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Some interventions, such as percutaneous fibrolysis, deep massages, performed on muscle tissues during the biological reparative period, can negatively interfere with the normal tissue reparative response, consequently altering the imaging control performed. Sometimes such therapies can cause iatrogenic damage to muscle tissues during its biological repair phase. Imaging examination, especially magnetic resonance imaging, can unmask these iatrogenic damages. The aim of this paper is to draw attention to the importance of careful evaluation concerning these therapies performed during the rehabilitation pathway, especially during the biological reparative period, since recent radiological techniques seem to show a higher frequency of iatrogenic lesions. [ABSTRACT FROM AUTHOR]

Background: The Nine Plus screening battery test (9+) is a functional movement test intended to identify limitations in fundamental movement patterns predisposing athletes to injury. However, the interseason variability is unknown.Aim: To examine the variability of the 9+ test between 2 consecutive seasons in professional male football players.Methods: Asymptomatic Qatar Star League players (n=220) completed the 9+ at the beginning of the 2013 and 2014 seasons. Time-loss injuries in training and matches were obtained from the Aspetar Injury and Illness Surveillance Program. No intervention was initiated between test occasions.Results: A significant increase in the mean total score of 1.6 points (95% CI 1.0 to 2.2, p<0.001) was found from season 1 (22.2±4.1 (SD)) to season 2 (23.8±3.3). The variability was large, as shown by an intraclass correlation coefficient (ICC) of 0.24 (95% CI 0.11 to 0.36) and a minimal detectable change (MDC) of 8.7 points. Of the 220 players, 136 (61.8%) suffered a time-loss injury between the 2 tests. There was an improvement in mean total scores in the injured (+2.0±0.4 (SE), p<0.001) group but not in the uninjured group (+0.9±0.5, p=0.089). The variability from season 1 to season 2 was large both in the injured (ICC 0.25, 0.09 to 0.40, MDC 8.3) and uninjured (ICC 0.24, 0.02 to 0.43, MDC 9.1) groups.Conclusions: The 9+ demonstrated substantial intraindividual variability in the total score between 2 consecutive seasons, irrespective of injury. A change above 8 points is necessary to represent a real change in the 9+ test between seasons. [ABSTRACT FROM AUTHOR]

Knee cartilage lesions are frequent in football players, but evidence for surgical treatment is lacking. The aim of this International Cartilage Regeneration & Joint Preservation Society, Fédération Internationale de Football Association, and Aspetar (ICRS-FIFA-Aspetar) consensus was to develop specific expert-based, patient-specific practical recommendations on the appropriateness of non-surgical or surgical treatments for symptomatic knee cartilage lesions in competitive football players. The RAND/UCLA appropriateness method was used, and 17 voting experts provided recommendations on the appropriateness of surgical treatment in 96 different clinical scenarios defined on 6 variables: cartilage injury onset, lesion location, defect size, bone involvement, player symptom level and preference towards higher priority of a quick return to play or long-term results. Surgical treatment of a cartilage lesion was considered appropriate in 32% of the scenarios, in 21% inappropriate, while in 47% of the scenarios, the appropriateness was considered uncertain. The parameters with the highest appropriateness for the surgical treatment of a cartilage lesion in a football player were the inability to play (75.0% of appropriate scenarios), a lesion sized 2 cm 2 or bigger (47.9% of appropriate scenarios) and the preference of the player for long-term results (41.7% of appropriate scenarios). In this ICRS-FIFA-Aspetar expert consensus, surgical treatment for cartilage injuries in competitive football players was considered appropriate only in one-third of the clinical scenarios, and the choice was mainly driven by the level of symptoms. Surgical preference was also influenced by larger lesions, lesions of the condyles and trochlea with subchondral bone involvement and player's preference towards long-term results., Competing Interests: Competing interests: EK reports consulting for Cartiheal, Green Bone, Geistlich and Bioveex, and speaking for Zimmer Biomet and Fidia Farmaceutici SPA. EP: General Board member ICRS, Editorial board JCJP, Advisory board Askel Healthcare, Lectures fees S&N, Lecture fees ConMedAS and AM declare full time employment by FIFA. PV: Royalties Conmed; Consultant Conmed, Adler, Geistlich, Symbios. PA: professorship: aesculap/tetec; consultant: aesculap, Arthrex; fifa: director fifa excellence centre regensburg. CF: Product Royalties and consulting agreement: Medacta, Karl Storz. CAL: Advisory Board: Vericel; Consultant: Smith and Nephew, Johnson and Johnson, Moximed. NN: Editorial Board, AJSM, JISAKOS, Cartilage, J Exp Orthop, J Orthops Sci; Institutional Research Support, Cell Source; Research Grant, Japan Agency for Medical Research and Development, Japan Society for the Promotion of Science DAP: editorial board of AJSM, JISAKOS, AP-SMART Journal, OJSM; hold shares in Peronalised Surgery, Ganymed Robotics; received royalties from Nil; done consulting work for Smith & Nephew; received institutional support from Smith & Nephew, Simmer, Corin, Arthrex. BS-C has received consulting fees and royalties from Arthrex. WvdM: Editorial board JISAKOS; Shareholder GRUCOX medical; Consultant S&N. AMW is on the editorial Board Member American Journal of Sports Medicine, is Share holder Innovate Orthopaedics, and share holder DocComs. SZ: consultant surgeon for Smith and Nephew and DePuy Synthes. The other authors declare no conflicts of interest., (© Author(s) (or their employer(s)) 2025. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Prospectively collected injury surveillance data are essential for designing and implementing injury prevention programmes. We investigated the incidence, characteristics and patterns of professional football injuries in Qatar, providing details on the most observed injuries' burden. We prospectively recorded individual time-loss injuries and training/match exposure from 17 professional football teams in Qatar during 8 seasons (2014/15 to 2021/22). Injury definitions and data collection procedures followed the 2006 consensus statement and results reported according to the 2020 IOC consensus statement on football injuries and methodology of epidemiological studies on injuries, respectively. In total, 1466 players with 4789 registered injuries were followed. The overall injury burden was 129 [95% CI: 128-130] days/1000 h. Over the 8 seasons there was a significant decreasing trend in the incidence of gradual onset injuries (p = 0.0012) and a non-significant decreasing trend for suddenonset match injuries (p = 0.063). The injury burden for match injuries was greater than the burden resulting from training injuries (460 [95% CI: 460-460] vs 56 [95% CI: 55-57] days/1000 h, p < 0.0001). There was no difference in time loss between index and recurrent injuries. Hamstring muscle strain represented the most frequent injury with a median of 11 (inter-quartile 5-20) days to return to play (RTP). ACL complete tear was the most impactful injury, in term of return to play, with a median of 200 (116-253) days to RTP. Re-injuries constituted 10.8% (4.7% of exacerbations). Mean illness incidence was 1.1 (SD = 0.4) illness/1000 hours, representing 5 illnesses per squad per season, with no variation over time. Qatari professional football is characterized by an overall injury pattern and risk similar to Asian and European norms. There was a significant decreasing trend in the incidence of gradual onset injuries and a non-significant decreasing trend for sudden-onset match injuries., Competing Interests: The authors declare no conflict of interest., (Copyright © Institute of Sport – National Research Instutite.)

