Injuries to kickers in American football: the National Football League experience

Correlation of Player and Imaging Characteristics With Severity and Missed Time in National Football League Professional Athletes With Hamstring Strain Injury: A Retrospective Review

BACKGROUND

Hamstring strain injuries (HSIs) are prevalent in US National Football League (NFL) players, but there is a paucity of information regarding imaging characteristics, injury severity, and player factors associated with time missed and risk of recurrent injury.

PURPOSE

To describe player, football activity, clinical, and imaging characteristics of NFL players with HSIs, as well as determine player characteristics, clinical examination results, and magnetic resonance imaging (MRI) findings associated with injury occurrence, severity, and missed time.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A retrospective cohort of NFL players with acute HSI (n = 180) during the 2018-2019 season was identified. Injury data were collected prospectively through a league-wide electronic health record system. Three musculoskeletal radiologists graded MRI muscle injury parameters using the British Athletics Muscle Injury Classification (BAMIC) system. Player, football, clinical, and imaging characteristics were correlated with HSI incidence and severity and with missed time from sport.

RESULTS

Of the 1098 HSIs identified during the 2018-2019 season, 416 (37.9%) were randomly sampled, and 180 (43.3%) had diagnostic imaging available. Game activity, preseason period, and wide receiver and defensive secondary positions disproportionately contributed to HSI. The biceps femoris was the most commonly injured muscle (n = 132, 73.3%), followed by the semimembranosus (n = 24, 13.3%) and semitendinosus (n = 17, 9.4%) muscles. The most common injury site was the distal third of the biceps femoris and semitendinosus muscles (n = 60, 45.5% and n = 10, 58.8%, respectively) and central part of the semimembranosus muscle (n = 17, 70.8%). Nearly half of the injuries (n = 83, 46.1%) were BAMIC grade 2; 25.6% (n = 46), grade 3; and 17.8% (n = 32), grade 4. MRI showed sciatic nerve abnormality in 30.6% (n = 55) of all HSIs and 81.3% (n = 26) of complete tendon injuries. BAMIC grade correlated with both median days and games missed. Combined biceps femoris and semitendinosus injuries resulted in the highest median days missed (27 days).

CONCLUSION

Among NFL players with acute HSIs, the most common injury was a moderate-severity injury of the distal biceps femoris. BAMIC grade was associated with missed time.

Platelet-Poor versus Platelet-Rich Plasma for the Treatment of Muscle Injuries

ABSTRACT

Muscle injury in sport results in significant lost time and potential for reinjury for athletes. Autologous blood product, namely, platelet-rich plasma (PRP), has been investigated for possible augmentation of the treatment timeline with prevention of reinjury; however, conflicting results have been identified. A growing body of basic science and clinical literature is forming that supports the use of platelet-poor plasma (PPP) for muscle injury. The purpose of this study was to provide a background of the basic science of PRP versus PPP for muscle injury and to identify and review the clinical evidence for both autologous blood products, including the author's clinical experience utilizing the blood products. At the tissue level, PRP causes myoblast proliferation while PPP has led to myoblast induction, potentially identifying improved native muscle healing. Conflicting studies have been identified for the use of PRP for muscle injury. A growing body of positive results for PPP was identified, but high-quality comparative studies are needed.

Quadriceps injuries

Injuries to the quadriceps muscle group are common in athletes performing high-speed running and kicking sports. The complex anatomy of the rectus femoris puts it at greatest risk of injury. There is variability in prognosis in the literature, with reinjury rates as high as 67% in the severe graded proximal tear. Studies have highlighted that athletes can reinjure after nonoperative management, and some benefit may be derived from surgical repair to restore function and return to sport (RTS). This injury is potentially career-threatening in the elite-level athlete, and we aim to highlight the key recent literature on interventions to restore strength and function to allow early RTS while reducing the risk of injury recurrence. This article reviews the optimal diagnostic strategies and classification of quadriceps injuries. We highlight the unique anatomy of each injury on MRI and the outcomes of both nonoperative and operative treatment, providing an evidence-based management framework for athletes.

Epidemiology of Injuries in Professional and Amateur Football Men (Part II)

Background (1): Men's football is a physically demanding contact sport that involves intermittent bouts of sprinting, jogging, walking, jumping and changes of direction. The physical demands of the game vary by level of play (amateur club, sub-elite and open club or international), but injury rates at all levels of the men's football game remain the highest of all sports. Objective: The aim of this study is to conduct a systematic review of data from the epidemiological literature regarding the profile, severity and mechanisms of injuries and the frequency of recurrent injuries in professional and amateur football players. Methods (2): A systematic review, according to PRISMA guidelines, was performed up to June 2023 in the databases of PubMed, Web of Science, Google academic, Google scholar and the Diva portal. Twenty-seven studies that reported data on the type, severity, recurrence and mechanisms of injury in professional and amateur men's football were selected and analyzed. Two reviewers independently audited data and assessed the study quality using the additional and adapted version of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement and the Newcastle Ottawa Scale (NOS) to assess risk of bias for the quality of external validity. Results (3): In professional male football players, the mean prevalence of muscle/tendon injuries was 39.78%, followed by joint and ligament injuries-21.13%, contusions-17.86%, and fractures-3.27%, and for amateur football players, the prevalence's were 44.56% (muscle/tendon injuries), 27.62% (joint and ligament injuries), 15.0% (contusions) and 3.05% (fracture), respectively. The frequency of traumatic injuries was higher in amateur football players (76.88%) compared to professional football players (64.16%), the situation being reversed in the case of overuse injuries: 27.62% in professional football players and 21.13% in amateur football players. Most contact injuries were found in professional footballers (50.70%), with non-contact injuries predominating in amateur footballers (54.04%). The analysis of the severity of injuries showed that moderate injuries dominated in the two categories of footballers; the severe injuries in amateur footballers exceeded the severe injuries recorded in professional footballers by 9.60%. Recurrence proportions showed an inverse relationship with the level of play, being higher in amateur footballers (16.66%) compared to professional footballers (15.25%). Conclusions (4): Football-related injuries have a significant impact on professional and amateur football players and their short- and long-term health status. Knowing the frequency of severe diagnoses, such as strains, tears and cramps of the thigh muscles, ankle ligament sprains and hip/groin muscle strain requires the establishment of adequate programs to prevent them, especially in amateur football players, who are more prone to serious injuries.

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.

