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The Use of Diagnostic Ultrasound in Sports Muscle Injuries in Football (Soccer) Players: State-of-the-art Review

Abstract

Recent findings

Muscle injuries count for one third of all sports injuries and are the most common injuries in football (soccer) players. There is a clear need to define the best approach for patients from an accurate diagnosis to complete functional recovery and return to play. In this context, especially in the last decades, the use of diagnostic ultrasound has become a key tool in the management of muscle injuries, even if complete agreement is still lacking.

Purpose of the review

This state-of-the-art review aims to critically discuss the use of diagnostic ultrasound in the management of muscle injuries in football. In the paper, the best available evidence and an experience-based approach are discussed, from basic technical aspects to advanced clinical evaluation. Beginning with diagnosis and classification to the serial evaluations in the return to play process, the paper underlines the key aspects that should be considered when using ultrasound results to guide the recovery process.

Summary

Diagnostic ultrasound is a useful and frequently performed procedure in sport and exercise medicine, especially in the management of football muscle injuries. Technical skills are needed to correctly interpret ultrasound findings that should always be considered in conjunction with the clinical and functional recovery of the athlete.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Edouard P, Branco P, Alonso J-M. Muscle injury is the principal injury type and hamstring muscle injury is the first injury diagnosis during top-level international athletics championships between 2007 and 2015. Br J Sports Med. 2016;50:619–30.

    PubMed  Article  Google Scholar 

  2. Barroso GC, Thiele ES. Muscle injuries in athletes. Rev Bras Ortop. 2015;46:354–8.

    PubMed  PubMed Central  Article  Google Scholar 

  3. Chan O, Del Buono A, Best TM, Maffulli N. Acute muscle strain injuries: a proposed new classification system. Knee Surg Sports Traumatol Arthrosc. 2012;20:2356–62.

    PubMed  Article  Google Scholar 

  4. Valle X. Clinical practice guide for muscular injuries: epidemiology, diagnosis, treatment and prevention. Br J Sports Med. 2011;45:e2–e2.

    Article  Google Scholar 

  5. Nanni G, Frizziero A, Miceli R, Vittadini F, Finotti P, Gamberini J, Oliva F, Freschi M, Buckthorpe M, Maffulli N (2020) Muscle injuries 2020 update of the I.S.Mu.L.T. Classification. Muscle Ligaments Tendons J 10:562

  6. Ekstrand J, Hägglund M, Waldén M. Epidemiology of muscle injuries in professional football (soccer). Am J Sports Med. 2011;39:1226–32.

    PubMed  Article  Google Scholar 

  7. Ueblacker P, Müller-Wohlfahrt H-W, Ekstrand J. Epidemiological and clinical outcome comparison of indirect (‘strain’) versus direct (‘contusion’) anterior and posterior thigh muscle injuries in male elite football players: UEFA Elite League study of 2287 thigh injuries (2001–2013). Br J Sports Med. 2015;49:1461–5.

    PubMed  Article  Google Scholar 

  8. Mueller-Wohlfahrt H-W, Haensel L, Mithoefer K, et al. Terminology and classification of muscle injuries in sport: the Munich consensus statement. Br J Sports Med. 2013;47:342–50.

    PubMed  Article  Google Scholar 

  9. Hall MM. Return to play after thigh muscle injury: utility of serial ultrasound in guiding clinical progression. Curr Sports Med Rep. 2018;17:296–301. The article suggests a protocol for managing muscle injuries from the acute phase to return to play, based on ultrasound criteria. It provides an extensive description of useful techniques and strategies to adequately perform an ultrasound examination to assess the progression of the healing process and define the proper progression during the rehabilitation phases.

    PubMed  Article  Google Scholar 

  10. Ishøi L, Krommes K, Husted R, Juhl C, Virgile A, Thorborg K (2020) Infographic. 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). Br J Sports Med 54:bjsports-2020

  11. Ekstrand J, Askling C, Magnusson H, Mithoefer K. Return to play after thigh muscle injury in elite football players: implementation and validation of the Munich muscle injury classification. Br J Sports Med. 2013;47:769–74.

    PubMed  Article  Google Scholar 

  12. Renoux J, Brasseur J-L, Wagner M, Frey A, Folinais D, Dibie C, Maiza D, Crema MD. Ultrasound-detected connective tissue involvement in acute muscle injuries in elite athletes and return to play: The French National Institute of Sports (INSEP) study. J Sci Med Sport. 2019;22:641–6. This study, based on the US evaluation of seventy consecutive athletes with an acute muscle injury, showed that ultrasound-detected connective tissue involvement in acute muscle injuries is related to longer return to play times. This finding supports the importance of ultrasonography in defining the prognosis in muscle injuries.

