Groin Pain Syndrome Italian Consensus Conference update 2023

Groin pain syndrome (GPS) is a controversial topic in Sports Medicine. The GPS Italian Consensus Conference on terminology, clinical evaluation and imaging assessment of groin pain in athletes was organized by the Italian Society of Arthroscopy in Milan, on 5 February 2016. In this Consensus Conference (CC) GPS etiology was divided into 11 different categories for a total of 63 pathologies. The GPS Italian Consensus Conference update 2023 is an update of the 2016 CC. The CC was based on a sequential, two-round online Delphi survey, followed by a final CC in the presence of all panelists. The panel was composed of 55 experts from different scientific and clinical backgrounds. Each expert discussed 6 different documents, one of which regarded the clinical and imaging definition of sports hernias, and the other 5 dealt with 5 new clinical situations thought to result in GPS. The panelists came to an agreement on the definition of a sports hernia. Furthermore, an agreement was reached, recognizing 4 of the 5 possible proposed pathologies as causes to GPS. On the contrary, the sixth pathology discussed did not find consensus given the insufficient evidence in the available scientific literature. The final document includes a new clinical and imaging definition of sports hernia. Furthermore, the etiology of GPS was updated compared to the previous CC of 2016. The new taxonomic classification includes 12 categories (versus 11 in the previous CC) and 67 pathologies (versus 63 in the previous CC).

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.

Long-standing groin pain syndrome in athletic women: a multidisciplinary assessment in keeping with the italian consensus agreement

BACKGROUND

Long-standing groin pain syndrome (LSGPS) is a form of groin pain syndrome in which the cohort of symptoms reported by patients is experienced for a long period, typically for over 12 weeks, and is recalcitrant to any conservative therapy. The aim of this prospective epidemiological study was to describe the clinical causes of LSGPS in 37 female athletic subjects in Italy through the Groin Pain Syndrome Italian Consensus Conference on terminology, clinical evaluation and imaging assessment in groin pain in athletes classification and guidelines.

METHODS

Thirty-seven female athletes affected by LSGPS were evaluated following the guidelines issued by the Groin Pain Syndrome Italian Consensus Conference on terminology, clinical evaluation and imaging assessment of groin pain in athletes.

RESULTS

In the considered population, each patient presented only one pathological cause for LSGPS. The most frequent aetiologies were inguinal pathologies (54.05% of the cases), acetabular labrum tear (18.92%) and pelvic floor disorders (8.11%). Adductor tendinopathy represented only 2.70% of cases.

CONCLUSIONS

Female athletic patients affected by LSGPS show a similar incidence of inguinal and hip pathologies as in male populations. However, these clinical situations do not seem to be associated in women unlike in the male population. This difference is probably due to particular anatomical differences related to gender. For this reason, women affected by LSGPS represent an important subset of patients. Moreover, adductor tendinopathy is probably overrated as an etiopathogenetic source of LSGPS in women.

A multidisciplinary assessment of 320 athletes with long-standing groin pain syndrome in keeping with the Italian consensus agreement: the high incidence and the multiple causes of inguinal and hip pathologies and pubic osteopathy

BACKGROUND

Groin pain syndrome is an important and increasing problem in numerous sports (e.g. soccer, football, ice hockey, handball and rugby). Long-standing groin pain syndrome is a form of groin pain syndrome in which the cohort of symptoms reported by the patient is experienced for a long period, typically for over 12 weeks, and is recalcitrant to any conservative therapy. Long-standing groin pain syndrome is potentially career-ending for elite athletes.

METHODS

A descriptive epidemiological study was carried out on 320 athletes (290 men and 30 women) affected by long-standing groin pain syndrome, following the Guidelines issued by the Groin Pain Syndrome Italian Consensus Conference on terminology, clinical evaluation and imaging assessment of groin pain in athlete.