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

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

The aim was to increase awareness about neuropathic pain in athletes and the available diagnostic criteria and explore the relevance to athletes and sports. In the report of its consensus meeting of 2016, the International Olympic Committee (IOC) noted the critical need to raise the awareness about pain and its management amongst sports physicians. The adequate management of pain requires recognition of its type and pathophysiological mechanisms. This is paramount in applying the multi-modal management of pain as a symptom or approach it as a disease. In athletes, the assessment of pain in general, and of neuropathic pain in particular, is more complex due to the impact of physiological, psychological and motivational factors and specific pathophysiological mechanisms on the pain threshold and tolerance. Neuropathic pain is not uncommon to encounter in athletes although not always recognised. Examples of neuropathic pain as a disease include complex regional pain syndrome (CRPS), peripheral neuropathy and spinal cord injuries. The recognition and diagnosis of neuropathic pain could be facilitated by the application of screening tools such as DN4 (Douleur Neuropathique 4) and LANSS (Leeds Assessment of Neuropathic Symptoms and Signs). Sports injuries may lead to neuropathic pain through different pathologies and mechanisms. Thus, neuropathic pain could be a real threat to athletes' career if not promptly recognised and treated. We therefore believe that early recognition and expert management are mandatory for the best outcome., Competing Interests: All authors declare having no conflict of interest., (Copyright © Biology of Sport 2022.)

Background: Long-standing groin pain syndrome (LSGPS) is a form of groin pain syndrome in which the cohort of symptoms reported by patients is experienced for a long period, typically for over 12 weeks, and is recalcitrant to any conservative therapy. The aim of this prospective epidemiological study was to describe the clinical causes of LSGPS in 37 female athletic subjects in Italy through the Groin Pain Syndrome Italian Consensus Conference on terminology, clinical evaluation and imaging assessment in groin pain in athletes' classification and guidelines., Methods: Thirty-seven female athletes affected by LSGPS were evaluated following the guidelines issued by the Groin Pain Syndrome Italian Consensus Conference on terminology, clinical evaluation and imaging assessment of groin pain in athletes., Results: In the considered population, each patient presented only one pathological cause for LSGPS. The most frequent etiologies were inguinal pathologies (54.05% of the cases), acetabular labrum tear (18.92%) and pelvic floor disorders (8.11%). Adductor tendinopathy represented only 2.70% of cases., Conclusions: Female athletic patients affected by LSGPS show a similar incidence of inguinal and hip pathologies as in male populations. However, these clinical situations do not seem to be associated in women unlike in the male population. This difference is probably due to particular anatomical differences related to gender. For this reason, women affected by LSGPS represent an important subset of patients. Moreover, adductor tendinopathy is probably overrated as an etiopathogenetic source of LSGPS in women.

