect of prevention programs. Finally, it is important to remember that the ethiology of ACL injuries is multifactorial. For this reason a prevention program able to prevent all the risk situations is utopian. STUDY DESIGN: Narrative review.

Return to sports after ACL reconstruction: a new functional test protocol.

BACKGROUND: In literature, there are lack of studies proposing clear and rationally designed test battery to be performed after an ACL reconstruction. METHODS: From 2006 to 2015, 80 football players were subjected, after ACL reconstruction, to a newly conceived test battery analyzing: Isometric and isokinetic force productionThe different phases during the jumpThe correct control of the landing phase after jumpThe control of valgus during landing after jump and cutting movements. RESULTS: The isokinetic and isometric test do not show any significant relationship with the another test. The laboratory test as well the field test showed them a significant correlation. CONCLUSIONS: The results showed that a normal force production during the laboratory does not guarantee an equally satisfactory production of force during the field test. STUDY DESIGN: Case series (Level III).

Groin pain syndrome: an association of different pathologies and a case presentation.

BACKGROUND: groin pain affects all types of athletes, especially soccer players. Many diseases with different etiologies may cause groin pain. PURPOSE: offer a mini review of groin pain in soccer accompanied by the presentation of a case report highlighting the possible association of more clinical frameworks into the onset of groin pain syndrome, in order to recommend that clinical evaluations take into account possible associations between bone, muscle and tendon such as inguinal canal disease. CONCLUSION: the multifactorial etiology of groin pain syndrome needs to be examined with a comprehensive approach, with standardized clinical evaluation based on an imaging protocol in order to evaluate all possible diseases. STUDY DESIGN: Mini review- Case report (Level V).