RESULTS

Amongst the clinical tests for inguinal pathologies, only the External Inguinal Ring Exploration proved conclusive (sensitivity: 0.97; specificity: 0.95; positive predictive value: 0.98; negative predictive value: 0.90; likelihood ratio: 19.4). In testing for adductor tendinopathies, only the Isometric Squeeze with flexed knee and distal resistance (sensitivity: 0.86; specificity: 0.45; positive predictive value: 0.48; negative predictive value: 0.85; likelihood ratio: 5.7) and the Palpatory Test at the pubic insertion of the adductor longus (sensitivity: 0.93; specificity: 0.89; positive predictive value: 0.96; negative predictive value: 0.79; likelihood ratio: 8.5) proved, respectively, useful at times and moderately useful. Among the tests for hip pathologies, only the Flexion Abduction External Rotation Test was seen to be conclusive (sensitivity: 0.90; specificity: 0.93; positive predictive value: 0.98; negative predictive value: 0.72; likelihood ratio: 12.9). In the male population on average, long-standing groin syndrome presents either a single cause or multiple causes in respectively 74% and 26% of cases. Furthermore, almost 58% of all cases traced to a single clinical cause can be attributed to inguinal pathologies alone. Long-standing groin syndrome in the female population shows only one pathological cause with inguinal pathologies, and acetabular labrum tear representing the most frequent etiologies.

CONCLUSIONS

Men and women exhibit different causes for long-standing groin pain syndrome. Several routine tests used in the clinical evaluation of this condition furnish a low likelihood ratio. Consequently, in order to optimize clinical evaluation and minimize patient discomfort, clinical evaluation should be based on tests with a greater likelihood ratio.

How does sleep help recovery from exercise-induced muscle injuries?

OBJECTIVES

Athletes and military personnel may experience sleep disturbances due to conditions of training and competitions or military missions/field operations. The risk of muscle injuries is greater for them when sleep duration decreases, and training load increases simultaneously, which can be exacerbated by fatigue. Accumulating evidence demonstrates that sleep extension improved performance, pain sensitivity and GH/IGF-I anabolic responses, which may be beneficial in accelerating recovery from muscle injuries.

DESIGN & METHODS

This narrative review describes the importance of sleep for the recovery/prevention of exercise-induced muscle injuries and provides perspectives on the transferability of currently available scientific evidence to the field.

RESULTS

The first part presents the role of sleep and its interaction with the circadian system for the regulation of hormonal and immune responses, and provides information on sleep in athletes and soldiers and its relationship to injury risk. The second part is an overview of muscle injuries in sport and presents the different phases of muscle regeneration and repair, i.e. degeneration, inflammation, regeneration, remodeling and maturation. Part three provides information on the deleterious effects of sleep deprivation on muscle tissue and biological responses, and on the benefits of sleep interventions. Sleep extension could potentially help and/or prevent recovery from exercise-induced muscle-injuries through increasing local IGF-I and controlling local inflammation.

CONCLUSIONS

Although the science of sleep applied to sport is still an emerging field, the current scientific literature shows many potential physiological pathways between sleep and exercise-related muscle injuries. More direct studies are needed to establish clear guidelines for medical personnel and coaches.

Injury and illness epidemiology in professional Asian football: lower general incidence and burden but higher ACL and hamstring injury burden compared with Europe

BACKGROUND

While football injury and illness epidemiology surveillance at professional club level in Europe is available, epidemiological data from other continents are lacking.

PURPOSE

Investigating injury and illness epidemiology in professional Asian football.

STUDY DESIGN

Descriptive prospective study.

METHODS

Professional teams from the Asian Football Confederation (AFC) league were followed prospectively for three consecutive AFC seasons (2017 through 2019, 13 teams per season, 322 team months). Time-loss injuries and illnesses in addition to individual match and training exposure were recorded using standardised digital tools in accordance with international consensus procedures.

RESULTS

In total, 232 665 hours of exposure (88.6% training and 11.4% matches) and 1159 injuries were recorded; 496 (42.8%) occurred during matches, 610 (52.6%) during training; 32 (2.8%) were reported as 'not applicable' and for 21 injuries (1.8%) information was missing. Injury incidence was significantly greater during match play (19.2±8.6 injuries per 1000 hours) than training (2.8±1.4, p<0.0001), resulting in a low overall incidence of 5.1±2.2.The injury burden for match injuries was greater than from training injuries (456±336 days per 1000 hours vs 54±34 days, p<0.0001). The two specific injuries causing the greatest burden were complete ACL ruptures (0.14 injuries (95% CI 0.9 to 0.19) and 29.8 days lost (29.1 to 30.5) per 1000 hours) and hamstring strains (0.86 injuries (0.74 to 0.99) and 17.5 days (17.0 to 18.1) lost per 1000 hours).Reinjuries constituted 9.9% of all injuries. Index injuries caused 22.6±40.8 days of absence compared with 25.1±39 for reinjuries (p=0.62). The 175 illnesses recorded resulted in 1.4±2.9 days of time loss per team per month.

