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.

Indirect Rectus Femoris Injury Mechanisms in Professional Soccer Players: Video Analysis and Magnetic Resonance Imaging Findings

OBJECTIVE

To describe injury mechanisms and magnetic resonance imaging (MRI) findings in acute rectus femoris (RF) injuries of soccer players using a systematic video analysis.

DESIGN

Descriptive case series study of consecutive RF injuries from November 2017 to July 2022.

SETTING

Two specialized sports medicine hospitals.

PARTICIPANTS

Professional male soccer players aged between 18 and 40 years, referred for injury assessment within 7 days after a RF injury, with an available video footage of the injury and a positive finding on an MRI.

INDEPENDENT VARIABLES

Rectus femoris injury mechanisms (specific scoring based on standardized models) in relation to RF muscle injury MRI findings.

MAIN OUTCOME MEASURES

Rectus femoris injury mechanism (playing situation, player/opponent behavior, movement, and biomechanics), location of injury in MRI.

RESULTS

Twenty videos of RF injuries in 19 professional male soccer players were analyzed. Three different injury mechanisms were seen: kicking (80%), sprinting (10%), and change of direction (10%). Isolated single-tendon injuries were found in 60% of the injuries. Of the kicking injuries, 62.5% included complete tendon ruptures, whereas both running injuries and none of the change of direction injuries were complete ruptures. The direct tendon was involved in 33% of the isolated injuries, and the common tendon was affected in all combined injuries.

CONCLUSIONS

Rectus femoris injuries typically occur during kicking among football players. Most of the RF injuries involve a complete rupture of at least one tendon. Kicking injuries can also affect the supporting leg, and sprinting can cause a complete tendon rupture, whereas change of direction seems not to lead to complete ruptures.

Mechanisms of Hamstring Injury in Professional Soccer Players: Video Analysis and Magnetic Resonance Imaging Findings

OBJECTIVE

To describe the injury mechanisms and magnetic resonance imaging (MRI) findings in acute hamstring injuries of male soccer players using a systematic video analysis.

DESIGN

Descriptive case series study of consecutive acute hamstring injuries from September 2017 to January 2022.

SETTING

Two specialized sports medicine hospitals.

PARTICIPANTS

Professional male soccer players aged between 18 and 40 years, referred for injury assessment within 7 days after an acute hamstring injury, with an available video footage of the injury and positive finding on MRI.

INDEPENDENT VARIABLES

Hamstring injury mechanisms (specific scoring based on standardized models) in relation to hamstring muscle injury MRI findings.

MAIN OUTCOME MEASURES

Hamstring injury mechanism (playing situation, player/opponent behavior, movement, and biomechanical body positions) and MRI injury location.

RESULTS

Fourteen videos of acute hamstring injuries in 13 professional male soccer players were analyzed. Three different injury mechanisms were seen: mixed-type (both sprint-related and stretch-related, 43%), stretch-type (36%), and sprint-type (21%). Most common actions during injury moments were change of direction (29%), kicking (29%), and running (21%). Most injuries occurred at high or very high horizontal speed (71%) and affected isolated proximal biceps femoris (BF) (36%). Most frequent body positions at defined injury moments were neutral trunk (43%), hip flexion 45-90 degrees (57%), and knee flexion <45 degrees (93%). Magnetic resonance imaging findings showed that 79% were isolated single-tendon injuries.

CONCLUSIONS

According to a video analysis, most hamstring injuries in soccer occur during high-speed movements. Physicians should suspect proximal and isolated single-tendon-most often BF-hamstring injury, if represented injury mechanisms are seen during game play. In addition to sprinting and stretching, also mixed-type injury mechanisms occur.

Are Football Players More Prone to Muscle Injury after COVID-19 Infection? The "Italian Injury Study" during the Serie a Championship

INTRODUCTION

Football was the first sport to resume competitions after the coronavirus disease 2019 (COVID-19) lockdown and promptly the hypothesis was raised of a potential relationship between the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and musculoskeletal injuries in athletes. This study aimed to confirm the association between SARS-CoV-2 infection and muscle strain injury in a large population of elite football players and to investigate if the COVID-19 severity level could affect the risk of injury.

METHODS

A retrospective cohort study involving 15 Italian professional male football teams was performed during the Italian Serie A 2020-2021 season. Injuries and SARS-CoV-2 positivity data were collected by team doctors through an online database.

