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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.

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.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.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.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.

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.

Introduction: Football was the first sport to resume competitions after the coronavirus disease 2019 (COVID-19) lockdown and promptly the hypothesis was raised of a potential relationship between the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and musculoskeletal injuries in athletes. This study aimed to confirm the association between SARS-CoV-2 infection and muscle strain injury in a large population of elite football players and to investigate if the COVID-19 severity level could affect the risk of injury. Methods: A retrospective cohort study involving 15 Italian professional male football teams was performed during the Italian Serie A 2020–2021 season. Injuries and SARS-CoV-2 positivity data were collected by team doctors through an online database. Results: Of the 433 included players, we observed 173 SARS-CoV-2 infections and 332 indirect muscle strains. COVID-19 episodes mostly belonged to severity level I and II. The injury risk significantly increased after a COVID-19 event, by 36% (HR = 1.36, CI95% 1.05; 1.77, p-value = 0.02). The injury burden demonstrated an 86% increase (ratio = 1.86, CI95% 1.21; 2.86, p-value = 0.005) in the COVID-19 severity level II/III versus players without a previous SARS-CoV-2 infection, while level I (asymptomatic) patients showed a similar average burden (ratio = 0.92, CI95% 0.54; 1.58, p-value = 0.77). A significantly higher proportion of muscle–tendon junction injuries (40.6% vs. 27.1%, difference = 13.5%, CI95% 0.002%; 26.9%, p-value = 0.047) was found when comparing level II/III versus Non-COVID-19. Conclusions: This study confirms the correlation between SARS-CoV-2 infection and indirect muscle injuries and highlights how the severity of the infection would represent an additional risk factor.

Longstanding (chronic) adductor-related groin pain syndrome is a widely common problem for athletes in many sports activities which often drastically reduces player activity and performance. The first choice in therapeutic treatment is conservative therapy. The objective of this study is to provide a systematic review regarding conservative treatment for longstanding adductor-related groin pain syndrome present in literature today. Furthermore, this study aims to give a critical vision of the current state of the art of the considered topic. After screening 234 articles, 19 studies following the inclusion criteria were included and summarized in this current systematic review and seven different types of therapeutic interventions were described. Compression clothing therapy, manual therapy together with strengthening exercise and prolotherapy were the therapeutic interventions which showed both the greatest level of strength of evidence (Moderate) and grade of recommendation (D). The remaining four types of therapeutic interventions i.e.: corticoid injection, platelet rich plasma therapy, intra-tissue percutaneous electrolysis and pulse-dose radiofrequency, showed both lower levels of strength of evidence (Conflicting) and grade of recommendation (C). In conclusion the literature available on the conservative treatment for longstanding adductor-related groin pain syndrome is limited and characterized by a low level of evidence. Therefore, our recommendation is to refer only to the few studies with higher level of evidence and at the same time to encourage further research in this area. The intervention showing the greater level of strength of evidence, and the greater grade of recommendation are compression clothing therapy, manual therapy and strengthening exercise, and prolotherapy. Other therapeutic interventions such as intra-tissue percutaneous electrolysis and pulse-dose radiofrequency seem promising but require further studies to confirm their efficacy.

Traumatic groin pain syndrome is the result of an acute trauma, usually an indirect muscle injury (i.e., an overstretching of the muscle fibers). The most affected muscles in traumatic groin pain syndrome are rectus abdominis, adductors, and iliopsoas. The internal obturator muscle lesion is very rare. The internal obturator muscle externally rotates the thigh and contributes to the stabilization of the hip joint and its indirect injury may cause the onset of traumatic groin pain syndrome. This case report describes a rare indirect injury of internal obturator in a 29-year-old professional male soccer player.

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.

Hamstring injuries and reinjuries are one of the most important sport lesions in several sport activities including soccer, Australian football, track and field, rugby, and in general in all sport activities requiring sprinting and acceleration. However, it is important to distinguish between the lesions of the biceps femoris and semitendinosus and semimembranosus. Indeed, three muscles representing the hamstring complex have a very different injury etiology and consequently require different prevention strategies. This fact may explain, at least in part, the high incidence of reinjuries. In soccer, hamstring injuries cause an important rate of time loss (i.e., in average 15–21 matches missed per club per season). The hamstring injury risk factors may be subdivided in three categories: “primary injury risk factors” (i.e., the risk factors mainly causing a first lesion), “recurrent injury risk factors” (i.e., the risk that can cause a reinjury), and bivalent injury risk factors” (i.e., the risk factors that can cause both primary injuries and reinjuries). The high incidence of hamstring lesions caused consequently an important increase in hamstring injury research. However, although the prevention has increased paradoxically, epidemiological data do not show a loss in injuries and/or reinjuries but, on the contrary, they show an increase in hamstring injuries. This apparent paradox highlights the importance both of the improvement in the prevention programs quality and the criteria for return to play after hamstring injury.