The prepubic aponeurotic complex anatomy (PPAC) consists in a fibrous capsule, which anteriorly lines the pubic symphysis, formed by the interconnection of different anatomical structures. Research of the studies (original articles, case series and review articles) was conducted without publication data limitation or language restriction on the following databases: PubMed/MEDLINE, Scopus, ISI, EXCERPTA. To date, evidence from the literature suggests that: 1) the PPAC is formed by interconnection between the tendons of the adductor longus, adductor brevis, gracilis and pectineus muscles, the aponeurosis of rectus abdominis, pyramidalis and external oblique muscles, the articular disc, the anterior pubic periostium and by the superior, inferior and anterior pubic ligament; 2) the PPAC clinical presentation may mimic a adductor longus tendon injury, the MRI examination can help to differentiate the two different clinical frameworks; 3) the PPAC injuries show a typical MRI presentation which must be differentiated from other similar but clinically different imaging frameworks; 4) the PACC injury can be treated conservatively, with medical therapies or surgically. This narrative structured review provides an insight into the PPAC the anatomy, the clinical presentation, the imaging and the treatment of the PPAC injuries.

Purpose: To investigate differences in athletes' knowledge, beliefs, and training practices during COVID-19 lockdowns with reference to sport classification and sex. This work extends an initial descriptive evaluation focusing on athlete classification., Methods: Athletes (12,526; 66% male; 142 countries) completed an online survey (May-July 2020) assessing knowledge, beliefs, and practices toward training. Sports were classified as team sports (45%), endurance (20%), power/technical (10%), combat (9%), aquatic (6%), recreational (4%), racquet (3%), precision (2%), parasports (1%), and others (1%). Further analysis by sex was performed., Results: During lockdown, athletes practiced body-weight-based exercises routinely (67% females and 64% males), ranging from 50% (precision) to 78% (parasports). More sport-specific technical skills were performed in combat, parasports, and precision (∼50%) than other sports (∼35%). Most athletes (range: 50% [parasports] to 75% [endurance]) performed cardiorespiratory training (trivial sex differences). Compared to prelockdown, perceived training intensity was reduced by 29% to 41%, depending on sport (largest decline: ∼38% in team sports, unaffected by sex). Some athletes (range: 7%-49%) maintained their training intensity for strength, endurance, speed, plyometric, change-of-direction, and technical training. Athletes who previously trained ≥5 sessions per week reduced their volume (range: 18%-28%) during lockdown. The proportion of athletes (81%) training ≥60 min/session reduced by 31% to 43% during lockdown. Males and females had comparable moderate levels of training knowledge (56% vs 58%) and beliefs/attitudes (54% vs 56%)., Conclusions: Changes in athletes' training practices were sport-specific, with few or no sex differences. Team-based sports were generally more susceptible to changes than individual sports. Policy makers should provide athletes with specific training arrangements and educational resources to facilitate remote and/or home-based training during lockdown-type events.

Objective: To investigate the relationship between training/match-play duration and time-loss groin injury in professional male soccer players, and to determine whether previously identified intrinsic risk factors influenced this relationship., Design: Prospective cohort study., Methods: A total of 579 professional male soccer players were prospectively followed from July 2013 to June 2015. Time-loss groin injuries and individual training and match-play duration were recorded using standardized surveillance methods. Acute training/match-play duration and chronic training/match-play duration were considered as interacting variables. Nonlinear Cox regression analysis (modeled using restricted cubic splines), clustered by player identification number, examined the relationship between training/match-play duration and groin injury. Previously identified intrinsic risk factors of previous groin injury and eccentric adduction strength were included in the multivariable regression analysis., Results: There was no clinically meaningful relationship between training/match-play duration and groin injury risk. Team played for had the strongest influence on groin injury risk (relative log hazard ratio -2.28 to 0.97). Groin injury risk was highest when accumulated chronic and acute training duration was also highest, but large confidence intervals indicate considerable uncertainty around this finding. Previous groin injury and eccentric adduction strength were not associated with groin injury risk when training/match-play duration and team were included in the model., Conclusion: In professional male soccer players, there was no clinically meaningful relationship between groin injury risk and training/match-play duration. Team played for either protected against or increased groin injury risk, indicating that team-related factors not measured in this study had greater effect on groin injury risk than training/match-play duration. J Orthop Sports Phys Ther 2022;52(4):217-223. Epub 5 Feb 2022. doi:10.2519/jospt.2022.10845 .