CONCLUSION

Professional Asian football is characterised by an overall injury incidence similar to that reported from Europe, but with a high rate of ACL ruptures and hamstring injury, warranting further investigations.

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.

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.

Harmful association of sprinting with muscle injury occurrence in professional soccer match-play: A two-season, league wide exploratory investigation from the Qatar Stars League

OBJECTIVES

To investigate the impact of physical efforts performed in the period preceding activity as a potential risk factor of muscle injury during match-play within a sample of professional soccer players.

DESIGN

Observational cohort study.

METHODS

Match load (running [>14.4-19.8km/h], high-speed running [>19.8-25.2km/h], sprinting [>25.2km/h], leading and explosive sprint type) averaged in 1-min and 5-min periods prior to an event or non event for 29 professional outfield soccer players. Conditional logistic and Poisson regression models estimated the relationship between load and injury for a 2 within-subject standard deviation in match load or 1-action increment in the number of sprinting activities, respectively. Associations were deemed beneficial or harmful based on non-overlap of the 95% confidence intervals against thresholds of 0.90 and 1.11, respectively.

RESULTS

An increment in sprinting distance [+2-SDs=11m] covered over a 1-min period (odds ratio [OR]: 1.22, 95%CI, 1.12 to 1.33) increased the odds of muscle injury.

CONCLUSIONS

Our study provides novel exploratory evidence that the volume of sprinting during competitive soccer match-play has a harmful association with muscle injury occurrence.

ACL injury incidence, severity and patterns in professional male soccer players in a Middle Eastern league

Aim

To ascertain ACL injury incidence, severity (injury burden) and patterns (contact/non-contact and reinjuries) in a professional male football league in the Middle East over five consecutive seasons.

Methods

Prospective epidemiological study reporting ACL injuries in professional male soccer players in the Qatar Stars League, with complete matches/training exposure over five seasons (2013–2014 to 2017–2018), corresponding to 2243 player seasons and 729 team months.

Results

37 complete ACL ruptures occurred in 37 players during 486 951  hours of player exposure. The overall ACL injury rate was 0.076 injuries/1000  hours of exposure (season range 0.045–0.098). Injury incidence during matches and training was 0.41 and 0.04 injuries/1000  hours of exposure, respectively. Match injury incidence was greater than that of training (OR 11.8, 95%  CI 6.21 to 23.23, p<0.001). Average injury-related time-loss following ACL injury was 225 days±65 (range 116–360). Overall injury burden was 16.3 days lost/1000  hours of exposure.

Conclusion

The overall ACL injury rate in professional male soccer players competing in the Middle East was 0.076 injuries/1000  hours of exposure, match injury incidence was greater than training, while the average ACL time-loss was 225 days.

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.

Muscle Strength Is a Poor Screening Test for Predicting Lower Extremity Injuries in Professional Male Soccer Players: A 2-Year Prospective Cohort Study

BACKGROUND

Lower extremity muscle strength tests are commonly used to screen for injury risk in professional soccer. However, there is limited evidence on the ability of such tests in predicting future injuries.

PURPOSE

To examine the association between hip and thigh muscle strength and the risk of lower extremity injuries in professional male soccer players.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Professional male soccer players from 14 teams in Qatar underwent a comprehensive strength assessment at the beginning of the 2013/2014 and 2014/2015 seasons. Testing consisted of concentric and eccentric quadriceps and hamstring isokinetic peak torques, eccentric hip adduction and abduction forces, and bilateral isometric adductor force (squeeze test at 45°). Time-loss injuries and exposure in training and matches were registered prospectively by club medical staff throughout each season. Univariate and multivariate Cox regression analyses were used to calculate hazard ratios (HRs) with 95% CIs.

RESULTS

In total, 369 players completed all strength tests and had registered injury and exposure data. Of these, 206 players (55.8%) suffered 538 lower extremity injuries during the 2 seasons; acute muscle injuries were the most frequent. Of the 20 strength measures examined, greater quadriceps concentric peak torque at 300 deg/s (HR, 1.005 [95% CI, 1.00-1.01]; P = .037) was the only strength measure identified as significantly associated with a risk of lower extremity injuries in multivariate analysis. Greater quadriceps concentric peak torque at 60 deg/s (HR, 1.004 [95% CI, 1.00-1.01]; P = .026) was associated with the risk of overuse injuries, and greater bilateral adductor strength adjusted for body weight (HR, 0.75 [95% CI, 0.57-0.97; P = .032) was associated with a lower risk for any knee injury. Receiver operating characteristic curve analyses indicated poor predictive ability of the significant strength variables (area under the curve, 0.45-0.56).