RESULTS

Of the 433 included players, we observed 173 SARS-CoV-2 infections and 332 indirect muscle strains. COVID-19 episodes mostly belonged to severity level I and II. The injury risk significantly increased after a COVID-19 event, by 36% (HR = 1.36, CI_95% 1.05; 1.77, p-value = 0.02). The injury burden demonstrated an 86% increase (ratio = 1.86, CI_95% 1.21; 2.86, p-value = 0.005) in the COVID-19 severity level II/III versus players without a previous SARS-CoV-2 infection, while level I (asymptomatic) patients showed a similar average burden (ratio = 0.92, CI_95% 0.54; 1.58, p-value = 0.77). A significantly higher proportion of muscle-tendon junction injuries (40.6% vs. 27.1%, difference = 13.5%, CI_95% 0.002%; 26.9%, p-value = 0.047) was found when comparing level II/III versus Non-COVID-19.

CONCLUSIONS

This study confirms the correlation between SARS-CoV-2 infection and indirect muscle injuries and highlights how the severity of the infection would represent an additional risk factor.

Fecal microbiota monitoring in elite soccer players along the 2019-2020 competitive season

Physical exercise affects the human gut microbiota that, in turn, influences athletes' performance. The current understanding of how the microbiota of professional athletes changes along with different phases of training is sparse. We aim to characterize the fecal microbiota in elite soccer players along with different phases of a competitive season using 16S rRNA gene sequencing. Fecal samples were collected after the summer off-season period, the pre-season retreat, the first half of the competitive season, and the 8 weeks COVID-19 lockdown that interrupted the season 2019-2020. According to our results, the gut microbiota of professional athletes changes along with the phases of the season, characterized by different training, diet, nutritional surveillance, and environment sharing. Pre-season retreat, during which nutritional surveillance and exercise intensity were at their peak, caused a decrease in bacterial groups related to unhealthy lifestyle and an increase in health-promoting symbionts. The competitive season and forced interruption affected other features of the athletes' microbiota, i.e. bacterial groups that respond to dietary fibers load and stress levels. Our longitudinal study, focusing on one of the most followed sports worldwide, provides baseline data for future comparisons and microbiome-targeting interventions aimed at developing personalized training and nutrition plans for performances maximization.

Regional Bioelectrical Phase Angle Is More Informative than Whole-Body Phase Angle for Monitoring Neuromuscular Performance: A Pilot Study in Elite Young Soccer Players

Background: The objective of this study was to investigate the association between regional and total phase angle (PhA) with lower-body neuromuscular performance in young elite soccer players. Methods: Sixteen elite male soccer players (14.3 ± 1.0 years) participated in this study. Lower (LPhA)- and upper (UPhA)-hemisome PhA together with whole-body PhA (WBPhA) were measured by a bioelectrical-impedance analysis (BIA), while appendicular arm and leg lean soft tissue (ALST and LLST, respectively) were estimated. Urine osmolarity (UOsm) and urine-specific gravity (USG) were also considered. Sprints over 10 m and 20 m and countermovement jump (CMJ) tests were employed to evaluate neuromuscular performance. Results: LPhA (p = 0.003) and UOsm (p = 0.012) explained 62% of the variance in the 10 m sprint. UOsm (p = 0.001) and both LPhA (p < 0.001) and WBPhA (p = 0.024) explained 81% of the total variance in the 20 m sprint. The CMJ height was affected by LPhA (p < 0.001) and UOsm (p = 0.024), which overall explained 68% of its variance (p < 0.05), while 93% of the CMJ power variance was explained by LPhA (p < 0.001), ALST (p < 0.001), and WBPhA (p = 0.011). Conclusions: Regional PhA is a relevant and non-invasive tool to monitor lower-body neuromuscular performance in elite youth soccer. Specifically, LPhA may be favored over WBPhA as more informative.

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.