The Role of Extracorporeal Shock Wave Therapy in the Treatment of Muscle Injuries: A Systematic Review

Muscle injuries commonly occur in sports and can be classified as indirect and direct, according to the 2013 Munich Consensus Statement (MCS). Since recent evidence suggests that extracorporeal shock wave therapy (ESWT) improves muscular microcirculation and may increase regeneration after acute muscle injury, we performed a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines to access the efficacy and safety of ESWT in the treatment of patients with muscle injuries. PubMed and Cochrane were searched to screen for potentially relevant articles and the literature search was last updated in June 2023. The inclusion criteria were randomized controlled trials, observational studies, or case controls published in English, Portuguese, or Spanish that studied the effect of ESWT on indirect and direct muscle injuries in individuals aged ≥18, with at least one of the following reported outcomes: pain on the visual analog scale (VAS), functionality assessed either with disability scales or subjectively, time for return to play (RTP), re-injury rate, and ultrasonographic evaluation. The exclusion criteria were literature reviews, systematic reviews, studies in animals, studies in other languages, studies that failed to meet the targeted population or intervention and studies that didn't report any of the outcomes of interest. The quality of the studies was analyzed using the Cochrane Assessment Tool, the Newcastle-Ottawa Quality Assessment Scale, and the JBI Critical Appraisal Checklist. Eight studies were included in the systematic review (two randomized controlled trials, one prospective observational study, two retrospective observational studies, and three case reports), with a total of 143 adult participants. ESWT was associated with less pain on VAS, better function, reduction of size of lesion on ultrasound evaluation, faster RTP and/or lower re-injury rate in patients with indirect and direct muscle injuries and muscular hematomas, a frequent secondary complication of muscle injuries. The evidence regarding the use of ESWT for these types of injuries is therefore promising. Nevertheless, higher-quality studies are needed in the future to prove its efficacy, better comprehend its mechanisms of action and define treatment protocols (timing, type and parameters of ESWT).

Relationship between anatomical injury site of rectus femoris muscle strain and time taken to return to play in Japanese professional soccer players

PURPOSE

The rectus femoris has three myotendinous or myoaponeurosis junctions and causes three types of muscle strain anatomically. We aimed to investigate the anatomical injury site of the rectus femoris muscle strain in professional soccer players as well as the characteristic findings on magnetic resonance imaging (MRI) and to evaluate its relationship with the time taken to return to play at competition levels.

METHODS

Thirteen Japanese professional soccer players who sustained injuries to the rectus femoris were included in this study. The mechanism of injury, anatomical injury site, severity, absence of hematomas, and time taken to return to competition were evaluated.

RESULTS

Ten patients were injured while kicking and three while sprinting. The anatomical injury site was the origin aponeurosis in two cases, intramuscular tendon in eight cases, and distal aponeurosis in three cases. The severity was one-degree in three cases and two-degree in 10 cases. Hematomas were observed in five cases. Cases with injuries caused by sprinting, two-degree injuries, or clear hematomas were associated with significantly longer periods of return to play than the other cases. Additionally, patients with distal aponeurosis-type injuries tended to take a long time to return to the competition.

CONCLUSIONS

In rectus femoris muscle strain, it is important to evaluate the anatomical injury site, severity, and absence of hematomas on MRI. Not only the injury mechanism, a clear hematoma, and high severity but also distal aponeurosis injuries may be associated with long periods of return to play at competition levels.

Characterization of acute American football spinal injuries in a multi-center healthcare system

PURPOSE

American football is considered one of the more injury-prone sports given its high-speed and high-impact nature. While much attention has been focused on chronic traumatic encephalopathy, spinal injuries represent the most common catastrophic injury incurred in football. The goal of this investigation is to describe the most common football-associated spinal lesions in a multi-center health system.

METHODS

This is a retrospective analysis of patients with imaging evidence of spinal injuries related to American football during a 10-year period. Injuries were classified based on the anatomic level, type injury, spinal cord compromise, and therapeutic management. Chi-squared and Fisher's exact test were used for statistical analysis of categorial variables, and simple logistic regression was used to determine individual odds ratios.

RESULTS

A total of 71 patients were included, with a median age of 17 (IQR, 15-22) years. The cervical spine was the most frequently affected segment (46%), followed by lumbar spine injuries (45%), and thoracic spine injuries (10%). Discogenic injuries were identified in 45 patients (63%). Spinal cord injury was documented in 7 subjects (10%), while cauda equina compression was reported in 1 patient (1%).

CONCLUSIONS

Acute spinal injuries continue to represent a significant cause of morbidity among American football players. Compared to national statistics, we found a similar distribution of spinal injuries in terms of anatomic location and an alarmingly high proportion of SCI. This investigation represents the largest single-center study addressing spinal injuries among football players.

Exercise-induced traumatic muscle injuries with active bleeding successfully treated by embolization: three case reports

Muscle injuries caused by indirect trauma during exercise are common. Most of these injuries can be managed conservatively; however, further treatment is required in extreme cases. Although transcatheter arterial embolization is a possible treatment modality, its role in traumatic muscle injuries remains unclear. In this case series, we present three cases of exercise-induced muscle hemorrhage treated by transcatheter arterial embolization with successful outcomes. The damaged muscles were the rectus abdominis, adductor longus, and iliopsoas, and the vascular injuries were accessed via the femoral artery during the procedures.

Association Between Injury Mechanisms and Magnetic Resonance Imaging Findings in Rectus Femoris Injuries in 105 Professional Football Players

OBJECTIVE

To describe the injury mechanism and its association with magnetic resonance imaging (MRI) injury findings in acute rectus femoris injuries.

DESIGN

Combined retrospective and prospective descriptive injury study. Retrospective cohort from January 2010 to October 2013 and prospective cohort from October 2013 to January 2019.

SETTING

Specialized sports medicine hospital.

PARTICIPANTS

Male professional football players older than 18 years playing in a national football league, referred for injury assessment within 7 days after an acute rectus femoris injury, with a positive finding on MRI.

INDEPENDENT VARIABLES

Rectus femoris muscle injury MRI findings in relation to injury mechanism in male football players.

MAIN OUTCOME MEASURES

Rectus femoris injury mechanism (kicking, sprinting, and others), MRI injury location, and grade.

RESULTS

There were 105 injuries in total, with 60 (57.1%) and 45 (42.8%) injuries from the retrospective and prospective cohorts, respectively. Kicking was the injury mechanism in 57 (54.3%) of all acute rectus femoris injuries, sprinting represented 32 (30.4%), and 16 (15.2%) were classified as others. There were 20 (19.05%) free tendon, 67 (63.8%) myotendinous junction and/or intramuscular tendon, and 18 (17.1%) peripheral myofascial located injuries. All free tendon injuries were related to kicking and graded as a complete tear of at least one of the tendons in 15/20 (75.0%) cases.

CONCLUSIONS

Kicking seems to be an important mechanism related to complete ruptures and injuries occurring at the proximal free tendon. Sprinting was the other most common mechanism but was never associated with injury to the proximal free tendon.