CONCLUSION

There was a weak association with the risk of lower extremity injuries for 2 strength variables: greater quadriceps concentric muscle strength at (1) high and (2) low speeds. These associations were too small to identify an "at-risk" player. Therefore, strength testing, as performed in the present study, cannot be recommended as a screening test to predict injuries in professional male soccer.

Musculoskeletal Screening Tests and Bony Hip Morphology Cannot Identify Male Professional Soccer Players at Risk of Groin Injuries: A 2-Year Prospective Cohort Study

BACKGROUND

Musculoskeletal hip/groin screening tests are commonly performed to detect at-risk individuals. Bony hip morphology is considered a potential intrinsic risk factor but has not been examined prospectively.

PURPOSE

To evaluate the association between intrinsic risk factors identified from musculoskeletal and radiographic screening tests and hip/groin injuries leading to time loss from training and/or match play in professional male soccer players.

STUDY DESIGN

Prospective cohort study; Level of evidence, 2.

METHODS

Male professional soccer players, aged ≥18 years, underwent screening specific for hip/groin pain during 2 consecutive seasons of the Qatar Stars League. The screening battery included pain provocation, range of motion, and strength tests as well as a hip radiographic examination. The radiographic examination included an anteroposterior pelvic view and 45° Dunn view, with bony hip morphology determined using quantitative methods. Time-loss (≥1 day) hip/groin injuries and individual player exposure (training and match play) were recorded prospectively, and injuries were categorized as adductor-related, inguinal-related, iliopsoas-related, pubic-related, or hip-related groin pain, or "other," as recommended in the Doha agreement. We calculated hazard ratios (HRs) from univariate and multivariate Cox regression models to assess the relationship between potential risk factors and hip/groin injuries.

RESULTS

There were 438 players, completing 609 player seasons, and 113 hip/groin injuries that met the criteria for inclusion, with 85 injuries categorized as adductor-related. The proportion of players with bony morphological variants was the following: cam, 71%; pincer, 5%; and acetabular dysplasia, 13%. Previous hip/groin injuries (HR, 1.8; 95% CI, 1.2-2.7) and eccentric adduction strength were associated with the risk of hip/groin injuries. Higher (>1 SD above the mean) than normal eccentric adduction strength was associated with an increased risk for all hip/groin injuries (HR, 1.6; 95% CI, 1.0-2.5). Lower (<1 SD below the mean) than normal eccentric adduction strength was associated with an increased risk for adductor-related injuries (HR, 1.7; 95% CI, 1.0-3.0). No other musculoskeletal screening test or bony hip morphology variables were associated with the injury risk.

CONCLUSION

Previous groin injuries and eccentric adduction strength were associated with the risk of groin injuries. However, these associations were not strong enough to identify an "at-risk" individual, and therefore, musculoskeletal screening tests were not useful to dictate individualized prevention strategies. Bony hip morphology was not associated with the risk of groin injuries.

Intramuscular tendon involvement on MRI has limited value for predicting time to return to play following acute hamstring injury

Background

Hamstring injury with intramuscular tendon involvement is regarded as a serious injury with a delay in return to play (RTP) of more than 50 days and reinjury rates up to 63%. However, this reputation is based on retrospective case series with high risk of bias.

Objective

Determine whether intramuscular tendon involvement is associated with delayed RTP and elevated rates of reinjury.

Methods

MRI of male athletes with an acute hamstring injury was obtained within 5 days of injury. Evaluation included standardised MRI scoring and scoring of intramuscular tendon involvement. Time to RTP and reinjury rate were prospectively recorded.