Effects of the COVID-19 Lockdown on Body Composition and Bioelectrical Phase Angle in Serie A Soccer Players: A Comparison of Two Consecutive Seasons

Simple Summary

In 2020, the first Italian soccer league (Serie A) was canceled due to the COVID-19 pandemic. Consequently, a detraining process was triggered in soccer players, leading coaches and sports scientists to implement alternative training strategies to prevent a remodeling in body composition. This study tested the hypothesis that male elite soccer players, when confined to their home during the coronavirus disease 2019 pandemic, will display unfavorable trends in bioelectrical and body composition parameters. The results of the present study showed that reduction in phase angle and muscle mass occurred in soccer players during the coronavirus disease 2019 pandemic lockdown. Recognizing these adverse effects of a detraining period is critical in avoiding adverse effects on body composition in soccer players. In addition, the bioelectrical phase angle has been identified as a valid predictor of muscle mass changes during the competitive soccer season. Considerably, the phase angle represents a parameter that can be measured directly through bioelectrical impedance analysis, and it is independent of predictive equations such as those that quantify muscle mass.

Abstract

The present study compared changes in body composition during the COVID-19-associated lockdown with the same period of the following season in elite soccer players. Fifteen elite male soccer players (30.5 ± 3.6 years.) underwent a bioelectrical impedance analysis (BIA) before (end of February) and after (end of May) the lockdown, which occurred during the 2019/2020 season, and at the same period during the following competitive season in 2020/2021, when restrictions were lifted. Fat and muscle mass were estimated using predictive equations, while phase angle (PhA) and bioelectrical impedance vector analysis (BIVA) patterns were directly measured. After lockdown, fat mass remained unchanged (p > 0.05), while muscle mass (95%CI = −1.12/−0.64; ES = −2.04) and PhA (95%CI = 0.51/−0.24, ES = −1.56) decreased. A rightward displacement of the BIVA vector was also found (p < 0.001, ES = 1.50). After the same period during the regular season, FM% and muscle mass did not change (p > 0.05), while the PhA increased (95%CI = 0.01/0.22; ES = 0.63). A leftward vector displacement (p < 0.001, ES = 1.05) was also observed. The changes in muscle mass correlated with changes in PhA (“lockdown” season 2019/2020: ß = −1.128, p = 0.011; “regular” season 2020/21: ß = 1.963, p = 0.011). In conclusion, coaches and strength conditioners should monitor muscle mass in soccer players during detraining periods as this parameter appears to be mainly affected by changes in training plans.

MPFL reconstruction and tibial tuberosity transposition in patients with patellar instability: May it troubleshots also trochlear dysplasia?

Purpose

This study aimed to highlight short- and medium-term outcomes of combined medial patello-femoral ligament (MPFL) reconstruction and anterior tibial tuberosity (ATT) transposition surgery in patients with recurrent patellar instability and different degrees of trochlear dysplasia.

Methods

Between January 2014 and May 2019, 25 patients with patellar instability underwent a surgical procedure combining the lowering/transposition of the ATT and the MPFL reconstruction. Each patient were preoperative assessed by Kujala score, International Knee Documentation Committee (IKDC), Tegner activity level scale. The assessment of instability predisposing factors was carried out with patellar height, tibial tuberosity-trochlear groove (TT-TG) distance, trochlear dysplasia, sulcus angle, patellar tilt and MPFL injuries. Functional outcomes were evaluated with Kujala, IKDC and Tegner scores at 3, 6 and 12 months after surgery.

Results

The average age of the patients was 20 years (range 13–43 years). Pre- operative Caton–Deschamps index was pathological in 10 (40%). Sulcus angle was elevated in 13 patients (52%) and TT-TG distance was irregular in 17 patients (68%). Trochlear dysplasia was present in 13 patients (9 type A, 3 type B, 1 type C according to Dejour’s Classification). No re-dislocation occurred during the follow-up. There was a significant increase in the Kujala, IKDC and Lysholm scores after 3, 6 and 12 months, and the results were compared for the different follow-up times and patient’s trochlear dysplasia degree.

Conclusion

This prospective observational longitudinal study identified good clinical outcomes in patients who underwent MPFL reconstruction and ATT transposition for patellar instability. Finally, the different risk factors for patellar instability examined, particularly the presence of trochlear dysplasia, did not significantly influence the final functional results, which range from good to excellent without re-dislocation episodes.