Time to return to full training and recurrence of rectus femoris injuries in elite track and field athletes 2010-2019; a 9-year study using the British Athletics Muscle Injury Classification

Rectus femoris (RF) injuries are common in sports requiring maximal acceleration and sprinting. The British Athletics Muscle Injury Classification (BAMIC) describes acute muscle injury based on the anatomical site of injury and has been associated with return to play in hamstring and calf muscle injury. The aim of this study was to describe and compare the time to return to full training (TRFT) and injury recurrence for BAMIC-classified RF injuries sustained by elite track and field (T&F) athletes over a 9-year period. All rectus femoris injuries sustained by elite T&F athletes on the British Athletics World Class Program between September 2010 and September 2019 that were investigated with an MRI within 7 days of acute onset anterior thigh pain were included. Injuries were graded from the MRI by a specialist musculoskeletal radiologist using the BAMIC, and TRFT and injury recurrence were determined by evaluation of the Electronic Medical Record. Athlete demographics and World Athletics event discipline were recorded. Specific injury details including mechanism, location of injury, and whether surgical or rehabilitation management was undertaken were recorded. There were 38 RF injuries in 27 athletes (24.7 ± 2.3 years; 10 male, 17 female). Average TRFT for rehabilitation managed cases was 20.4 ± 14.8 days. Grade 1 injuries had significantly shorter TRFT compared with grades 2 (p = 0.04) and 3 (p = 0.01). Intratendinous (c) and surgically managed RF injuries each had significantly longer TRFT compared with other injury classes (p < 0.001). Myofascial (a) injuries had reduced repeat injury rates compared with b or c classes (p = 0.048). Grade 3 injuries had an increased repeat injury rate compared with other grades (p = 0.02). There were 4 complete (4c) proximal free tendon injuries sustained during sprinting and all in female athletes. The average TRFT for RF injuries in elite T&F is similar to that previously identified in elite football and Australian Rules. Similar to previous research in hamstring and calf injury, RF injuries extending into the tendon (BAMIC class c) had delayed TRFT which may reflect the longer duration required for tendon healing and adaptation. Grade 3 injuries had in increased repeat injury rate compared with grades 1 and 2. The BAMIC diagnostic framework may provide useful information for clinicians managing rectus femoris injuries in T&F.

Interval Kicking Program for the Punting and Place-Kicking Athlete: A Systematic Literature Review and Need Analysis

Interval programs have been developed for multiple sports, allowing athletes to return to sport-specific activity in a graded fashion, minimizing the risk of reinjury. However, there currently exists a gap in the literature surrounding the use of interval programs for the rehabilitation of punting and place-kicking athletes. We aim to perform a systematic review of the literature examining the use of interval kicking programs to aid punting and place-kicking athletes following a lower-extremity injury. Following PRISMA guidelines, a review was performed using PubMed and MEDLINE databases to evaluate the literature surrounding interval kicking programs for punting and place-kicking athletes. Search terms were combined using Boolean operators of "AND" and "OR". Articles included in this review met these criteria: 1) included patients with lower-extremity pain/injury, 2) reported a return to sport progressive program, and 3) analyzed the measure's ability to predict a successful return to sport. The initial search returned 115 articles. Seventy-nine of these articles were excluded after initial screening, leaving 36 full-text articles for final review. Of these final articles, there were no studies outlining the use of interval kicking programs by punting or place-kicking athletes. Of the articles reviewed, the most relevant was an interval kicking program developed by Arundale et al. specifically for the soccer athlete. Punting and place-kicking use biomechanically distinct patterns of movement, warranting a specific interval program. This review identified a gap in knowledge surrounding the use of interval programs in the rehabilitation of punting and place-kicking athletes. This review will now describe what is currently known regarding biomechanics of punting and place kicking, the injuries experienced by these athletes, and the benefit an individualized interval program could provide. There currently exists a gap in the literature surrounding the use of interval programs for the rehabilitation of punting and place-kicking athletes. The biomechanics and application of these skills are distinct, and an interval program designed specifically for these athletes is warranted. Future research should be dedicated to the development, implementation, and analysis of an interval kicking program designed for these athletes.

Avulsion Injuries and Ruptures of the Proximal Rectus Femoris in Skeletally Mature, High-Level Athletes: A Critical Analysis Review

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Injuries to the proximal rectus femoris remain rare, occurring primarily in soccer and American football athletes during kicking and sprinting because of its unique biarthrodial nature.

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The appropriate diagnosis is dependent on careful physical examination and imaging interpretation.

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While no universal treatment algorithm has been adopted for high-level athletes, recent investigations support operative repair using suture anchors to restore strength and function in order to allow an effective return to competition while minimizing the risk of injury recurrence.

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Complications following surgical management include injury to the lateral femoral cutaneous nerve and hematoma formation, and there are reports of residual pain and weakness with chronic injuries that fail the initial nonoperative treatment.

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Current investigations examining outcomes following treatment remain limited, warranting additional studies that examine patient-reported results, return-to-play rates, and the role of orthobiologics and accelerated rehabilitation protocols following injury to further improve athlete health and safety.

[Analysis of muscle injuries and return-to-training in elite Taekwondo athletes: results of a prospective cohort study over a period of five years]

BACKGROUND

 Muscle injuries frequently occur in sports involving explosive movement patterns, and they can cause considerable downtime. There is a lack of detailed data on muscle injuries in Olympic elite Taekwondo.

METHODS

 All injuries sustained by 76 elite Taekwondo athletes from a national Olympic training centre during training and competition were prospectively recorded over a period of five years. Data on muscle injuries, including location and time elapsed until return-to-training, were extracted from medical records. Injuries were diagnosed by means of MRI and were classified according to the British Athletes Muscle Injury System. The relationship between MRI classification subgroups and time elapsed until return-to-training was assessed.

RESULTS

 Mean age of athletes was 22.5 ± 3.2 (16-27) years with an average Taekwondo experience of 12.1 ± 4.0 (7-20) years. Hamstring muscles were most commonly injured (48.4 %), followed by quadriceps muscles (32.3 %) and calf muscles (9.6 %). The analysis of MRI injury subgroups showed grade 1 (32.2 %) and grade 2 (41.9 %) injuries in most cases. A positive correlation was found between injury groups and return-to-training (r = 0.56). The comparison between different injury groups and time elapsed until return-to-training also revealed significant differences (p < 0.0001).

CONCLUSION

 Hamstring muscles are the most injured muscles in Taekwondo besides the quadriceps femoris muscle. Most injuries were mild to moderate (grade 1-2). The time needed for return-to-training increased significantly with the severity of injuries diagnosed by MRI.

Outcomes of Surgical Repair Versus Primary Tenodesis for Proximal Rectus Femoris Avulsion Injuries in Professional Athletes

BACKGROUND

Surgical repair of proximal rectus femoris avulsion injuries is associated with prolonged periods of rehabilitation and highly variable risk of injury recurrence. Surgical tenodesis of these injuries is often reserved for recurrent injuries or revision surgery. To our knowledge, the outcomes of proximal rectus femoris avulsion injuries treated with surgical repair versus primary tenodesis have not been previously reported.

HYPOTHESIS

Primary tenodesis of proximal rectus femoris avulsion injuries is associated with reduced risk of injury recurrence as compared with surgical repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

This study included 25 patients (22 male and 3 female) who underwent surgical repair versus 30 patients (26 male and 4 female) who received primary tenodesis for proximal rectus femoris avulsion injuries. Predefined outcomes were recorded at regular intervals after surgery. Mean follow-up time was 27.9 months (range, 24.0-31.7 months) from date of surgery.