Results

Out of 70 included participants, intramuscular tendon disruption was present in 29 (41.4%) injuries. Injuries without intramuscular tendon disruption had a mean time to RTP of 22.2±7.4 days. Injuries with <50%, 50%–99% and 100% disruption of tendon cross-sectional area had a mean time to RTP of 24.0±9.7, 25.3±8.6 and 31.6±10.9 days, respectively. Injuries with full-thickness disruption took longer to RTP compared with injuries without disruption (p=0.025). Longitudinal intramuscular tendon disruption was not significantly associated with time to RTP. Waviness was present in 17 (24.3%) injuries. Mean time to RTP for injuries without and with waviness was 22.6±7.5 and 30.2±10.8 days (p=0.014). There were 11 (15.7%) reinjuries within 12 months, five (17.2%) in the group with intramuscular tendon disruption and six (14.6%) in the group without intramuscular tendon disruption.

Conclusion

Time to RTP for injuries with full-thickness disruption of the intramuscular tendon and waviness is significantly longer (by slightly more than 1 week) compared with injuries without intramuscular tendon involvement. However, due to the considerable overlap in time to RTP between groups with and without intramuscular tendon involvement, its clinical significance for the individual athlete is limited.

Epidemiology of time loss groin injuries in a men's professional football league: a 2-year prospective study of 17 clubs and 606 players

BACKGROUND/AIM

Groin injury epidemiology has not previously been examined in an entire professional football league. We recorded and characterised time loss groin injuries sustained in the Qatar Stars League.

METHODS

Male players were observed prospectively from July 2013 to June 2015. Time loss injuries, individual training and match play exposure were recorded by club doctors using standardised surveillance methods. Groin injury incidence per 1000 playing hours was calculated, and descriptive statistics used to determine the prevalence and characteristics of groin injuries. The Doha agreement classification system was used to categorise all groin injuries.

RESULTS

606 footballers from 17 clubs were included, with 206/1145 (18%) time loss groin injuries sustained by 150 players, at an incidence of 1.0/1000 hours (95% CI 0.9 to 1.1). At a club level, 21% (IQR 10%-28%) of players experienced groin injuries each season and 6.6 (IQR 2.9-9.1) injuries were sustained per club per season. Of the 206 injuries, 16% were minimal (1-3 days), 25% mild (4-7 days), 41% moderate (8-28 days) and 18% severe (>28 days), with a median absence of 10 days/injury (IQR 5-22 days). The median days lost due to groin injury per club was 85 days per season (IQR 35-215 days). Adductor-related groin pain was the most common entity (68%) followed by iliopsoas (12%) and pubic-related (9%) groin pain.

CONCLUSION

Groin pain caused time loss for one in five players each season. Adductor-related groin pain comprised 2/3 of all groin injuries. Improving treatment outcomes and preventing adductor-related groin pain has the potential to improve player availability in professional football.

The functional movement test 9+ is a poor screening test for lower extremity injuries in professional male football players: a 2-year prospective cohort study

Background

The 9+ screening battery test consists of 11 tests to assess limitations in functional movement.

Aim

To examine the association of the 9+ with lower extremity injuries and to identify a cut-off point to predict injury risk.

Methods

Professional male football players in Qatar from 14 teams completed the 9+ at the beginning of the 2013/2014 and 2014/2015 seasons. Time-loss injuries and exposure in training and matches were registered prospectively by club medical staff during these seasons. Univariate and multivariate Cox regression analyses were used to calculate HR and 95% CI. Receiver operating characteristic (ROC) curves were calculated to determine sensitivity and specificity and identify the optimal cut-off point for risk assessment.

Results

362 players completed the 9+ and had injury and exposure registration. There were 526 injuries among 203 players (56.1%) during the two seasons; injuries to the thigh were the most frequent. There was no association between 9+ total score and the risk of lower extremity injuries (HR 1.02, 95% CI 0.99 to 1.05, p=0.13), even after adjusting for other risk factors in a multivariate analysis (HR 1.01, 95% CI 0.98 to 1.04, p=0.37). ROC curve analysis revealed an area under the curve of 0.48, and there was no cut-off point that distinguished injured from non-injured players.

Conclusion

The 9+ was not associated with lower extremity injury, and it was no better than chance for distinguishing between injured and uninjured players. Therefore, the 9+ test cannot be recommended as an injury prediction tool in this population.

Interseason variability of a functional movement test, the 9+ screening battery, in professional male football players

BACKGROUND

The Nine Plus screening battery test (9+) is a functional movement test intended to identify limitations in fundamental movement patterns predisposing athletes to injury. However, the interseason variability is unknown.

AIM

To examine the variability of the 9+ test between 2 consecutive seasons in professional male football players.