Association of phase angle and appendicular upper and lower body lean soft tissue with physical performance in young elite soccer players: a pilot study

BACKGROUND

In soccer, a better understanding of the bioimpedance parameters with physical performance may be useful to efficiently monitor and interpret players' performance variation throughout a certain period of the season. Therefore, this study aimed to examine the association between phase angle (PhA) and arms and legs lean soft tissue (ALST and LLST) with physical performance in young elite soccer players.

METHODS

Fifteen young male elite soccer players (age = 14.2±1.2 years, BMI = 20.51±1.38 kg/m2) participated in this investigation. Raw bioimpedance parameters (reactance, resistance, and phase angle) were obtained by a bioelectrical impedance analysis (BIA) device. Then, ALST and LLST were estimated. All players underwent a physical testing battery including countermovement jump (CMJ), 10-m and 20-m sprint, and Yo-Yo Intermittent Recovery Test level 1 (YoYo IRTL1) in the domains of anaerobic and aerobic performance, respectively.

RESULTS

The results showed that LST (total, arms and legs) positively correlated with CMJ (0.64 < r < 0.69; p < 0.001) and negatively correlated with 10-m (-0.59 < r < -0.63; p < 0.05) and 20-m sprint (-0.67 < r < -0.73; p < 0.001), while PhA positively correlated with CMJ (r = 0.57; p < 0.05) and negatively correlated (r = -0.54; p < 0.05) only with 20-m sprint. No significant association was found between the BIA-related parameters (PhA and LST) and Yo- Yo IRT level 1.

CONCLUSIONS

The present findings highlight the existing association of PhA and LST with jumping and sprinting performance in young elite soccer players. This result supports the use of BIA-related measures as a simple and practical approach to monitoring anaerobic performance changes, rather than aerobic, over time throughout the season.

Relationship of regional and whole body morphology to vertical jump in elite soccer players: a data-driven approach

BACKGROUND

This study aimed to analyse the relationship of regional and whole body morphology to vertical jump performance and to compare the morphological features outlining high and low performers in professional soccer players.

METHODS

Twenty-one male soccer players were recruited. Whole and regional (upper and lower limbs) features were obtained in the form of body dimensional measurements. Then, all players were tested for vertical jump performance. A data-driven approach was used to group players according to their jump performance parameters (high vs low).

RESULTS

The regional morphological features presented higher correlations with vertical jump than whole body features. High and low performers were significantly different among upperand lower-limb morphology. No differences were observed among whole body features.

CONCLUSIONS

These findings indicate that, rather than the whole body, the use of morphological features linked to specific body regions may ensure a better interpretation of the soccer players' physical potential in jump performance.

A New Strategy to Integrate Heath-Carter Somatotype Assessment with Bioelectrical Impedance Analysis in Elite Soccer Player

Easy-to-apply and quick methods for evaluate body composition are often preferred when assessing soccer teams. This study aimed to develop new equations for the somatotype quantification that would reduce the anthropometric measurements required by the Heath and Carter method, integrating the somatotype assessment to the bioelectrical impedance analysis (BIA). One hundred and seventy-six male elite soccer players (age 26.9 ± 4.5 years), registered in the Italian first division (Serie A), underwent anthropometric measurements and BIA. Endomorphy, mesomorphy, and ectomorphy were obtained according to the Heath and Carter method, while fat mass (FM) and fat free mass (FFM) estimated using a BIA-derived equation specific for athletes. The participants were randomly split into development (n = 117) and validation groups (n = 59, 1/3 of sample). The developed models including resistance2/stature, FM%, FFM, contracted arm and calf circumference, triceps, and supraspinal skinfolds had high predictive ability for endomorphy (R2 = 0.83, Standard Error of Estimate (SEE) = 0.16) mesomorphy (R2 = 0.80, SEE = 0.36), and ectomorphy (endomorphy (R2 = 0.87, SEE = 0.22). Cross validation revealed R2 of 0.80, 0.84, 0.87 for endomorphy, mesomorphy, and ectomorphy, respectively. The proposed strategy allows the integration of somatotype assessment to BIA in soccer players, reducing the number of instruments and measurements required by the Heath and Carter approach.