RESULTS

All patients returned to their preinjury levels of sporting activity. Primary tenodesis was associated with earlier return to preinjury level of sporting function as compared with surgical repair (mean ± SD, 12.4 ± 1.6 vs 15.8 ± 2.2 weeks; P < .001) and reduced risk of recurrence (0% vs 16%; P < .001). At 1-year follow-up, there was no difference in surgical repair versus primary tenodesis relating to patient satisfaction scores (12 very satisfied and 13 satisfied vs 16 very satisfied and 14 satisfied; P = .70), isometric quadriceps strength (95.6% ± 2.8% vs 95.2% ± 6.3%; P = .31), Tegner scores (median [interquartile range], 9 [8-9] vs 9 [8-9]; P = .54), and lower extremity functional scores (73 [72-76] vs 74 [72-75]; P = .41). High patient satisfaction, quadriceps muscle strength, and functional outcome scores were maintained and remained comparable between treatment groups at 2-year follow-up.

CONCLUSION

Primary tenodesis was associated with reduced time for return to preinjury level of sporting function and decreased risk of injury recurrence when compared with surgical repair for proximal rectus femoris avulsion injuries. There were no differences in patient satisfaction, functional outcome scores, and quadriceps muscle strength between the treatment groups at 1- and 2-year follow-up.

Prevalence and risk factors for back pain in sports: a systematic review with meta-analysis

OBJECTIVES

We aimed to determine the prevalence of low back pain (LBP) in sport, and what risk factors were associated with LBP in athletes.

DESIGN

Systematic review with meta-analysis.

DATA SOURCES

Literature searches from database inception to June 2019 in Medline, Embase, Cumulated Index to Nursing and Allied Health Literature (CINAHL), Web of Science and Scopus, supplemented by grey literature searching.

ELIGIBILITY CRITERIA

Studies evaluating prevalence of LBP in adult athletes across all sports.

RESULTS

Eighty-six studies were included (30 732, range 20-5958, participants), of which 45 were of 'high' quality. Definitions of LBP varied widely, and in 17 studies, no definition was provided. High-quality studies were pooled and the mean point prevalence across six studies was 42%; range 18%-80% (95% CI 27% to 58%, I2=97%). Lifetime prevalence across 13 studies was 63%; range 36%-88% (95% CI 51% to 74%, I2=99%). Twelve-month LBP prevalence from 22 studies was 51%; range 12%-94% (95% CI 41% to 61%, I2=98%). Comparison across sports was limited by participant numbers, study quality and methodologies, and varying LBP definitions. Risk factors for LBP included history of a previous episode with a pooled OR of 3.5; range 1.6-4.0 (95% CI 1.9 to 6.4). Statistically significant associations were reported for high training volume, periods of load increase and years of exposure to the sport.

CONCLUSION

LBP in sport is common but estimates vary. Current evidence is insufficient to identify which sports are at highest risk. A previous episode of LBP, high training volume, periods of load increase and years of exposure are common risk factors.

Diagnosis, prevention and treatment of common lower extremity muscle injuries in sport - grading the evidence: a statement paper commissioned by the Danish Society of Sports Physical Therapy (DSSF)

This statement summarises and appraises the evidence on diagnosis, prevention and treatment of the most common lower extremity muscle injuries in sport. We systematically searched electronic databases, and included studies based on the highest available evidence. Subsequently, we evaluated the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework, grading the quality of evidence from high to very low. Most clinical tests showed very low to low diagnostic effectiveness. For hamstring injury prevention, programmes that included the Nordic hamstring exercise resulted in a hamstring injury risk reduction when compared with usual care (medium to large effect size; moderate to high quality of evidence). For prevention of groin injuries, both the FIFA 11+programme and the Copenhagen adductor strengthening programme resulted in a groin injury risk reduction compared with usual care (medium effect size; low to moderate quality of evidence). For the treatment of hamstring injuries, lengthening hamstring exercises showed the fastest return to play with a lower reinjury rate compared with conventional hamstring exercises (large effect size; very low to low quality of evidence). Platelet-rich plasma had no effect on time to return-to-play and reinjury risk (trivial effect size; moderate quality of evidence) after a hamstring injury compared with placebo or rehabilitation. At this point, most outcomes for diagnosis, prevention and treatment were graded as very low to moderate quality of evidence, indicating that further high-quality research is likely to have an important impact on the confidence in the effect estimates.

Surgical Release of the Adductor Longus With or Without Sports Hernia Repair Is a Useful Treatment for Recalcitrant Groin Strains in the Elite Athlete

Background

Chronic strain and/or tendinopathy of the adductor longus tendon can be a cause of long-standing groin pain in the elite athlete, resulting in significant time lost from competition. Accurate diagnosis and treatment can expedite return to play.

Purpose/Hypothesis

To evaluate return to sport and performance in National Collegiate Athletic Association (NCAA) Division I football players and National Football League (NFL) players following adductor longus release with or without sports hernia repair. We hypothesized that adductor release will be an effective method of treatment for recalcitrant groin/adductor pain in these athletes.

Study Design

Case series; Level of evidence, 4.

Methods

A cohort study was performed of all NFL players and NCAA Division I college athletes who had undergone an adductor longus tendon release with or without sports hernia repair by 1 of 2 fellowship-trained orthopaedic surgeons between May 1999 and January 2013. All patients reported groin pain below the inguinal ligament and localized to their adductor longus. Symptoms lasted longer than 10 weeks and limited their ability to effectively perform during sport, as assessed by their coach and self-assessment. Questionnaires were given to all 26 patients to assess long-term surgical outcomes. A subgroup analysis was performed for NFL players, in which "performance scores" were calculated according to individual player statistics while playing. Scores obtained before the diagnosis of chronic adductor longus tendinopathy or strain were compared with those after surgery. Patients with prior abdominal or pelvic surgery, radiographic evidence of degenerative joint disease of the hip, labral tears or femoral acetabular impingement, prostatic or urinary tract disease, or nerve entrapment of the ilioinguinal, genitofemoral, or lateral femoral cutaneous nerves were excluded from the study.

Results

A total of 32 athletes underwent an adductor longus tenotomy during the study period. Of these patients, 28 were college- or professional-level athletes who underwent an adductor longus tenotomy, with a mean ± SD follow-up time of 6.2 ± 4.2 years (range, 12-178 months). Of the 32 patients, 20 had a concomitant sports hernia repair in addition to an adductor longus tenotomy. Thirty-one patients (97%) were able to return to their previous sport, and 30 (94%) were able to return at their previous level of play. Thirty patients (94%) reported that they were satisfied with their decision to have surgery. No player complained of weakness or a decrease in running speed or power. Mean return to play was 12 weeks from date of surgery. In the subgroup analysis of 16 NFL players, there were no statistically significant differences for the pre- versus postoperative comparisons of the athlete performance scores (P = .74) and the percentage of the games started versus played (P = .46). After separation of players who had a concomitant hernia repair from players who did not, there was no statistically significant difference in performance scores or percentages of games started.