Objective: Our objective was to explore the training-related knowledge, beliefs, and practices of athletes and the influence of lockdowns in response to the coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)., Methods: Athletes (n = 12,526, comprising 13% world class, 21% international, 36% national, 24% state, and 6% recreational) completed an online survey that was available from 17 May to 5 July 2020 and explored their training behaviors (training knowledge, beliefs/attitudes, and practices), including specific questions on their training intensity, frequency, and session duration before and during lockdown (March-June 2020)., Results: Overall, 85% of athletes wanted to "maintain training," and 79% disagreed with the statement that it is "okay to not train during lockdown," with a greater prevalence for both in higher-level athletes. In total, 60% of athletes considered "coaching by correspondence (remote coaching)" to be sufficient (highest amongst world-class athletes). During lockdown, < 40% were able to maintain sport-specific training (e.g., long endurance [39%], interval training [35%], weightlifting [33%], plyometric exercise [30%]) at pre-lockdown levels (higher among world-class, international, and national athletes), with most (83%) training for "general fitness and health maintenance" during lockdown. Athletes trained alone (80%) and focused on bodyweight (65%) and cardiovascular (59%) exercise/training during lockdown. Compared with before lockdown, most athletes reported reduced training frequency (from between five and seven sessions per week to four or fewer), shorter training sessions (from ≥ 60 to < 60 min), and lower sport-specific intensity (~ 38% reduction), irrespective of athlete classification., Conclusions: COVID-19-related lockdowns saw marked reductions in athletic training specificity, intensity, frequency, and duration, with notable within-sample differences (by athlete classification). Higher classification athletes had the strongest desire to "maintain" training and the greatest opposition to "not training" during lockdowns. These higher classification athletes retained training specificity to a greater degree than others, probably because of preferential access to limited training resources. More higher classification athletes considered "coaching by correspondence" as sufficient than did lower classification athletes. These lockdown-mediated changes in training were not conducive to maintenance or progression of athletes' physical capacities and were also likely detrimental to athletes' mental health. These data can be used by policy makers, athletes, and their multidisciplinary teams to modulate their practice, with a degree of individualization, in the current and continued pandemic-related scenario. Furthermore, the data may drive training-related educational resources for athletes and their multidisciplinary teams. Such upskilling would provide athletes with evidence to inform their training modifications in response to germane situations (e.g., COVID related, injury, and illness)., (© 2021. The Author(s).)

During cancer treatments in childhood hematological malignancies, reduced exercise tolerance is one of the main hardships. Precision-based training programs help children, adolescents, and young adults and their families to resume regular physical activity, exercise, and sports once they return to their communities after the intensive phases spent in hospital. This study was aimed at verifying whether an intermittent recovery test, the Yo-Yo AD, could provide a simple and valid way to evaluate an individual’s capacity to perform repeated intense exercise and to follow up on the impact of tailored exercise in children, adolescents, and young adults with hematological malignancies. The Yo-Yo AD involved the repetition of several shuttles to muscle exhaustion, at pre-established speeds (walking and slow running). The heart rate (HR) and oxygen saturation (SaO2) were monitored during the test. The total distance and the walking/running ability, measured as the slope of the HR vs. distance correlation, were investigated before (T0) and after 11 weeks (T1) of precision exercise intervention. The Yo-Yo AD was also performed by healthy children (CTRL). Ninety-seven patients (10.58 ± 4.5 years, 46% female) were enrolled. The Yo-Yo AD showed the positive impact of the exercise intervention by increasing the distance covered by the individuals (T0 = 946.6 ± 438.2 vs. T1 = 1352.3 ± 600.6 m, p < 0.001) with a more efficient walking/running ability (T0 = 2.17 ± 0.84 vs. T1 = 1.73 ± 0.89 slope, p < 0.0164). CTRLs performed better (1754.0 ± 444.0 m, p = 0.010). They were equally skillful (1.71 ± 0.27 slope) when compared to the patients after they received the precision-based intervention. No adverse events occurred during the Yo-Yo AD and it proved to be an accurate way of correctly depicting the changes in performance in childhood hematological malignancies.

Background: Groin pain is a very common injury in multidirectional sports such as soccer, ice hockey, rugby and Australian football. Long-standing adductor-related groin pain is a persistent clinical condition and a frequent complaint in athletes involved in sports that require multiplanar movement patterns (change of direction, high-speed sprinting and kicking). To date, the lack of rehabilitation guidelines and return-to-play criteria makes this clinical entity difficult to manage. The aim of the present Delphi was to suggest, based on opinion and practical experience of a panel of experts, potential criteria that could be taken into consideration by clinicians in the RTP decision-making process in athletes suffering from long-standing adductor-related groin pain., Methods: Thirty two out of 40 experts participated to a 3-Round Delphi questionnaire. In round 1, open-ended and closed questions about 9 different sections (palpation, flexibility, strength, patient-reported outcome measures, imaging, intersegmental control, performance tests, sport-specific skills, training load) were proposed to investigate return to play evaluation criteria used by each expert. Responses were analysed and coded to produce round 2 questionnaire that investigated only the sections and the items that reached the cut-off value (≥ 70%). Round 3 questionnaire was based on sections and items that reached cut-off value in previous rounds and experts rated their agreement for return to play criteria with a 5-point Likert Scale. Descriptive statistics enabled interpretation of consensus., Results: High participation rate (80%) and response rate across the 3 rounds (100%) were recorded. 6 sections reached positive consensus in round 1, 1 section reached negative consensus. In round 2 positive consensus was confirmed only for 3 sections and negative consensus for 1 section. In round 3, positive agreement was established for strength (3 items), performance tests (3 items) and sport-specific skills (2 items) sections. Negative consensus was confirmed for imaging section., Conclusion: Experts agreed that strength, performance tests and sport-specific skills can be used to support RTP decision, while imaging cannot be used. These findings could be useful in assisting clinicians in the RTP decision making., (© 2022. The Author(s).)