    PubMed  Article  Google Scholar 

  13. Allen GM. The use of ultrasound in athletes. Eur J Radiol. 2018;109:136–41.

    PubMed  Article  Google Scholar 

  14. Guermazi A, Roemer FW, Robinson P, Tol JL, Regatte RR, Crema MD. Imaging of muscle injuries in sports medicine: sports imaging series. Radiology. 2017;282:646–63. This is a state-of-the-art review that discusses the main imaging modalities for the assessment of sports-related muscle injuries, including advanced imaging techniques, with the focus on the clinical relevance of imaging features of muscle injuries. It provides both US and MRI imaging of different types of muscle injuries.

    PubMed  Article  Google Scholar 

  15. Yamada AF, Godoy IRB, Pecci Neto L, Taneja AK, Hernandez Filho G, Skaf AY. Diagnostic imaging of muscle injuries in sports medicine: new concepts and radiological approach. Curr Radiol Rep. 2017;5:27.

    Article  Google Scholar 

  16. Henderson REA, Walker BF, Young KJ. The accuracy of diagnostic ultrasound imaging for musculoskeletal soft tissue pathology of the extremities: a comprehensive review of the literature. Chiropr Man Therap. 2015;23:31.

    PubMed  PubMed Central  Article  Google Scholar 

  17. Pedret C, Balius R, Blasi M, Dávila F, Aramendi JF, Masci L, de la Fuente J. Ultrasound classification of medial gastrocnemious injuries. Scand J Med Sci Sports. 2020;30:2456–65.

    PubMed  Article  Google Scholar 

  18. Chambers G, Kraft J, Kingston K. The role of ultrasound as a problem-solving tool in the assessment of paediatric musculoskeletal injuries. Ultrasound. 2019;27:6–19.

    PubMed  Article  Google Scholar 

  19. Bisciotti GN, Volpi P, Alberti G, et al. Italian consensus statement (2020) on return to play after lower limb muscle injury in football (soccer). BMJ Open Sport Exerc Med. 2019;5: e000505.

    PubMed  PubMed Central  Article  Google Scholar 

  20. Drakonaki EE, Sudoł-Szopińska I, Sinopidis C, Givissis P. High resolution ultrasound for imaging complications of muscle injury: is there an additional role for elastography? J Ultrason. 2019;19:137–44. This article discusses the utility of high-resolution ultrasound imaging equipped with high-frequency probes and advanced B-mode and doppler technology for the diagnosis, grading and follow-up of muscle injuries. It contains valuable information on the histology and ultrasound appearance of normal and abnormal muscle healing with an emphasis on the sonographic appearances of muscle injury complications. It also discusses pitfalls, provides tips for less experienced sonographers and presents the possible role of strain elastography in the diagnosis of complications, such as scar tissue.

    PubMed  PubMed Central  Article  Google Scholar 

  21. Peetrons P. Ultrasound of muscles. Eur Radiol. 2002;12:35–43.

    CAS  PubMed  Article  Google Scholar 

  22. Takebayashi S, Takasawa H, Banzai Y, Miki H, Sasaki R, Itoh Y, Matsubara S. Sonographic findings in muscle strain injury: clinical and MR imaging correlation. J Ultrasound Med. 1995;14:899–905.

    CAS  PubMed  Article  Google Scholar 

  23. Megliola A, Eutropi F, Scorzelli A, Gambacorta D, De Marchi A, De Filippo M, Faletti C, Ferrari FS. Ultrasound and magnetic resonance imaging in sports-related muscle injuries. Radiol med. 2006;111:836–45. This article compares US and MRI evaluations in acute muscle injuries and supports the role of the US as the first-line technique for examination of muscle injuries. It also argues that MRI is able to reveal lesions that may be missed at US and provide a more accurate assessment of site and extent of injury.

    CAS  PubMed  Article  Google Scholar 

  24. Flores DV, Mejía Gómez C, Estrada-Castrillón M, Smitaman E, Pathria MN. MR imaging of muscle trauma: anatomy, biomechanics, pathophysiology, and imaging appearance. Radiographics. 2018;38:124–48.

    PubMed  Article  Google Scholar 

  25. Nazarian LN. The top 10 reasons musculoskeletal sonography is an important complementary or alternative technique to MRI. AJR Am J Roentgenol. 2008;190:1621–6.

    PubMed  Article  Google Scholar 

  26. Manara M, Manari D, Pasta G. Diagnostic imaging in muscle injury. Muscle Injuries in Sport Medicine. 2013. https://doi.org/10.5772/56472.