Conclusion

In this study of elite athletes, adductor longus tenotomy with or without a concomitant sports hernia repair provided overall acceptable and excellent results. Athletes were able to return to their previous level of athletic competition and performance with consistent relief of groin pain. Return to play in an NFL game averaged 12 weeks following surgery.

A Systematic Review of the Orthopaedic Literature Involving National Football League Players

Background

Orthopaedic injuries of National Football League (NFL) players can have a deleterious effect on their health, with minimal to no high-level evidence on the management of these injuries.

Purpose

To summarize all data published between January 1980 and March 2018 on orthopaedic injuries experienced by NFL candidates and professional players in the NFL.

Study Design

Systematic review; Level of evidence, 4.

Methods

A literature search of studies examining orthopaedic injuries in the NFL was performed through the PubMed, Embase, and CINAHL databases. The review included studies of orthopaedic injuries in college football recruits attending the NFL Combine as well as professional NFL players. Excluded were studies of nonorthopaedic injuries, such as concussions, traumatic brain injury, facial injuries, and vascular injuries, as well as case reports.

Results

A total of 147 articles met the inclusion criteria and were divided into 11 topics based on anatomic site: general (16%), spine (13%), shoulder (13%), elbow (3%), hand and wrist (3%), trunk (0.7%), hip and pelvis (7%), thigh (3%), knee (24%), ankle (5%), and foot (12%). Of these studies, 74% were of level 4 evidence. Most studies obtained data from the NFL Combine database (26%), by searching the internet (24%), and via the NFL Injury Surveillance System (22%). Studies using internet search methods to identify injuries consistently found fewer participants than studies using the NFL Injury Surveillance System.

Conclusion

This systematic review provides National Collegiate Athletic Association and NFL team physicians with a single source of the most current literature regarding orthopaedic injuries in NFL players. Most research was published on knee, spine, shoulder, and foot injuries and consisted of level 4 evidence. A substantial portion of the published literature was based on data obtained from internet searches and may not accurately represent the NFL population.

Short-term Effect of Ultrasound-Guided Iliopsoas Peritendinous Corticosteroid Injection

OBJECTIVES

Treatment for iliopsoas tendinopathy includes ultrasound (US)-guided iliopsoas peritendinous corticosteroid injection. Evidence is lacking regarding US-guided iliopsoas injection efficacy in patients with iliopsoas tendinopathy and intra-articular (IA) hip abnormalities. The purpose of this study was to examine the efficacy of US-guided iliopsoas corticosteroid injection for iliopsoas tendinopathy in patients with and without IA hip abnormalities.

METHODS

This work was a prospective study evaluating patients aged 12 to 50 years with iliopsoas tendinopathy. Participants completed a Hip Disability and Osteoarthritis Outcome Score (HOOS) questionnaire before and 6 weeks after injection. The main outcome measure was the change in HOOS subcategory scores. Independent variables included time and hip status. Normal hips were compared to abnormal hips with IA abnormalities. A 2-way repeated measures analysis of covariance with effect size (η² ) was used to determine injection effects on HOOS scores before and 6 weeks after injection.

RESULTS

A total of 178 patients (154 female and 24 male) were analyzed. Time effects were found for both normal and abnormal hips in all HOOS subcategories: symptoms (P = .041; η²  = 0.050), pain (P = .001; η²  = 0.184), activities of daily living (P = .011; η²  = 0.076), function in sports and recreation (P = .001; η²  = 0.151), and quality of life (QOL; P = .001; η²  = 0.193). Significant differences between normal versus abnormal hips were found in the sports and recreation (P = .032; η²  = 0.056) and QOL scores (P = .001; η²  = 0.135).

CONCLUSIONS

In patients with iliopsoas tendinopathy, US-guided iliopsoas corticosteroid injection improved outcomes regardless of coexisting IA hip abnormalities. Patients without IA hip abnormalities showed greater improvement in sports and recreation and QOL scores compared to patients with IA hip abnormalities. Ultrasound-guided iliopsoas injection for iliopsoas tendinopathy may advance short-term care and help continue with nonsurgical treatment regimens.

Changes in rectus femoris architecture induced by the reverse nordic hamstring exercises

BACKGROUND

Injuries and mechanical stimuli alter the muscle architecture and, therefore, its function. The changes in the architecture of the rectus femoris (RF) induced by an eccentric training protocol with reverse nordic hamstring exercises (RNHE) have never been studied. Therefore, the aim of the present study was to determine the architectural adaptations of the RF after an eccentric training with RNHE, followed by a subsequent detraining period.

METHODS

Twenty-six subjects performed a first week of control, 8 weeks of eccentric training, concluding with a 4-week period of detraining. The architectural characteristics of the RF were evaluated using 2D ultrasound at rest (pretest: week 1), after the training (post-test: week 9), and at the end of the detraining period (retest: week 13).

RESULTS

At the end of the training period, a significant increase in the muscle fascicle length (FL) (t=-8.96, d=2.22, P<0.001), muscle thickness (MT) (t=-8.76, d=2.219, P<0.001), pennation angle (PA) (t=-9.83, d=2.49, P<0.05) and cross-sectional area (CSA) (t=-13.06, d=3.06, P<0.001) was observed. After the detraining period FL, MT, PA and CSA showed a significant decrease.

CONCLUSIONS

The eccentric training with RNHE may cause changes in the architectural conditions of RF, which, in addition, are also reversible after a 4-week detraining period. The adaptations produced by RNHE may have practical implications for injury prevention and rehabilitation programs, which include the changes in muscle architecture variables.

Intermittent Treadmill Running Induces Kinematic Compensations to Maintain Soccer Kick Foot Speed Despite No Change in Knee Extensor Strength

Kicking is a fundamental skill and a primary noncontact mechanism of injury in soccer, with injury incidence increasing during the latter stages of match-play. Ten male professional soccer players completed a 90-minute treadmill protocol based on the velocity profile of soccer match-play. Preexercise, and at 15-minute intervals, players completed a maximal velocity kick subjected to kinematic analysis at 200 Hz. Preexercise, and at the end of each half, players also completed isokinetic concentric knee extensor repetitions at 180°·s^-1, 300°·s^-1, and 60°·s^-1. Kicking foot speed was maintained at ∼19 m·s^-1, with no main effect for exercise duration. In relation to proximal-distal sequencing during the kicking action, there was a significant increase in the duration (but not magnitude) of thigh rotation, with a compensatory decrease in the duration (but not magnitude) of shank rotation during the latter stages of the exercise protocol. In relation to long-axis rotation, pelvic orientation at ball contact was maintained at ∼6°, representing a total pelvic rotation in the order of ∼15° during the kicking action. Peak knee extensor torque at all speeds was also maintained throughout the protocol, such that kinematic modifications are not attributable to a decline in knee extensor strength.

