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.

Arthroscopic transtendon repair of partial articular-sided supraspinatus tendon avulsion

PURPOSE

To evaluate the outcomes of arthroscopic transtendon repair of partial articular-sided supraspinatus tendon avulsion (PASTA) in a large study group.

METHODS

A retrospective review of prospectively collected data was conducted. One hundred and eighteen patients with PASTA lesion (grade A2-A3) who underwent arthroscopic transtendon repair were identified, of which 110 were eligible for the study. Ten patients were lost at final follow-up leaving a study group of 100 patients (52 male, 48 female). The average follow-up was 37 months (minimum 24 months, range 24-50, median 40). Mean age at the time of surgery was 50.4 (range 17-71, median 45). Patients were assessed before surgery and at 24-month follow-up, using the Simple Shoulder Test (SST), UCLA shoulder rating scale and the visual analogue scale (VAS). ROM was measured bilaterally and was evaluated before surgery, at 3-, 6- and 24-month follow-up. The satisfaction rate was calculated. Data were analysed using a paired Student's t test with 95 % confidence interval (significance p < 0.05).

RESULTS

Significant improvement in UCLA, SST and VAS score was observed. Fifty-four cases were rated excellent, 42 good, 2 fair, 2 poor according to the UCLA score. No significant differences in ROM were noted compared to the contra-lateral side (p < 0.001) at the 24-month follow-up. Eighteen patients presented with a stiff shoulder at the 3-month follow-up, but they recovered full ROM by the 6-month follow-up evaluation.

CONCLUSIONS

The arthroscopic transtendon repair of partial articular-sided rotator cuff tears is an effective procedure that leads to significant improvement in pain and shoulder function, with high patients' satisfaction rate, while the complication rate is low. This study demonstrated the effectiveness and safety of this technique in a large homogeneous study group.

LEVEL OF EVIDENCE

IV.

Atypical localizations of calcific deposits in the shoulder

INTRODUCTION

Calcific tendinopathies of the shoulder are due to inflammation around deposits of calcium within periarticular tendineal structures.

PRESENTATION OF CASES

We present three cases of atypical localization of calcium deposits in the shoulder. All of the cases have been treated with arthroscopic excision, followed by post-operative rehabilitation, regaining excellent results. Patients were evaluated 6 months after surgery using the Visual Analogue Scale (VAS), the Simple Shoulder Test (SST) and the UCLA modified shoulder rating.

DISCUSSION

Calcific tendinopathy is a self-limiting condition or is successfully treated with conservative therapy especially during the early phases of the pathology. If conservative measures fail, removal of calcium deposits is recommended. Arthroscopic management showed good results in our three cases.

CONCLUSION

We suggest that arthroscopic treatment of calcific tendonitis guarantees good results even when calcium deposits are in atypical locations.

Neurovascular alterations in chronic hepatitis C: a case-control study

Introduction: Hepatitis C is a major health problem: approximately 170 million people are infected with the hepatitis C virus worldwide. It is unclear whether chronic hepatitis C affects atherosclerosis and whether it can cause endothelial and/or autonomic nervous system (ANS) dysfunction. Materials and methods: From April 2008 through April 2009, we studied 76 patients with biopsyconfirmed chronic hepatitis C and no evidence of cirrhosis, ascites, portal hypertension, encephalopathy, or hepatocellular carcinoma. The age-, sex-, BMI- and cardiovascular risk factor- matched control group comprised 76 healthy, HCV-negative individuals with no evidence of liver, autoimmune, or immunoproliferative diseases and no history of cardiovascular events. Twenty five of the hepatitis C patients were treatment-naive; the other 51 had been treated with interferon (but only 25 had persistent virological responses). Color Doppler sonography was used to measure the intima-media-thickness (IMT) of the common and internal carotid arteries. Endothelial function was assessed in the brachial artery with the flow-mediated-dilatation (FMD) test. The ANS was assessed with the tilt, laying to standing, Valsalva, hand grip, deep breath, and stroop tests. Results: The case group (mean age 52 + 13 years) had a significantly higher internal carotid IMT (0.86 + 0.3 vs 0.67 + 0.1 mmfor controls; p = 0.002). Chronic hepatitis C was also associated with an odds ratio for carotid plaque formation (reflected by an IMT > 1.3 mm) of 2.15. Cases also had significantly reduced FMD in the brachial artery (0.46 + 0.9 vs 0.76 + 0.7 for controls; p = 0.005) and significantly altered sympathetic and parasympathetic function (p = 0.001 vs controls in the Valsalva, hand grip, deep breath, and stroop tests). Within the case group, all alterations were more severe in patients with significant viremia. Discussion: Our findings suggest that chronic hepatitis C may be a nonclassic cardiovascular risk factor since it seems to influence the onset of pre-atherosclerotic lesions and to promote atherosclerotic plaque formation in patients with pre-existing increases in carotid IMT. It also seems to cause dysfunctions of the vascular endothelium and ANS. Conclusions: Chronic hepatitis C may increase cardiovascular risk and promote ANS dysfunctions, particularly when patients have experienced treatment failure and have persistent viremia. These patients may require cardiovascular and neurologic follow-up.