Importance of anthropometric features to predict physical performance in elite youth soccer: a machine learning approach

The present study aimed to determine the contribution of soccer players' anthropometric features to predict their physical performance. Sixteen players, from a professional youth soccer academy, were recruited. Several anthropometric features such as corrected arm muscle area (AMA_corr), arm muscle circumference (AMC) and right and left suprapatellar girths (RSPG and LSPG) were employed in this study. Players' physical performance was assessed by the change of direction (COD), sprint (10-m and 20-m), and vertical jump (CMJ) tests, and Yo-Yo Intermittent Recovery Test level 1 (Yo-Yo IRT1). Using an extra tree regression (ETR) model, the anthropometric features permitted to accurately predict 10-m sprint, 20-m sprint and Yo-Yo IRTL 1 performance (p < 0.05). ETR showed that upper-body features as AMA_corr, and AMC affected 10-m and 20-m sprint performances, while lower-body features as RSPG and LSPG influenced the Yo-Yo IRTL 1 (Overall Gini importance ≥ 0.22). The model predicting COD and CMJ presented a poor level of prediction, suggesting that other factors, rather than anthropometric features, may concur to predict their changes in performance. These findings demonstrated that the upper- and lower-body anthropometric features are strictly related to sprint and aerobic fitness performance in elite youth soccer.

The role of six biomarkers in diagnosis of hemophilic arthropathy: review of the literature

The aim of our narrative review of the literature is to identify the role of six important biomarkers: synovial fluid thrombomodulin, fibroblast-like synoviocytes, synovial tissue growth factor , vascular endothelial growth factor in synovium and peripheral blood, urinary C-terminal telopeptide of type II collagen, and synovial fluid tumor necrosis factor alpha. These urinary, serum and synovial biomarkers illustrated should be evaluated in patients with hemophilic arthropathy for early diagnosis of hemophilic arthropathy, because they have important implications in the development of arthrofibrosis, altered inflammatory response and bleeding. Moreover, better knowledge of their biological activity is important to identify possible new biological treatment options.

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.

The biomolecular interactions between endothelium and bone cells: an overview

Bone turnover is a complex set of different molecules pathways and it is strictly connected with bone vasculature. It includes every bone process concerning bone modelling and remodelling such us skeletal growth and healing process. A fundamental component of this bone architecture is played by the endothelium, that acts in a paracrine fashion on other bone stromal cells via humoral factors, growth factors and chemokines/cytokines. The alteration of those biochemical interactions between endothelium, vasculature and bone tissue may cause various pathological manifestations. Understanding the bases of the interaction between those different pathways could provide novel therapeutic strate¬gies for bone disease. The Authors present an updated overview of the most common communication biomolecules between bone cells and endothelium and their interactions both in healthy and pathological conditions. Furthermore, focusing on gene and related therapies, possible future therapeutic strategies for bone vasculature/metabolic diseases are presented.

Primary total knee replacement in hemophiliacs: experience of a single institution over fourteen years of surgical procedures

This retrospective study reports clinical and functional orthopedic outcomes and complications after 14 primary total knee replacement (TKR) performed between 2000 and 2014. The mean age at surgery was 42 years (range 26-59), with a removal-free survival of 100% at the end of follow-up (months 109.85). The KSS score was 49.64 pre-operatively (range 31-63) and 78.14 at final follow-up (range 45-90), the KSS function score was 64.64 pre-operatively (range 35-80) and 84.57 at final follow-up (range 45-100). According to this study, there are three main factors that can influence long-term and early surgical outcomes: post-operative fibrosis, a previous synovectomy and presence of inhibitors. Even if our results are slightly suboptimal compared to those obtained in non-hemophilic patients, this study shows that TKR is an effective surgical procedure in hemophiliacs.

Radiosynoviorthesis in children with haemophilia

Recurrent bleeding into joints represents the clinical hallmark of haemophilia and, if not adequately treated, it may cause chronic synovitis and degenerative arthropathy. The first treatment option of recurrent haemarthroses and/or chronic synovitis is represented by synoviorthesis, both chemical and radioisotopic, with a success rate of approximately 80% for both. However, radioisotopic synoviorthesis should be preferred because it makes it possible to obtain complete synovial fibrosis usually in one session, without the need for repeated injections, thus reducing the risk of bleeding complications and concentrate consumption. For all these reasons this procedure should be implemented and supported, particularly in developing countries.

Perivascular Adductor Longus muscle injury: Ultrasound and Magnetic Resonance Imaging findings

Background

Muscle injuries affecting the Adductor Longus are not all localised at the level of the proximal myotendinous junction and enthesis. Thus, the main purpose of this article was to raise awareness of the imaging features of the Perivascular Adductor Longus muscle injury, which currently remains widely under-recognised.