Muscle Injuries in Sports: A New Evidence-Informed and Expert Consensus-Based Classification with Clinical Application

Muscle injuries are among the most common injuries in sport and continue to be a major concern because of training and competition time loss, challenging decision making regarding treatment and return to sport, and a relatively high recurrence rate. An adequate classification of muscle injury is essential for a full understanding of the injury and to optimize its management and return-to-play process. The ongoing failure to establish a classification system with broad acceptance has resulted from factors such as limited clinical applicability, and the inclusion of subjective findings and ambiguous terminology. The purpose of this article was to describe a classification system for muscle injuries with easy clinical application, adequate grouping of injuries with similar functional impairment, and potential prognostic value. This evidence-informed and expert consensus-based classification system for muscle injuries is based on a four-letter initialism system: MLG-R, respectively referring to the mechanism of injury (M), location of injury (L), grading of severity (G), and number of muscle re-injuries (R). The goal of the classification is to enhance communication between healthcare and sports-related professionals and facilitate rehabilitation and return-to-play decision making.

National Football League Skilled and Unskilled Positions Vary in Opportunity and Yield in Return to Play After an Anterior Cruciate Ligament Injury

BACKGROUND

Anterior cruciate ligament (ACL) injuries pose a significant risk to the careers of players in the National Football League (NFL). The relationships between draft round and position on return to play (RTP) among NFL players are not well understood, and the ability to return to preinjury performance levels remains unknown for most positions.

PURPOSE

To test for differences in RTP rates and changes in performance after an ACL injury by position and draft round. We hypothesized that skilled positions would return at a lower rate compared to unskilled positions. We further hypothesized that early draft-round status would relate to a greater rate of RTP and that skilled positions and a lower draft round would correlate with decreased performance for players who return to sport.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Utilizing a previously established database of publicly available information regarding ACL tears among NFL players, athletes with ACL tears occurring between the 2010 and 2013 seasons were identified. Generalized linear models and Kaplan-Meier time-to-event models were used to test the study hypotheses.

RESULTS

The overall RTP rate was 61.7%, with skilled players and unskilled players returning at rates of 64.1% and 60.4%, respectively (P = .74). Early draft-round players and unskilled late draft-round players had greater rates of RTP compared to skilled late draft-round players and both unskilled and skilled undrafted free agents (UDFAs). Skilled early draft-round players constituted the only cohort that played significantly fewer games after an injury. Unskilled UDFAs constituted the only cohort to show a significant increase in the number of games started and ratio of games started to games played, starting more games in which they played, after an injury.

CONCLUSION

Early draft-round and unskilled players were more likely to return compared to their later draft-round and skilled peers. Skilled early draft-round players, who displayed relatively high rates of RTP, constituted the only cohort to show a decline in performance. Unskilled UDFAs, who exhibited relatively low rates of RTP, constituted the only cohort to show an increase in performance. The significant effect of draft round and position type on RTP may be caused by a combination of differences in talent levels and in opportunities given to returning to play.

Surgical Management of Rectus Femoris Avulsion Among Professional Soccer Players

BACKGROUND

Rectus femoris injuries are common among athletes, especially in kicking sports such as soccer; however, proximal rectus femoris avulsions in athletes are a relatively rare entity.

PURPOSE/HYPOTHESIS

The purpose of this study was to describe and report the results of an original technique of surgical excision of the proximal tendon remnant followed by a muscular suture repair. Our hypothesis was that this technique limits the risk of recurrence in high-level athletes and allows for rapid recovery without loss of quadriceps strength.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Our retrospective series included 5 players aged 31.8 ± 3.9 years with acute proximal rectus femoris avulsion injuries who underwent a surgical resection of the proximal tendon between March 2012 and June 2014. Four of these players had recurrent rectus femoris injuries in the 9 months before surgery, while 1 player had surgery after a first injury. Mean follow-up was 18.2 ± 12.6 months, and minimum follow-up was 9 months. We analyzed the age, sex distribution, physical examination outcomes, type and mechanism of injury, diagnosis, treatment and complications during surgery, postoperative follow-up, and time to return to play. The Lower Extremity Functional Scale (LEFS) and Marx scores were obtained at 3-month follow-up, and isokinetic tests were performed before return to sports. A telephone interview was completed to determine the presence of recurrence at an average follow-up of 18.2 months.

RESULTS

At 3-month follow-up, all patients had Marx activity scores of 16 and LEFS scores of 80. Return to the previous level of play occurred at a mean of 15.8 ± 2.6 weeks after surgery, and none of the athletes suffered a recurrence. Isokinetic test results were comparable between both sides.

CONCLUSION

The surgical treatment of proximal rectus femoris avulsions, consisting of resection of the tendinous part of the muscle, is a reliable and safe technique allowing a fast recovery in professional athletes.

Acute Gastrocnemius-Soleus Complex Injuries in National Football League Athletes

BACKGROUND

Lower extremity muscle injuries are common in professional football. Although less common than hamstring or quadriceps injuries in National Football League (NFL) athletes, calf injuries occur with relative frequency and have not previously been studied.

PURPOSE

To evaluate gastrocnemius-soleus complex muscle injuries over the past 13 years from a single NFL team to determine the incidence of such injuries, their imaging characteristics, and return to play after such injuries and any correlation between imaging findings and prolonged return to play.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A retrospective review of all acute calf muscle injuries on a single NFL team from 2003 to 2015 was performed. Player demographics and return-to-play data were obtained from the medical records. All available magnetic resonance images (MRIs) were reviewed by a musculoskeletal radiologist for specific imaging findings that correlated with return to play.

RESULTS

A total of 27 calf injuries in 24 NFL players were reviewed, yielding an incidence of 2.3 acute calf injuries per year on a single NFL team. Of these 27 injuries, 20 (74%) were isolated injuries to the gastrocnemius muscle, 4 (15%) were isolated injuries to the soleus muscle, and the remaining 3 injuries (11%) involved both. Defensive players were more likely to sustain injuries (P = .043). The mean time to return to play for all 27 players was 17.4 ± 14.6 days (range, 3-62 days). MRIs were available in 14 of the 27 injuries. The average size of the fascial defect (P = .032) and the presence of a fluid collection (P = .031) both correlated with return to play of longer than 2 weeks.

CONCLUSION

Although less common than hamstring or quadriceps muscle injuries, calf muscle injuries occur with relative frequency in the NFL, and more so in defensive players. The majority of these injuries occur in the gastrocnemius and result in significant disability, with at least 2 weeks of missed playing time on average. MRI may have an important role in the evaluation of calf injuries in NFL players, as certain injury imaging characteristics, including the anteroposterior size of any fascial tear and the presence of a fluid collection, are associated with longer return-to-play times after injury.

Injuries to the Collateral Ligaments of the Metacarpophalangeal Joint of the Thumb, Including Simultaneous Combined Thumb Ulnar and Radial Collateral Ligament Injuries, in National Football League Athletes

BACKGROUND

Thumb collateral ligament injuries occur frequently in the National Football League (NFL). In the general population or in recreational athletes, pure metacarpophalangeal (MCP) abduction or adduction mechanisms yield isolated ulnar collateral ligament (UCL) and radial collateral ligament (RCL) tears, respectively, while NFL athletes may sustain combined mechanism injury patterns.