Background: While football injury and illness epidemiology surveillance at professional club level in Europe is available, epidemiological data from other continents are lacking., Purpose: Investigating injury and illness epidemiology in professional Asian football., Study Design: Descriptive prospective study., Methods: Professional teams from the Asian Football Confederation (AFC) league were followed prospectively for three consecutive AFC seasons (2017 through 2019, 13 teams per season, 322 team months). Time-loss injuries and illnesses in addition to individual match and training exposure were recorded using standardised digital tools in accordance with international consensus procedures., Results: In total, 232 665 hours of exposure (88.6% training and 11.4% matches) and 1159 injuries were recorded; 496 (42.8%) occurred during matches, 610 (52.6%) during training; 32 (2.8%) were reported as 'not applicable' and for 21 injuries (1.8%) information was missing. Injury incidence was significantly greater during match play (19.2±8.6 injuries per 1000 hours) than training (2.8±1.4, p<0.0001), resulting in a low overall incidence of 5.1±2.2.The injury burden for match injuries was greater than from training injuries (456±336 days per 1000 hours vs 54±34 days, p<0.0001). The two specific injuries causing the greatest burden were complete ACL ruptures (0.14 injuries (95% CI 0.9 to 0.19) and 29.8 days lost (29.1 to 30.5) per 1000 hours) and hamstring strains (0.86 injuries (0.74 to 0.99) and 17.5 days (17.0 to 18.1) lost per 1000 hours).Reinjuries constituted 9.9% of all injuries. Index injuries caused 22.6±40.8 days of absence compared with 25.1±39 for reinjuries (p=0.62). The 175 illnesses recorded resulted in 1.4±2.9 days of time loss per team per month., Conclusion: Professional Asian football is characterised by an overall injury incidence similar to that reported from Europe, but with a high rate of ACL ruptures and hamstring injury, warranting further investigations., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Athletes and military personnel may experience sleep disturbances due to conditions of training and competitions or military missions/field operations. The risk of muscle injuries is greater for them when sleep duration decreases, and training load increases simultaneously, which can be exacerbated by fatigue. Accumulating evidence demonstrates that sleep extension improved performance, pain sensitivity and GH/IGF-I anabolic responses, which may be beneficial in accelerating recovery from muscle injuries., Design & Methods: This narrative review describes the importance of sleep for the recovery/prevention of exercise-induced muscle injuries and provides perspectives on the transferability of currently available scientific evidence to the field., Results: The first part presents the role of sleep and its interaction with the circadian system for the regulation of hormonal and immune responses, and provides information on sleep in athletes and soldiers and its relationship to injury risk. The second part is an overview of muscle injuries in sport and presents the different phases of muscle regeneration and repair, i.e. degeneration, inflammation, regeneration, remodeling and maturation. Part three provides information on the deleterious effects of sleep deprivation on muscle tissue and biological responses, and on the benefits of sleep interventions. Sleep extension could potentially help and/or prevent recovery from exercise-induced muscle-injuries through increasing local IGF-I and controlling local inflammation., Conclusions: Although the science of sleep applied to sport is still an emerging field, the current scientific literature shows many potential physiological pathways between sleep and exercise-related muscle injuries. More direct studies are needed to establish clear guidelines for medical personnel and coaches., (Copyright © 2021 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.)

Background: Groin pain syndrome is an important and increasing problem in numerous sports (e.g. soccer, football, ice hockey, handball and rugby). Long-standing groin pain syndrome is a form of groin pain syndrome in which the cohort of symptoms reported by the patient is experienced for a long period, typically for over 12 weeks, and is recalcitrant to any conservative therapy. Long-standing groin pain syndrome is potentially career-ending for elite athletes., Methods: A descriptive epidemiological study was carried out on 320 athletes (290 men and 30 women) affected by long-standing groin pain syndrome, following the Guidelines issued by the Groin Pain Syndrome Italian Consensus Conference on terminology, clinical evaluation and imaging assessment of groin pain in athlete., Results: Amongst the clinical tests for inguinal pathologies, only the External Inguinal Ring Exploration proved conclusive (sensitivity: 0.97; specificity: 0.95; positive predictive value: 0.98; negative predictive value: 0.90; likelihood ratio: 19.4). In testing for adductor tendinopathies, only the Isometric Squeeze with flexed knee and distal resistance (sensitivity: 0.86; specificity: 0.45; positive predictive value: 0.48; negative predictive value: 0.85; likelihood ratio: 5.7) and the Palpatory Test at the pubic insertion of the adductor longus (sensitivity: 0.93; specificity: 0.89; positive predictive value: 0.96; negative predictive value: 0.79; likelihood ratio: 8.5) proved, respectively, useful at times and moderately useful. Among the tests for hip pathologies, only the Flexion Abduction External Rotation Test was seen to be conclusive (sensitivity: 0.90; specificity: 0.93; positive predictive value: 0.98; negative predictive value: 0.72; likelihood ratio: 12.9). In the male population on average, long-standing groin syndrome presents either a single cause or multiple causes in respectively 74% and 26% of cases. Furthermore, almost 58% of all cases traced to a single clinical cause can be attributed to inguinal pathologies alone. Long-standing groin syndrome in the female population shows only one pathological cause with inguinal pathologies, and acetabular labrum tear representing the most frequent etiologies., Conclusions: Men and women exhibit different causes for long-standing groin pain syndrome. Several routine tests used in the clinical evaluation of this condition furnish a low likelihood ratio. Consequently, in order to optimize clinical evaluation and minimize patient discomfort, clinical evaluation should be based on tests with a greater likelihood ratio.