METHODS

Asymptomatic Qatar Star League players (n=220) completed the 9+ at the beginning of the 2013 and 2014 seasons. Time-loss injuries in training and matches were obtained from the Aspetar Injury and Illness Surveillance Program. No intervention was initiated between test occasions.

RESULTS

A significant increase in the mean total score of 1.6 points (95% CI 1.0 to 2.2, p<0.001) was found from season 1 (22.2±4.1 (SD)) to season 2 (23.8±3.3). The variability was large, as shown by an intraclass correlation coefficient (ICC) of 0.24 (95% CI 0.11 to 0.36) and a minimal detectable change (MDC) of 8.7 points. Of the 220 players, 136 (61.8%) suffered a time-loss injury between the 2 tests. There was an improvement in mean total scores in the injured (+2.0±0.4 (SE), p<0.001) group but not in the uninjured group (+0.9±0.5, p=0.089). The variability from season 1 to season 2 was large both in the injured (ICC 0.25, 0.09 to 0.40, MDC 8.3) and uninjured (ICC 0.24, 0.02 to 0.43, MDC 9.1) groups.

CONCLUSIONS

The 9+ demonstrated substantial intraindividual variability in the total score between 2 consecutive seasons, irrespective of injury. A change above 8 points is necessary to represent a real change in the 9+ test between seasons.

At return to play following hamstring injury the majority of professional football players have residual isokinetic deficits

Background

There is an ongoing debate regarding the optimal criteria for return to sport after an acute hamstring injury. Less than 10% isokinetic strength deficit is generally recommended but this has never been documented in professional football players after rehabilitation. Our aim was to evaluate isokinetic measurements in MRI-positive hamstring injuries.

Methods

Isokinetic measurements of professional football players were obtained after completing a standardised rehabilitation programme. An isokinetic strength deficit of more than 10% compared with the contralateral site was considered abnormal. Reinjuries within 2 months were recorded.

Results

52 players had a complete set of isokinetic testing before clinical discharge. There were 27 (52%) grade 1 and 25 (48%) grade 2 injuries. 35 of 52 players (67%) had at least one of the three hamstring-related isokinetic parameters that display a deficit of more than 10%. The percentage of players with 10% deficit for hamstring concentric 60°/s, 300°/s and hamstring eccentric was respectively 39%, 29% and 28%. There was no significant difference of mean isokinetic peak torques and 10% isokinetic deficits in players without reinjury (N=46) compared with players with reinjury (N=6).

Conclusions

When compared with the uninjured leg, 67% of the clinically recovered hamstring injuries showed at least one hamstring isokinetic testing deficit of more than 10%. Normalisation of isokinetic strength seems not to be a necessary result of the successful completion of a football-specific rehabilitation programme. The possible association between isokinetic strength deficit and increased reinjury risk remains unknown.

Different injury pattern in goalkeepers compared to field players: a three-year epidemiological study of professional football

OBJECTIVES

Goalkeepers have a specific physiological and biomechanical profile including hip loading with increased frontal plane kinetics and explosive side jumps. The aim of this study is to analyze the injury incidence in professional goalkeepers and to compare this with field players.

DESIGN

Descriptive Epidemiology Study.

METHODS

Prospective (3 seasons, 2008-2011) registration of injuries and exposure of first division professional footballers of Qatar.

RESULTS

Of the 527 players, 49 were goalkeepers. Sixty-seven injuries occurred during 17.858 h of exposure. Goalkeepers had a lower total (p=0.01) and training (p=0.007) injury incidence than field players, while there was no injury difference during matches (p=0.279). Moreover, goalkeepers presented a lower incidence of injuries that were: non contact (p=0.002), traumatic (p<0.001), strains (p<0.001), thigh (p<0.001), and hamstring (p=0.038). Adductor strains were the most common subtype of injury for goalkeepers and this incidence was higher in goalkeepers than in field players (p=0.045). In goalkeepers, mean lay off time for adductor strains was 2.5 times longer than for hamstring strains. More than one third of the overuse injuries were hip and groin injuries. While the overall and lower body injury incidence in goalkeepers was lesser than in field players, upper body incidence was higher.

CONCLUSIONS

Football goalkeepers have a peculiar injury epidemiology, possibly due to their specific physiological and biomechanical performance requirements. Goalkeepers are prone to acute adductor and overuse hip and groin injuries, while muscle strains, in particular located in the hamstrings, are lower compared with field players. Specific prevention program should be implemented in this category of footballers.