    Article  Google Scholar 

  27. Tok F, Özçakar L, De Muynck M, Kara M, Vanderstraeten G (2012) Musculoskeletal ultrasound for sports injuries. Eur J Phys Rehabil Med 48:651–663; quiz 707

  28. Purohit NB, King LJ. Ultrasound of lower limb sports injuries. Ultrasound. 2015;23:149–57.

    PubMed  PubMed Central  Article  Google Scholar 

  29. Petersen J, Thorborg K, Nielsen MB, Skjødt T, Bolvig L, Bang N, Hölmich P. The diagnostic and prognostic value of ultrasonography in soccer players with acute hamstring injuries. Am J Sports Med. 2014;42:399–404.

    PubMed  Article  Google Scholar 

  30. Yu J-Y, Jeong J-G, Lee B-H. Evaluation of muscle damage using ultrasound imaging. J Phys Ther Sci. 2015;27:531–4.

    PubMed  PubMed Central  Article  Google Scholar 

  31. Balius R, Rodas G, Pedret C, Capdevila L, Alomar X, Bong DA. Soleus muscle injury: sensitivity of ultrasound patterns. Skeletal Radiol. 2014;43:805–12.

    PubMed  Article  Google Scholar 

  32. Balius R, Pedret C, Iriarte I, Sáiz R, Cerezal L. Sonographic landmarks in hamstring muscles. Skeletal Radiol. 2019;48:1675–83.

    PubMed  PubMed Central  Article  Google Scholar 

  33. Valle X, Alentorn-Geli E, Tol JL, et al. Muscle injuries in sports: a new evidence-informed and expert consensus-based classification with clinical application. Sports Med. 2017;47:1241–53.

    PubMed  Article  Google Scholar 

  34. Muñoz ChS, Astudillo AC, Miranda VE, Albarracin GJF. Lesiones musculares deportivas: correlación entre anatomía y estudio por imágenes. Rev chil radiol. 2018;24:22–33.

    Google Scholar 

  35. Pasta G, Nanni G, Molini L, Bianchi S. Sonography of the quadriceps muscle: examination technique, normal anatomy, and traumatic lesions. J Ultrasound. 2010;13:76–84.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  36. Ihnatsenka B, Boezaart AP. Ultrasound: basic understanding and learning the language. Int J Shoulder Surg. 2010;4:55–62.

    PubMed  PubMed Central  Article  Google Scholar 

  37. Em MD. Practical musculoskeletal ultrasound. 2nd ed. Philadelphia: Churchill Livingstone; 2014.

    Google Scholar 

  38. Lento PH, Primack S. Advances and utility of diagnostic ultrasound in musculoskeletal medicine. Curr Rev Musculoskelet Med. 2008;1:24–31.

    PubMed  Article  Google Scholar 

  39. Woodhouse JB, McNally EG. Ultrasound of skeletal muscle injury: an update. Semin Ultrasound CT MR. 2011;32:91–100.

    PubMed  Article  Google Scholar 

  40. Becciolini M, Bonacchi G, Bianchi S. Ultrasound features of the proximal hamstring muscle-tendon-bone unit. J Ultrasound Med. 2019;38:1367–82.

    PubMed  Article  Google Scholar 

  41. Connell DA, Schneider-Kolsky ME, Hoving JL, Malara F, Buchbinder R, Koulouris G, Burke F, Bass C. Longitudinal study comparing sonographic and MRI assessments of acute and healing hamstring injuries. AJR Am J Roentgenol. 2004;183:975–84.

    PubMed  Article  Google Scholar 

  42. Yoshida K, Itoigawa Y, Maruyama Y, Kaneko K. Healing process of gastrocnemius muscle injury on ultrasonography using B-mode imaging, power Doppler imaging, and shear wave elastography. J Ultrasound Med. 2019;38:3239–46.

    PubMed  Article  Google Scholar 

  43. Mattiussi G, Baldassi PT, Pasta G, Burani A, Moreno C. Perivascular adductor longus muscle injury: ultrasound and magnetic resonance imaging findings. Muscles Ligaments Tendons J. 2017;7:376–87.

    PubMed  PubMed Central  Article  Google Scholar 

  44. Bright JM, Fields KB, Draper R. Ultrasound diagnosis of calf injuries. Sports Health. 2017;9:352–5.

    PubMed  PubMed Central  Article  Google Scholar 

  45. Balius R, Pedret C, Blasi M, Miguel M, Vallejo B, Margalet E, Bong DA, Martinoli C. Sonographic evaluation of the distal iliopsoas tendon using a new approach. J Ultrasound Med. 2014;33:2021–30.

    PubMed  Article  Google Scholar 

  46. Draghi F, Zacchino M, Canepari M, Nucci P, Alessandrino F. Muscle injuries: ultrasound evaluation in the acute phase. J Ultrasound. 2013;16:209–14.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  47. Tranquart F, Grenier N, Eder V, Pourcelot L. Clinical use of ultrasound tissue harmonic imaging. Ultrasound Med Biol. 1999;25:889–94.