Background Femoroacetabular impingement is characterised by an abnormal contact between the acetabulum and the femoral head-neck junction. Femoroacetabular impingement shows three main clinical frameworks: Pincer-FAI, Cam-FAI and Cam-Pincer mixed form. The aim of the study was to investigate the correlation between femoroacetabular impingement, imaging, activity and chondral damages. Methods Forty-one patients, undergoing arthroscopic chondroartroplasty for Cam and Cam-Pincer mixed form were considered. All patients underwent an X-ray hip evaluation (G1 group), while 15 patients also underwent a pelvis MRI evaluation (G2 subgroup). For G1 patients, the superior-inferior offset ratio and alpha angle were calculated from the X-ray examinations. For G2 patients, the antero-posterior offset ratio was also calculated from pelvis MRI. Chondral damage was classified according to the Outerbridge classification. Results The superior-inferior offset ratio and the antero-posterior offset ratio were respectively 0.50 ± 0.23 and 0.33 ± 0.19. The α angle predictive for a chondral damage of IV degree was 81.5°.The chondral damage of the patients suffering from Cam-FAI and Cam-Pincer mixed form were respectively 3.53±0.80 and 3.00±1.41. Conclusions From the results was possible to: - Elaborate two tables providing a reliable indirect calculation of the alpha angle. - Establish an alpha angle cut-off value indicative for a IV degree chondral damage. - Show that Pincer-FAI does not represent an aggravating factor for chondral damage - Show that the level of sports activity was related to the severity of chondral damage. - Show that a physically demanding occupation was not an aggravating factor for chondral damage.

Introduction Anterior cruciate ligament (ACL) lesion represents one of the most dramatic injuries in a football (soccer) player's career. There are many injury risk factors related to intrinsic (non-modifiable) and/or extrinsic (modifiable) factors of ACL injury. Evidence acquisition Research of the studies was conducted until September 2018 without publication data limitation or language restriction on the following databases: PubMed/MEDLINE, Scopus, ISI, EXCERPTA. Evidence synthesis To date, evidence from the literature suggests that the risk of ACL injury is multifactorial and involves biomechanical, anatomical, hormonal, and neuromuscular factors. Despite this relative complexity, the mechanisms of injury are well known and rationally classified into two categories: mechanisms of injury based on contact or on non-contact with another player, with the non-contact injury mechanisms clearly prevailing over the mechanisms of contact injury. One of the most frequent biomechanical risk factors, associated with ACL non-contact injury, is represented by the valgus knee in the pivoting and cutting movements and in the landing phase after jumping. Gender-related risk factors show female populations to have a higher predisposition to ACL injury than males However, there are still some theoretical and practical aspects that need further investigation such as; genetic risks together with the role of estrogen and progesterone receptors in female populations, and the in-vivo interaction shoe-playing surface. In particular, the genetic risk factors of ACL lesion seem to be an interesting and promising field of investigation, where considerable progress has still to be made. Conclusions This narrative review provides an insight into the risk factors of ACL injury that could be used by practitioners for preventing injury in football (soccer).

Return to play (RTP) decisions in football are currently based on expert opinion. No consensus guideline has been published to demonstrate an evidence-based decision-making process in football (soccer). Our aim was to provide a framework for evidence-based decision-making in RTP following lower limb muscle injuries sustained in football. A 1-day consensus meeting was held in Milan, on 31 August 2018, involving 66 national and international experts from various academic backgrounds. A narrative review of the current evidence for RTP decision-making in football was provided to delegates. Assembled experts came to a consensus on the best practice for managing RTP following lower limb muscle injuries via the Delphi process. Consensus was reached on (1) the definitions of ‘return to training’ and ‘return to play’ in football. We agreed on ‘return to training’ and RTP in football, the appropriate use of clinical and imaging assessments, and laboratory and field tests for return to training following lower limb muscle injury, and identified objective criteria for RTP based on global positioning system technology. Level of evidence IV, grade of recommendation D.