The lockdown caused by the COVID-19 pandemic represents a great unknown regarding the physiological changes induced in elite football players. Although it will differ from country to country, the return to sport for professional football players will follow a forced lockdown never experienced and longer than the normal annual season break. Moreover, in addition to an obvious decrease in performance, the lockdown will possibly lead to an increase of the injury risk. In fact, preseason is always a period with a specific football injury epidemiology, with an increase in the incidence and prevalence of overuse injuries. Therefore, it seems appropriate to recommend that specific training and injury prevention programmes be developed, with careful load monitoring. Training sessions should include specific aerobic, resistance, speed and flexibility training programmes. The aerobic, resistance and speed training should respect some specific phases based on the progressiveness of the training load and the consequent physiological adaptation response. These different phases, based on the current evidence found in the literature, are described in their practical details. Moreover, injury prevention exercises should be incorporated, especially focusing on overuse injuries such as tendon and muscle lesions. The aim of this paper is to provide practical recommendations for the preparation of training sessions for professional footballers returning to sport after the lockdown., Competing Interests: All authors declare having no conflict of interest., (Copyright © Biology of Sport 2020.)

In early 2020, the world is facing a global emergency called COVID-19. Many professional footballers around the world are home confined. The maintenance of physical capacity is a fundamental requirement for the athlete, so the training sessions must be adapted to this unique situation. Specific recommendations must be followed concerning the type of training, its intensity, the precautions that have to be followed to avoid the possibility of contagion, and the restrictions in accordance with the presence of any symptoms. This article analyses the available scientific evidence in order to recommend a practical approach., Competing Interests: All authors declare having NO conflict of interest, (Copyright © Biology of Sport 2020.)

Objectives: To investigate the impact of physical efforts performed in the period preceding activity as a potential risk factor of muscle injury during match-play within a sample of professional soccer players., Design: Observational cohort study., Methods: Match load (running [>14.4-19.8km/h], high-speed running [>19.8-25.2km/h], sprinting [>25.2km/h], leading and explosive sprint type) averaged in 1-min and 5-min periods prior to an event or non event for 29 professional outfield soccer players. Conditional logistic and Poisson regression models estimated the relationship between load and injury for a 2 within-subject standard deviation in match load or 1-action increment in the number of sprinting activities, respectively. Associations were deemed beneficial or harmful based on non-overlap of the 95% confidence intervals against thresholds of 0.90 and 1.11, respectively., Results: An increment in sprinting distance [+2-SDs=11m] covered over a 1-min period (odds ratio [OR]: 1.22, 95%CI, 1.12 to 1.33) increased the odds of muscle injury., Conclusions: Our study provides novel exploratory evidence that the volume of sprinting during competitive soccer match-play has a harmful association with muscle injury occurrence., (Copyright © 2019 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.)

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., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

Aim: To ascertain ACL injury incidence, severity (injury burden) and patterns (contact/non-contact and reinjuries) in a professional male football league in the Middle East over five consecutive seasons., Methods: Prospective epidemiological study reporting ACL injuries in professional male soccer players in the Qatar Stars League, with complete matches/training exposure over five seasons (2013-2014 to 2017-2018), corresponding to 2243 player seasons and 729 team months., Results: 37 complete ACL ruptures occurred in 37 players during 486 951  hours of player exposure. The overall ACL injury rate was 0.076 injuries/1000  hours of exposure (season range 0.045-0.098). Injury incidence during matches and training was 0.41 and 0.04 injuries/1000  hours of exposure, respectively. Match injury incidence was greater than that of training (OR 11.8, 95%  CI 6.21 to 23.23, p<0.001). Average injury-related time-loss following ACL injury was 225 days±65 (range 116-360). Overall injury burden was 16.3 days lost/1000  hours of exposure., Conclusion: The overall ACL injury rate in professional male soccer players competing in the Middle East was 0.076 injuries/1000  hours of exposure, match injury incidence was greater than training, while the average ACL time-loss was 225 days., Competing Interests: Competing interests: None declared.