    CAS  PubMed  Article  Google Scholar 

  48. Kim SY, Cheon JH, Seo WJ, Yang GY, Choi YM, Kim KH. A pictorial review of signature patterns living in musculoskeletal ultrasonography. Korean J Pain. 2016;29:217–28.

    PubMed  PubMed Central  Article  Google Scholar 

  49. Young H-J, Southern WM, Mccully KK. Comparisons of ultrasound-estimated intramuscular fat with fitness and health indicators. Muscle Nerve. 2016;54:743–9.

    CAS  PubMed  Article  Google Scholar 

  50. Manini TM, Clark BC, Nalls MA, Goodpaster BH, Ploutz-Snyder LL, Harris TB. Reduced physical activity increases intermuscular adipose tissue in healthy young adults. Am J Clin Nutr. 2007;85:377–84.

    CAS  PubMed  Article  Google Scholar 

  51. Serafin-Król M, Maliborski A. Diagnostic errors in musculoskeletal ultrasound imaging and how to avoid them. J Ultrason. 2017;17:188–96.

    PubMed  PubMed Central  Article  Google Scholar 

  52. Longo V, Jacobson JA, Fessell DP, Mautner K. Ultrasound findings of delayed-onset muscle soreness. J Ultrasound Med. 2016;35:2517–21.

    PubMed  Article  Google Scholar 

  53. Balius R, Blasi M, Pedret C, et al. A histoarchitectural approach to skeletal muscle injury: searching for a common nomenclature. Orthop J Sports Med. 2020. https://doi.org/10.1177/2325967120909090.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Aspetar Sports Medicine Journal - Return to play after acute hamstring injuries. https://www.aspetar.com/journal/viewarticle.aspx?id=252#.YEUrp5NKhQI. Accessed 7 Mar 2021

  55. Echlin PS, Upshur RE, McKeag DB, Jayatilake HP. Traumatic deep vein thrombosis in a soccer player: a case study. Thromb J. 2004;2:8.

    PubMed  PubMed Central  Article  Google Scholar 

  56. Lutterbach-Penna RA, Kalume-Brigido M, Robertson BL, Jacobson JA, Girish G, Fessell DP. Deep vein thrombosis simulating hamstring injury on sonography. J Ultrasound Med. 2012;31:660–2.

    PubMed  Article  Google Scholar 

  57. Alessandrino F, Balconi G. Complications of muscle injuries. J. Ultrasound. 2013;16:215–22.

    CAS  Article  Google Scholar 

  58. Tercero AA, Fernandez RV, Murillo IG. Muscle tear: innovation in the classification and imagenological approach of sports muscle injuries. Int J Fam Commun Me. 2020;4(6):169–77.

    Article  Google Scholar 

  59. Orlandi D, Corazza A, Arcidiacono A, Messina C, Serafini G, Sconfienza LM, Silvestri E. Ultrasound-guided procedures to treat sport-related muscle injuries. Br J Radiol. 2016;89(1057):20150484.

    PubMed  Article  Google Scholar 

  60. Quiñones PK, Hattori S, Yamada S, Kato Y, Ohuchi H. Ultrasonography-guided muscle hematoma evacuation. Arthrosc Tech. 2019;8:e721–5.

    PubMed  PubMed Central  Article  Google Scholar 

  61. Sales RM, Cavalcante MC, Cohen M, Ejnisman B, Andreoli CV, Pochini A de C (2019) Treatment of acute thigh muscle injury with or without hematoma puncture in athletes. Rev Bras Ortop (Sao Paulo) 54:6–12

  62. Vermeulen R, Almusa E, Buckens S, Six W, Whiteley R, Reurink G, Weir A, Moen M, Kerkhoffs GMMJ, Tol JL. Complete resolution of a hamstring intramuscular tendon injury on MRI is not necessary for a clinically successful return to play. Br J Sports Med. 2020. https://doi.org/10.1136/bjsports-2019-101808.

    Article  PubMed  Google Scholar 

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Correspondence to Pierpaolo Zunarelli.

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Zunarelli, P., Lucenteforte, G., Miceli, M. et al. The Use of Diagnostic Ultrasound in Sports Muscle Injuries in Football (Soccer) Players: State-of-the-art Review. Curr Phys Med Rehabil Rep (2022). https://doi.org/10.1007/s40141-022-00354-7

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Keywords

  • Muscle injuries
  • Muscle ultrasonography
  • Return to play
  • Muscle injury classification
  • Musculoskeletal ultrasound