PURPOSE

To evaluate the incidence of simultaneous combined thumb UCL and RCL tears among all thumb MCP collateral ligament injuries in NFL athletes on a single team.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A retrospective review of all thumb injuries on a single NFL team from 1991 to 2014 was performed. All players with a thumb MCP collateral ligament injury were included. Collateral ligament injuries were confirmed by review of both physical examination findings and magnetic resonance imaging. Player demographics, surgical details, and return-to-play data were obtained from the team electronic medical record and surgeons' records.

RESULTS

A total of 36 thumbs in 32 NFL players were included in the study, yielding an incidence of 1.6 thumb MCP collateral ligament injuries per year on a single NFL team. Of these, 9 thumbs (25%) had a simultaneous combined UCL and RCL tear injury pattern confirmed on both physical examination and MRI. The remaining 27 thumbs (75%) were isolated UCL injuries. All combined UCL/RCL injuries required surgery due to dysfunction from instability; 63.0% of isolated UCL injuries required surgical repair ( P = .032) due to continued pain and dysfunction from instability. Repair, when required, was delayed until the end of the season. All players with combined UCL/RCL injuries and isolated UCL injuries returned to play professional football the following season.

CONCLUSION

Simultaneous combined thumb UCL and RCL tear is a previously undescribed injury pattern that occurred in 25% of thumb MCP collateral ligament injuries on a single NFL team over a 23-year period. All players with combined thumb UCL/RCL injuries required surgical repair, which was significantly higher compared with players with isolated UCL injuries. Team physicians and hand surgeons treating elite football players with suspected thumb collateral ligament injuries should examine for RCL and UCL instability and consider MRI if any concern exists for a combined ligament injury pattern, as this injury is likely frequently missed.

Treatment of muscle injuries in football

Muscle injuries are frequent and represent one of the most substantial medical problems in professional football. They can have both traumatic and overuse causes with direct practical consequence due to differences in terms of the post-primary care regimen and prognosis. An accurate diagnosis is the first step towards a specific treatment and usually allows to predict return to play (RTP). Current treatment principles have no firm scientific basis; they are practiced largely as empirical medicine due to a lack of prospective randomised studies. Immediate treatment usually follows the PRICE-principle (protection, rest, ice, compression, elevation). Depending on the type of the muscle injury, specific physical and physiotherapeutical procedures as well as rehabilitative exercises and gradual training therapy are used to recondition the injured structure, to restore coordination and proprioception, and to normalise movement patterns. Injection therapy with various substances is frequently used, with positive results empirically, but evidence in form of prospective randomised studies is lacking. A precise rehabilitation plan should be developed for every muscle injury, including recommendations for sport-specific training with increasing intensity. Since there are no guidelines regarding safe RTP, regular follow-up examinations on the current muscle status are crucial to evaluate the progress made in terms of healing and to determine when the injured muscle can be exposed to the next step of load. This narrative review describes the various factors that a medical team should consider during assessment, treatment and rehabilitation of a muscle injury with particular focus on professional football.

Imaging of rectus femoris proximal tendinopathies

The rectus femoris is the most commonly injured muscle of the anterior thigh among athletes, especially soccer players. Although the injury pattern of the muscle belly is well documented, less is known about the anatomy and specific lesions of the proximal tendons. For each head, three distinctive patterns may be encountered according to the location of the injury, which can be at the enthesis, within the tendon, or at the musculotendinous junction. In children, injuries correspond most commonly to avulsion of the anteroinferior iliac spine from the direct head and can lead to subspine impingement. Calcific tendinitis and traumatic tears may be encountered in adults. Recent studies have shown that traumatic injuries of the indirect head may be underdiagnosed and that injuries of both heads may have a surgical issue. Finally, in the case of tears, functional outcome and treatment may vary if the rupture involves one or both tendons and if the tear is partial or complete. Thus, it is mandatory for the radiologist to know the different ultrasound and magnetic resonance imaging (MRI) patterns of these lesions in order to provide accurate diagnosis and treatment. The purpose of this article is to recall the anatomy of the two heads of rectus femoris, describe a reliable method of assessment with ultrasound and MRI and know the main injury patterns, through our own experience and literature review.

EXTRACORPOREAL SHOCKWAVE TERAPY TO TREAT CHRONIC MUSCLE INJURY

Objective: To evaluate the low energy extracorporeal shock waves therapy (ESWT) associated with physical therapy in the treatment of chronic muscle injuries classified as grades 2 and 3 in the lower limbs of amateur athletes. Methods: Eight athletes presenting with lower limb muscle injury for more than three weeks were treated with physiotherapy and ESWT. We evaluated the following parameters during treatment: palpable gap, muscle strength, pain, and Tegner score, as well as ultrasound image features and the ability to return to sports practice. Results: The average time of the first evaluation of the injury was 8.75 weeks. All patients presented muscle strength grade V after eight weeks. The pain score evolved from 5.75 to 0.5 points of the visual analogue scale (VAS), at the end of the treatment. The Tegner score after treatment was six points on average. Patients returned to sports practice after 8.14 weeks. Conclusion: ESWT associated with physical therapy proved to be effective to treat long-term muscle injury, with good performance and the ability to return to sport practice for all patients. Level of Evidence IV, Case Series, Prospective Study.

Suture anchor repair of proximal rectus femoris avulsions in elite football players

PURPOSE

To report the results of suture anchor repair of proximal rectus femoris avulsions in elite football players.

METHODS

Four professional football players (first-team regulars of European first division football clubs) underwent suture anchor repair of complete proximal rectus femoris avulsions with significant tendon retraction. The following parameters were analysed: demographic data, mechanism of injury, type of injury, classification according to the Munich consensus statement, time between injury and surgery, time between surgery and full participation in training and availability for match and/or competition selection (return to play/RTP), and time between surgery and the comeback to the first official league match (return to competition/RTC). Radiographic evaluation was performed by magnetic resonance imaging (MRI) obtained pre-operatively and at 6 and 12 weeks post-operatively. All players were followed for at least 24 months after return to play to exclude recurrence.

RESULTS

Mean age at surgery was 30 ± 2 years. All injuries occurred while kicking a ball, with the dominant leg affected in all patients. The injury was considered acute in three cases and chronic in one case. According to the Munich classification, all injures were type 4. Mean time to surgery was 60 ± 88 days (range, 8-191), mean time to RTP was 111 ± 15 days (range, 100-134), and mean time to RTC was 140 ± 23 days (range, 114-166). Follow-up MRIs demonstrated anatomically reinserted tendons with decreasing signal intensity over time in all cases. After a mean follow-up of 35 ± 6 months, all players were still competing at the same level as before the injury without re-injury.

CONCLUSION

Suture anchor repair of proximal rectus femoris avulsions allows unrestricted return to play in professional elite football players. Return to play can be expected at approximately 16 weeks post-operatively.