Previous literature suggests that human behaviour and physiology are somehow altered by the moon-cycle, with particular emphasis on poorer sleep quality and increased aggressive behaviour during full moon. The latter variables can negatively impact athletes' recovery and increase the likelihood of injury resulting from collision with another athlete. Therefore, the current study aimed to investigate the association between the lunar cycle and injury risk in professional football players (soccer). We monitored injuries and player exposure in the premier professional league in Qatar during four consecutive seasons (2013-2014 through 2016-2017). Acute (sudden-onset traumatic) injuries (n = 1184; 587 from contact with another player and 597 without player contact) recorded during matches and training were classified according to the lunar cycle characteristics on the date of injury: (i) moon illumination, (ii) lunar distance from earth and (iii) tidal coefficient, acquired from the lunar calendar and tide tables. We used a Poisson regression model to examine the relationship between injury risk and lunar cycle characteristics. We did not detect any association between injury risk and moon illumination, earth-to-moon distance or tidal coefficient, not for all acute injuries, nor for contact and non-contact injuries when examined separately. The findings suggest that the full moon or new moon or the gravitational pull have no effect on football injuries. Thus, organisers need not consult moon or tide tables when planning future event schedules.

Background: The 9+ screening battery test consists of 11 tests to assess limitations in functional movement., Aim: To examine the association of the 9+ with lower extremity injuries and to identify a cut-off point to predict injury risk., Methods: Professional male football players in Qatar from 14 teams completed the 9+ at the beginning of the 2013/2014 and 2014/2015 seasons. Time-loss injuries and exposure in training and matches were registered prospectively by club medical staff during these seasons. Univariate and multivariate Cox regression analyses were used to calculate HR and 95% CI. Receiver operating characteristic (ROC) curves were calculated to determine sensitivity and specificity and identify the optimal cut-off point for risk assessment., Results: 362 players completed the 9+ and had injury and exposure registration. There were 526 injuries among 203 players (56.1%) during the two seasons; injuries to the thigh were the most frequent. There was no association between 9+ total score and the risk of lower extremity injuries (HR 1.02, 95% CI 0.99 to 1.05, p=0.13), even after adjusting for other risk factors in a multivariate analysis (HR 1.01, 95% CI 0.98 to 1.04, p=0.37). ROC curve analysis revealed an area under the curve of 0.48, and there was no cut-off point that distinguished injured from non-injured players., Conclusion: The 9+ was not associated with lower extremity injury, and it was no better than chance for distinguishing between injured and uninjured players. Therefore, the 9+ test cannot be recommended as an injury prediction tool in this population., Competing Interests: Competing interests: KMK is the Editor-in-Chief of BJSM and was at arm’s length (and blinded) from the review process., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Provide the state of the art concerning (1) biology and aetiology, (2) classification, (3) clinical assessment and (4) conservative treatment of lower limb muscle injuries (MI) in athletes. Seventy international experts with different medical backgrounds participated in the consensus conference. They discussed and approved a consensus composed of four sections which are presented in these documents. This paper represents a synthesis of the consensus conference, the following four sections are discussed: (i) The biology and aetiology of MIs. A definition of MI was formulated and some key points concerning physiology and pathogenesis of MIs were discussed. (ii) The MI classification. A classification of MIs was proposed. (iii) The MI clinical assessment, in which were discussed anamnesis, inspection and clinical examination and are provided the relative guidelines. (iv) The MI conservative treatment, in which are provided the guidelines for conservative treatment based on the severity of the lesion. Furthermore, instrumental therapy and pharmacological treatment were discussed. Knowledge of the aetiology and biology of MIs is an essential prerequisite in order to plan and conduct a rehabilitation plan. Another important aspect is the use of a rational MI classification on prognostic values. We propose a classification based on radiological investigations performed by ultrasonography and MRI strongly linked to prognostic factors. Furthermore, the consensus conference results will able to provide fundamental guidelines for diagnostic and rehabilitation practice, also considering instrumental therapy and pharmacological treatment of MI. Expert opinion, level IV., Competing Interests: Competing interests: None declared.