Clinical review of patients subjected to mini-Mumford arthroscopy

PURPOSE

assessment of the clinical efficacy of isolated arthroscopic mini-Mumford surgery, associated with shoulder surgery in patients with degenerative disease of the acromioclavicular joint.

MATERIALS AND METHODS

52 patients (group A) underwent isolated arthroscopic mini-Mumford and 84 (group B) additional arthroscopic surgery of rotator cuff and/or long head of biceps. They were evaluated clinically using Visual Analogue Scale (VAS), Simple Shoulder Test (SST) and Modified UCLA shoulder rating, pre- and post-operatively after a mean period of 18.1 months.

RESULTS

the results obtained in groups A and B overlap.

DISCUSSION

arthroscopic mini-Mumford is a simple, low-risk procedure, which has proved effective in treating degenerative disease of the acromioclavicular joint, both in isolation and in association with reconstruction of the rotator cuff and/or biceps long head tenotomy.

Prospective study of three surgical procedures for long head biceps tendinopathy associated with rotator cuff tears

PURPOSE

simple tenotomy in the treatment of long head biceps (LHB) lesion offers good results, as well as tenotomy/tenodesis.

MATERIALS AND METHODS

we prospectively evaluated 252 patients, divided into 3 groups, treated with rotator cuff repair associated with LHB tenotomy or 2 different types of tenodesis in cases where there had been a partial lesion of the LHB or instability of the bicipital groove. We ascertained whether there was residual pain and the presence of the "Popeye sign" in the post-operative stage.

RESULTS

patients who underwent tenotomy alone achieved an improvement on the Visual Analogue Scale (VAS), Simple Shoulder Test (SST) and modified UCLA shoulder rating compared to patients who underwent LHB tenodesis. A positive Popeye sign is poorly perceived by patients.

CONCLUSION

we considered the LHB tenotomy as treatment of choice for the rotator cuff surgical repair when there was an evident LHB lesion.

Autonomic dysfunction and endothelial changes in migraine sufferers

AIM

The aims of this study were: 1) to quantify endothelial function by flow-mediated dilation (FMD) and atherosclerotic vascular lesions by intima-media thickness (IMT) in migraine sufferers without any of the common atherosclerotic risk factors, comparing them with paired controls; 2) to evaluate their potential autonomic function impairment; and 3) to seek any correlations with vascular modifications.

METHODS

Twenty patients suffering from migraine and 20 matched controls were studied, using echo-color-Doppler imaging to measure IMT in the carotid district and FMD of the brachial artery in the non-dominant arm. Autonomic function was studied using the Tilt, Lying-to-Standing, Valsalva, Hand grip, Deep breath, Stroop and Sweat tests.

RESULTS

Migraine sufferers had lower FMD and higher IMT values than controls. The former also had autonomic changes revealed by the Tilt, Valsalva, Hand Grip, Deep Breath and Stroop tests, which correlated with their reduced FMD.

CONCLUSION

Autonomic dysfunctions modify vascular reactivity in migraine sufferers and this type of change can probably determine endothelial dysfunction and intima-media thickening.