How injuries affect rehabilitation workload in a National Team during an elite soccer event? An experience from the FIFA 2010 World Cup

AIM

Many epidemiological studies have been performed in soccer but none of them investigated the incidence of injury in association with the utilization of clinical and rehabilitation services of the medical team. This study aims to examine such correlation in a National football team during the recent 2010 World Cup.

METHODS

All injuries occurred to the Algerian National Team players during the pre competition stage and the World Cup were recorded, together with the exposure. Moreover, duration and frequency of each consultation performed by doctors, physiotherapists, masseurs and pitch rehabilitator was recorded.

RESULTS

Incidence of injuries was 7.54 per 1000h exposure and six players were injured at the beginning of the stage but all players were available for official matches. Difference in the duration of rehabilitation sessions on the field is present among the players who joined the camp already injured and the players who were not injured at the commencement of the camp (8.83±10.63 vs. 2.00±4.46 hours, P<0.05) while there was no difference in rehabilitation between players that occurred in an injury during after the beginning of the camp and uninjured players.

CONCLUSION

A medical team composed of two physicians, four physiotherapists, one pitch rehabilitator and two masseurs facilitated us to reasonably distribute this workload with good rehabilitation outcomes based on players' availability during competition. Moreover, the skills of a pitch rehabilitator appear to be useful, most evidently when starting the camp with previously injured athletes. Conversely, injuries occurring during the tournament didn't affect rehabilitation workload significantly.

Use of platelet rich plasma in an isolated complete medial collateral ligament lesion in a professional football (soccer) player: a case report

Purpose

Platelet-rich plasma (PRP) is derived from centrifuging whole blood to obtain a high platelet concentration containing numerous growth factors. Despite its widespread use, there is still a lack of high-level evidence regarding randomized clinical trials assessing the efficacy of PRP in treating ligament injuries. Although there is research showing an improvement in the early stages of healing in the animal model of acute medial collateral ligament (MCL) injury of the knee, there is no strong evidence to support the efficacy of PRP injections for treating MCL lesions in humans.

Case Report

In this report, we present a case of an elite football player, treated with multiple PRP local injections followed by rehabilitation, for a high grade MCL lesion of the knee. He was able to resume training at day 18, painfree, with full range of motion and the ability to complete a functional test based on all sport specific movements. He played matches at 25 days with no residual symptoms or functional deficit. There were no further complaints or recurrences at the 16 months follow up.

Conclusions

On the basis of this report, we can assume that the treatment of high grade acute MCL lesions of the knee with PRP is a promising therapeutic option to be further explored with good quality Randomized Controlled Trials (RCTs).

Low injury rate strongly correlates with team success in Qatari professional football

Background

Although the incidence of football injuries should relate to team success there is little empirical evidence.

Objective

We investigated the relationship between injury incidence and team success in Qatar first-division football clubs.

Methods

Using a prospective cohort study design, we captured exposure and injuries in Qatar male elite football for a season. Club performance was measured by total league points, ranking, goal scored, goals conceded and number of matches won, drawn or lost.

Results

Lower injury incidence was strongly correlated with team ranking position (r=0.929, p=0.003), more games won (r=0.883, p=0.008), more goals scored (r=0.893, p=0.007), greater goal difference (r=0.821, p=0.003) and total points (r=0.929, p=0.003).

Conclusions

Lower incidence rate was strongly correlated with team success. Prevention of injuries may contribute to team success.

Platelet enriched plasma for acute muscle injury

Hamstring muscle strains are among the most common injuries in sport, but despite increasing research into the epidemiology, aetiology and management the rates of both injury and re-injury remain high. Typically, hamstring injury management is conservative, but recently the use of autologous platelet enriched plasma (PEP), has been proposed as a treatment tool which may optimise muscle regeneration and enhance clinical outcomes. Unfortunately however, there remains little scientific evidence for the clinical use of these techniques in muscle injuries. This report outlines the current clinical evidence for the use of PEP in muscle injuries. A case report of a patient with a grade II semi-membranosus muscle strain, injected with PEP while concurrently using platelet inhibitors will illustrate the clinical, radiological and theoretical challenges of this new technique. Further clinical research into the clinical utility of PEP in muscle injury is required and it is incumbent on Sports Physicians and researchers to address this research deficit, if PEP is to live up to its high public profile.