Methods

The ultrasound (US) and Magnetic Resonance imaging (MRI) images of five professional football players were retrospectively reassessed to identify distinctive imaging details of the Perivascular Adductor Longus muscle injury. Complementary information regarding the traumatic mechanics is presented as well.

Results

All the players presented similar US images in the first seventy-two hours: loss of ecostructural integrity of the lateral epimysium, in proximity to the femoral vessels, and perilesional oedema were the main pathological findings. The injury lead to the formation of a hypoechoic, intramuscular haematoma in three of the subjects. Anyway, this was detectable only after five days, or later. Moreover, MRI sequences showed long-standing haematoma-related signal alterations which were also observable at three months after trauma. Typically, kicking was the traumatic motor task.

Conclusions

The main practical value of this technical note is to compensate for the lack of studies concerning the Perivascular Adductor Longus muscle injury. Promptly identifying its typical imaging features is crucial in order to establish the correct diagnosis and to implement a highly specific rehabilitative program.

Level of evidence

V.

Achievements, challenges and unmet needs for haemophilia patients with inhibitors: Report from a symposium in Paris, France on 20 November 2014

Over the past 20 years, there have been many advances in haemophilia treatment that have allowed patients to take greater control of their disease. However, the development of factor VIII (FVIII) inhibitors is the greatest complication of the disease and a challenge in the treatment of haemophilia making management of bleeding episodes difficult and surgical procedures very challenging. A meeting to discuss the unmet needs of haemophilia patients with inhibitors was held in Paris on 20 November 2014. Topics discussed were genetic and non-genetic risk factors for the development of inhibitors, immunological aspects of inhibitor development, FVIII products and inhibitor development, generation and functional properties of engineered antigen-specific T regulatory cells, suppression of immune responses to FVIII, prophylaxis in haemophilia patients with inhibitors, epitope mapping of FVIII inhibitors, current controversies in immune tolerance induction therapy, surgery in haemophilia patients with inhibitors and future perspectives for the treatment of haemophilia patients with inhibitors. A summary of the key points discussed is presented in this paper.

ISMuLT Guidelines for muscle injuries

Muscle injuries are frequent in high demand sports. No guidelines are available in the scientific literature. ISMuLT, the "Italian Society of Muscles, Ligaments and Tendons", in line with its multidisciplinary mission, is proud to cover this gap.

Sonography of the quadriceps muscle: Examination technique, normal anatomy, and traumatic lesions

Lesions of the quadriceps muscle (QM) are frequently seen by sonographers, and in most cases they are the result of sports-related trauma. An accurate assessment of the severity of the lesion is essential, particularly when the patient is a professional athlete. In most cases, careful history-taking and a thorough physical examination are sufficient for making the diagnosis and indicating the most suitable imaging studies for each case. Clinical assessment alone, however, may not be sufficient for distinguishing contusions from small, partial tears or for estimating the size of a tear. Therefore, at least in patients who are professional athletes, imaging studies are necessary to plan appropriate therapy that will allow prompt functional recovery. Muscles cannot be visualized with conventional radiography, but it is used routinely in prepubertal patients because it can detect apophyseal detachments, which are the most frequent muscle lesion in this age group. Radiography is also useful when myositis ossificans is suspected. Magnetic resonance imaging, thanks to its excellent tissue contrast, allows simultaneous assessment of muscle, joint, and bone planes. It remains a second-line study due to its high cost and relatively low availability. It is also associated with various contraindications, the most important of which is the presence of a cardiac pacemaker. Ultrasonography has a number of advantages, including widespread availability, absence of contraindications, and low cost. It can also be used for dynamic studies of the muscle during contraction and relaxation, and if doubts arise, scans can easily be obtained of the contralateral muscle for comparison purposes. These qualities make it an excellent tool for follow-up of patients with QM lesions, when follow-up is necessary. This article reviews the anatomy of the QM, the technique used for standard ultrasound examination of this muscle, its normal appearance on ultrasound, and the sonographic characteristics of the most common traumatic lesions that affect it.