Background: Musculoskeletal hip/groin screening tests are commonly performed to detect at-risk individuals. Bony hip morphology is considered a potential intrinsic risk factor but has not been examined prospectively., Purpose: To evaluate the association between intrinsic risk factors identified from musculoskeletal and radiographic screening tests and hip/groin injuries leading to time loss from training and/or match play in professional male soccer players., Study Design: Prospective cohort study; Level of evidence, 2., Methods: Male professional soccer players, aged ≥18 years, underwent screening specific for hip/groin pain during 2 consecutive seasons of the Qatar Stars League. The screening battery included pain provocation, range of motion, and strength tests as well as a hip radiographic examination. The radiographic examination included an anteroposterior pelvic view and 45° Dunn view, with bony hip morphology determined using quantitative methods. Time-loss (≥1 day) hip/groin injuries and individual player exposure (training and match play) were recorded prospectively, and injuries were categorized as adductor-related, inguinal-related, iliopsoas-related, pubic-related, or hip-related groin pain, or "other," as recommended in the Doha agreement. We calculated hazard ratios (HRs) from univariate and multivariate Cox regression models to assess the relationship between potential risk factors and hip/groin injuries., Results: There were 438 players, completing 609 player seasons, and 113 hip/groin injuries that met the criteria for inclusion, with 85 injuries categorized as adductor-related. The proportion of players with bony morphological variants was the following: cam, 71%; pincer, 5%; and acetabular dysplasia, 13%. Previous hip/groin injuries (HR, 1.8; 95% CI, 1.2-2.7) and eccentric adduction strength were associated with the risk of hip/groin injuries. Higher (>1 SD above the mean) than normal eccentric adduction strength was associated with an increased risk for all hip/groin injuries (HR, 1.6; 95% CI, 1.0-2.5). Lower (<1 SD below the mean) than normal eccentric adduction strength was associated with an increased risk for adductor-related injuries (HR, 1.7; 95% CI, 1.0-3.0). No other musculoskeletal screening test or bony hip morphology variables were associated with the injury risk., Conclusion: Previous groin injuries and eccentric adduction strength were associated with the risk of groin injuries. However, these associations were not strong enough to identify an "at-risk" individual, and therefore, musculoskeletal screening tests were not useful to dictate individualized prevention strategies. Bony hip morphology was not associated with the risk of groin injuries.

Background: Lower extremity muscle strength tests are commonly used to screen for injury risk in professional soccer. However, there is limited evidence on the ability of such tests in predicting future injuries., Purpose: To examine the association between hip and thigh muscle strength and the risk of lower extremity injuries in professional male soccer players., Study Design: Case-control study; Level of evidence, 3., Methods: Professional male soccer players from 14 teams in Qatar underwent a comprehensive strength assessment at the beginning of the 2013/2014 and 2014/2015 seasons. Testing consisted of concentric and eccentric quadriceps and hamstring isokinetic peak torques, eccentric hip adduction and abduction forces, and bilateral isometric adductor force (squeeze test at 45°). Time-loss injuries and exposure in training and matches were registered prospectively by club medical staff throughout each season. Univariate and multivariate Cox regression analyses were used to calculate hazard ratios (HRs) with 95% CIs., Results: In total, 369 players completed all strength tests and had registered injury and exposure data. Of these, 206 players (55.8%) suffered 538 lower extremity injuries during the 2 seasons; acute muscle injuries were the most frequent. Of the 20 strength measures examined, greater quadriceps concentric peak torque at 300 deg/s (HR, 1.005 [95% CI, 1.00-1.01]; P = .037) was the only strength measure identified as significantly associated with a risk of lower extremity injuries in multivariate analysis. Greater quadriceps concentric peak torque at 60 deg/s (HR, 1.004 [95% CI, 1.00-1.01]; P = .026) was associated with the risk of overuse injuries, and greater bilateral adductor strength adjusted for body weight (HR, 0.75 [95% CI, 0.57-0.97; P = .032) was associated with a lower risk for any knee injury. Receiver operating characteristic curve analyses indicated poor predictive ability of the significant strength variables (area under the curve, 0.45-0.56)., Conclusion: There was a weak association with the risk of lower extremity injuries for 2 strength variables: greater quadriceps concentric muscle strength at (1) high and (2) low speeds. These associations were too small to identify an "at-risk" player. Therefore, strength testing, as performed in the present study, cannot be recommended as a screening test to predict injuries in professional male soccer.

Background/aim: Groin injury epidemiology has not previously been examined in an entire professional football league. We recorded and characterised time loss groin injuries sustained in the Qatar Stars League., Methods: Male players were observed prospectively from July 2013 to June 2015. Time loss injuries, individual training and match play exposure were recorded by club doctors using standardised surveillance methods. Groin injury incidence per 1000 playing hours was calculated, and descriptive statistics used to determine the prevalence and characteristics of groin injuries. The Doha agreement classification system was used to categorise all groin injuries., Results: 606 footballers from 17 clubs were included, with 206/1145 (18%) time loss groin injuries sustained by 150 players, at an incidence of 1.0/1000 hours (95% CI 0.9 to 1.1). At a club level, 21% (IQR 10%-28%) of players experienced groin injuries each season and 6.6 (IQR 2.9-9.1) injuries were sustained per club per season. Of the 206 injuries, 16% were minimal (1-3 days), 25% mild (4-7 days), 41% moderate (8-28 days) and 18% severe (>28 days), with a median absence of 10 days/injury (IQR 5-22 days). The median days lost due to groin injury per club was 85 days per season (IQR 35-215 days). Adductor-related groin pain was the most common entity (68%) followed by iliopsoas (12%) and pubic-related (9%) groin pain., Conclusion: Groin pain caused time loss for one in five players each season. Adductor-related groin pain comprised 2/3 of all groin injuries. Improving treatment outcomes and preventing adductor-related groin pain has the potential to improve player availability in professional football., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)