A Unique Rectus Femoris Injury in an Adolescent Professional Soccer Player: A Case Report

CASE

A sixteen-year-old professional soccer player presented with persistent pain in the right thigh of two years' duration and the inability to return to play. Evaluation revealed a chronic rupture of the rectus femoris muscle. Because physiotherapy and rehabilitation failed to help, a surgical repair was performed. He returned to his previous activity level within nine months after surgery.

CONCLUSION

Rupture of the proximal part of the rectus femoris should be acknowledged in the differential diagnosis, especially when presenting with persistent pain in the anterior aspect of the thigh lasting more than one year. Delayed repair might be recognized as a reasonable option for chronic rupture of the proximal part of the rectus femoris.

The recognition and evaluation of patterns of compensatory injury in patients with mechanical hip pain

Context:

In active individuals with femoroacetabular impingement (FAI), the resultant reduction in functional range of motion leads to high impaction loads at terminal ranges. These increased forces result in compensatory effects on bony and soft tissue structures within the hip joint and hemipelvis. An algorithm is useful in evaluating athletes with pre-arthritic, mechanical hip pain and associated compensatory disorders.

Evidence Acquisition:

A literature search was performed by a review of PubMed articles published from 1976 to 2013.

Level of Evidence:

Level 4.

Results:

Increased stresses across the bony hemipelvis result when athletes with FAI attempt to achieve supraphysiologic, terminal ranges of motion (ROM) through the hip joint required for athletic competition. This can manifest as pain within the pubic joint (osteitis pubis), sacroiliac joint, and lumbosacral spine. Subclinical posterior hip instability may result when attempts to increase hip flexion and internal rotation are not compensated for by increased motion through the hemipelvis. Prominence of the anterior inferior iliac spine (AIIS) at the level of the acetabular rim can result in impingement of the anterior hip joint capsule or iliocapsularis muscle origin against the femoral head-neck junction, resulting in a distinct form of mechanical hip impingement (AIIS subspine impingement). Iliopsoas impingement (IPI) has also been described as an etiology for anterior hip pain. IPI results in a typical 3-o’clock labral tear as well as an inflamed capsule in close proximity to the overlying iliopsoas tendon. Injury in athletic pubalgia occurs during high-energy twisting activities in which abnormal hip ROM and resultant pelvic motion lead to shearing across the pubic symphysis.

Conclusion:

Failure to recognize and address concomitant compensatory injury patterns associated with intra-articular hip pathology can result in significant disability and persistent symptoms in athletes with pre-arthritic, mechanical hip pain.

Strength-of-Recommendation Taxonomy (SORT):

B

Effectiveness of a selective partial adductor release for chronic adductor-related groin pain in professional athletes

BACKGROUND

Chronic adductor enthesopathy is a well-known cause of groin pain in athletes. Currently, percutaneous nonselective adductor tenotomies give mixed results and not always predictable outcomes.

HYPOTHESIS

A selective partial adductor longus release as treatment for recalcitrant chronic adductor longus enthesopathy provides excellent pain relief with a prompt and consistent return to preinjury levels of sport.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

All athletes were assessed in a standard way for adductor dysfunction. They received radiographs and a specifically designed magnetic resonance imaging groin study protocol. Only professional athletes who received a selective partial adductor release were included. Pain and functional improvement were assessed with the visual analog scale (VAS) pain score and time to return to sport.

RESULTS

Forty-three professional athletes (39 soccer and 4 rugby) with chronic adductor-related groin pain were treated with a selective partial adductor release. The average follow-up time was 40.2 months (range, 25-72 months). Forty-two of 43 athletes returned to their preinjury level of sport after an average of  9.21 weeks (range, 4-24 weeks; SD, 4.68 weeks). The preoperative VAS score improved significantly (Wilcoxon signed-rank test, P < .001) from 5.76 ± 1.08 (range, 3-8) to 0.23 ± 0.61 (range, 0-3) postoperatively.

CONCLUSION

A selective partial adductor longus release provides excellent pain relief for chronic adductor enthesopathy in professional athletes with a consistent high rate of return to the preinjury level of sport.

Terminology and classification of muscle injuries in sport: the Munich consensus statement

Objective

To provide a clear terminology and classification of muscle injuries in order to facilitate effective communication among medical practitioners and development of systematic treatment strategies.

Methods

Thirty native English-speaking scientists and team doctors of national and first division professional sports teams were asked to complete a questionnaire on muscle injuries to evaluate the currently used terminology of athletic muscle injury. In addition, a consensus meeting of international sports medicine experts was established to develop practical and scientific definitions of muscle injuries as well as a new and comprehensive classification system.

Results

The response rate of the survey was 63%. The responses confirmed the marked variability in the use of the terminology relating to muscle injury, with the most obvious inconsistencies for the term strain. In the consensus meeting, practical and systematic terms were defined and established. In addition, a new comprehensive classification system was developed, which differentiates between four types: functional muscle disorders (type 1: overexertion-related and type 2: neuromuscular muscle disorders) describing disorders without macroscopic evidence of fibre tear and structural muscle injuries (type 3: partial tears and type 4: (sub)total tears/tendinous avulsions) with macroscopic evidence of fibre tear, that is, structural damage. Subclassifications are presented for each type.

Conclusions

A consistent English terminology as well as a comprehensive classification system for athletic muscle injuries which is proven in the daily practice are presented. This will help to improve clarity of communication for diagnostic and therapeutic purposes and can serve as the basis for future comparative studies to address the continued lack of systematic information on muscle injuries in the literature.

What are the new things

Consensus definitions of the terminology which is used in the field of muscle injuries as well as a new comprehensive classification system which clearly defines types of athletic muscle injuries.

Level of evidence

Expert opinion, Level V.

Chronic tears of the reflected head of the rectus femoris: results of operative treatment

BACKGROUND

While the majority of quadriceps muscle strains can be managed nonoperatively, rare cases remain symptomatic despite nonoperative treatment.

PURPOSE

The purpose of this study is to report on results of surgical treatment of a limited number of cases of persistently symptomatic tears of the reflected head of the rectus femoris.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The records of 5 patients with chronic tears of the rectus femoris treated with excision of the reflected head were reviewed. A telephone interview regarding return to sport and current limitations was completed if patients were available for further follow-up.

RESULTS

A review of 5 cases of surgical treatment of chronic tears of the reflected head of the rectus was completed. Patients included 1 woman and 4 men with an average age of 21 years (range, 18-24 years). Three patients played football (2 kickers) and 2 played soccer at a collegiate level. All 5 reported a significant decrease in pain during sport and activities of daily living and were able to return to collegiate athletics. Two patients had a late recurrence of pain with kicking that resolved with nonoperative treatment, 1 had residual thigh pain with intense play, 1 had no pain but noted decreased kicking accuracy, and 1 patient returned to play without symptoms.

CONCLUSION

Strain injuries to the reflected head of the rectus femoris can benefit from delayed excision in rare cases that fail nonoperative management. High-level kicking athletes are likely to experience significant reduction in pain, but may have some residual or recurrent symptoms that limit competitive level of play postoperatively.