Radiosynoviorthesis in children with haemophilia

Recurrent bleeding into joints represents the clinical hallmark of haemophilia and, if not adequately treated, it may cause chronic synovitis and degenerative arthropathy. The first treatment option of recurrent haemarthroses and/or chronic synovitis is represented by synoviorthesis, both chemical and radioisotopic, with a success rate of approximately 80% for both. However, radioisotopic synoviorthesis should be preferred because it makes it possible to obtain complete synovial fibrosis usually in one session, without the need for repeated injections, thus reducing the risk of bleeding complications and concentrate consumption. For all these reasons this procedure should be implemented and supported, particularly in developing countries.

Synoviorthesis in haemophilia patients with inhibitors

Recurrent bleeding into joints represents the clinical hallmark of haemophilia and, if not adequately treated, it may cause chronic synovitis and degenerative arthropathy. In haemophilia patients with inhibitors, a more severe degree of synovitis is often observed owing to the fact that treatment is more problematic in this setting. The first treatment option of recurrent haemarthroses and/or chronic synovitis is represented by synoviorthesis, both chemical and radioisotopic, with a success rate of approximately 80% for both. However, radioisotopic synoviorthesis should be preferred in inhibitor patients because it makes it possible to obtain complete synovial fibrosis usually in one session, without the need for repeated injections, thus reducing the risk of bleeding complications and concentrate consumption. For all these reasons this procedure should be implemented and supported, particularly in developing countries.

Orthopaedic management of haemophilia arthropathy of the ankle

Joint bleeding, or haemarthrosis, is the most common type of bleeding episode experienced by individuals with haemophilia A and B. This leads to changes within the joints, including synovial proliferation, which results in further bleeding and chronic synovitis. Blood in the joint can also directly damage the cartilage, and with repeated bleeding, there is progressive destruction of both cartilage and bone. The end result is known as haemophilic arthropathy. The joints most commonly affected are the knees, elbows and ankles, although any synovial joint may be involved. In the ankle, both the tibiotalar and subtalar joints may be affected and joint bleeding and arthropathy can lead to a number of deformities. Haemophilic arthropathy can be prevented through regular factor replacement prophylaxis and implementing physiotherapy. However, when necessary, there are multiple surgical and non-surgical options available. In early ankle arthropathy with absent or minimal joint changes, both radioisotopic and chemical synoviorthesis can be used to reduce the hypertrophied synovium. These procedures can decrease the frequency of bleeding episodes, minimizing the risk of articular cartilage damage. Achilles tendon lengthening can be performed, in isolation or in combination with other surgical measures, to correct Achilles tendon contractures. Both arthroscopic and open synovectomies are available as a means to remove the friable villous layer of the synovium and are often indicated when bleeding episodes cannot be properly controlled by factor replacement therapy or synoviorthesis. In the later stages of ankle arthropathy, other surgical options may be considered. Debridement may be indicated when there are loose pieces of cartilage or anterior osteophytes, and can help to improve the joint function, even in the presence of articular cartilage damage. Supramalleolar tibial osteotomy may be indicated in patients with a valgus deformity of the hindfoot without degenerative radiographic findings. Joint fusion, or arthrodesis, is the treatment of choice in the advanced stages of ankle arthropathy although total ankle replacement is currently available. Early ankle replacement components were associated with a poor outcome, but as implant designs have improved, there have been successful outcomes achieved. As the ankle is a commonly affected joint in many individuals with haemophilia, it is important to add to the knowledge base to validate indications and timing of surgical and non-surgical interventions in ankle arthropathy.

Total joint replacement in patients with inhibitors

Today, total joint replacement is the treatment of choice for chronic haemophilic arthropathy of the knee and hip in developed and developing countries. After the last World Haemophilia Congress and Musculoskeletal Congress, we cannot say the same for haemophilic patients with inhibitors because elective surgery today is still limited to few centres and extremely few patients. This is because until the first half of the 1990s, performing surgery in haemophilic patients with inhibitors was associated with a high risk of bleeding. With the availability of activated recombinant factor VII, the first surgical procedures were performed, but they still remain limited because of the elevated costs of replacement therapy. Our goal for the future must be to ensure the same possibility of surgical intervention in haemophilic patients both with and without inhibitors. This will be possible, thanks to the experience of some centres with an increased number of patients, where today this kind of surgery is routinely performed.