Are Hodgkin and non-Hodgkin patients at a greater risk of atherosclerosis? A follow-up of 3 years

Aims and background are to ascertain whether Hodgkin and non-Hodgkin patients are more affected by atherosclerotic process. We studied 96 patients during a period of 3 years (2003-2007). Patients were assessed in the first year soon after receiving radiotherapy and chemotherapy and then reassessed in the third year. All the cases underwent echo-colour Doppler of the carotid axis, and the intima-media thickness (IMT) was measured. When the two time points were compared, the IMT was greater in the arterial district examined at the first assessment; while at the second there was a reduction in the IMT, so patients seemed to improve with time. Flow-mediated dilatation did not improve. Hodgkin and non-Hodgkin patients experience an increase in IMT during treatment, but afterwards they return in their precedent condition. They seem to have a persistently reduced flow-mediated dilatation. Lymphoma therapy probably predisposes patients to early atherosclerosis, and it would be worth trying to reverse this tendency by administering antioxidant therapy.

Flow-Mediated Arterial Dilation in Primary Antiphospholipid Syndrome

Objective.

To investigate precocious alterations in the artery wall of patients with primary antiphospholipid syndrome (APS). Methods. We evaluated flow-mediated dilation (FMD) of the brachial artery and intima-media thickness (IMT) of carotid arteries in 16 patients and 16 healthy controls matched for age, gender, and other cardiovascular risk factors. Results. FMD of the brachial artery was significantly lower in patients than in controls (6.3 ± 5.2% vs 18.2 ± 2.7; P < .005). IMT was similar in the 2 groups. FMD was significantly reduced in patients with anticardiolipin antibodies IgM. Conclusions. APS correlates closely with precocious atherosclerosis, and the correlation with a type of anticardiolipin antibody may be predictive of more accelerated atherosclerosis.

Carotid and femoral atherosclerosis in chronic hepatitis C: a 5-year follow-up

The objective of this study was to assess the progression of atherosclerosis in carotid and femoral arteries after a 5-year period using ultrasound in subjects with chronic hepatitis C and in controls matched for classic atherosclerotic risk factors. A total of 40 patients and 40 controls were assessed by echocolor Doppler in 2001 and in 2006 to evaluate plaque and intima-media thickness. The patients showed no changes in plaque and intima-media thickness during the 5-year period in all districts examined, whereas a significant increase in intima-media thickness in the carotid sections was recorded in the controls. Chronic hepatitis C seems to cause delay in the atherosclerotic process.

Dementia of the frontal type: neuropsychological and [99Tc]-HM-PAO SPET features

Dementia of the frontal type (DFT) is a degenerative disorder with early behavioral and language disturbances and with relative preservation of memory and visuospatial abilities. On neuropathology, DFT lacks the pathologic hallmarks of Alzheimer's disease (AD). We assessed the neuropsychological and SPET imaging features of 11 DFT and 16 AD patients. The two groups had similar performances on verbal learning, while the former had significantly higher nonverbal learning scores. Testing of verbal and nonverbal instrumental abilities showed that this different behavior could be due to poorer verbal fluency of DFT patients, and not necessarily to poorer learning. Neuropsychological data indicated that the often reported sparing of memory in daily functions of DFT patients can also be shown with formal neuropsychological testing of nonverbal learning. SPET showed a comparatively higher perfusion deficit of frontal regions in the left hemisphere of DFT patients, suggesting that this region might be affected more often in the disease.

Dopamine receptor SPET imaging in Parkinson's disease: a [123I]-IBZM and [99mTc]-HM-PAO study

Single photon emission tomography (SPET) with the novel ligand [123I]-IBZM was used to image central dopamine D2 receptors in Parkinson's disease (PD) patients. The aim was to assess basal ganglia (BG) receptor densities in relation to the response to L-dopa therapy. To better characterize the clinical potential of [123I]-IBZM SPET, each patient underwent a second study with the regional perfusion tracer [99mTc]-HM-PAO. Tracer activity ratios were calculated for caudate and putamen with mean activity over the cerebellar hemispheres as internal standard. In PD patients we found a significant decline of mean caudate [123I]-IBZM activity, as compared with age-matched control subjects. However, when patients were grouped according to their therapeutic behavior, the [123I]-IBZM uptake in BG ganglia regions of the PD patient group with a poor and fluctuating response to L-dopa was significantly reduced from mean values of patients with a sustained response to L-dopa therapy. [99mTc]-HM-PAO caudate and putamen uptake indexes in PD were similar to control values, even in patients with deteriorated therapeutic response. Our results indicate that BG D2 receptor alterations in PD may contribute to the altered response to L-dopa.