Italian consensus conference on guidelines for conservative treatment on lower limb muscle injuries in athlete

Abstract

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.

Biological Basis of Treatments of Acute Muscle Injuries: A Short Review

“…The long-established PRICE principle (Protection, Rest, Ice, Compression, Elevation) followed by early mobilization and physical therapy is widely used in the initial management of muscle strains and fits well with the biological model of muscle injury, although there is no good evidence of its efficacy. [4][5][6][7] Protection and rest prevent further muscle tearing. Ice packs or towels soaked in ice water applied for 15 to 20 minutes at intervals of 45 to 60 minutes induce vasoconstriction resulting in a 50% reduction in blood flow within 10 minutes, thus reducing swelling and hematoma formation.…”

“…5 Compression and elevation also reduce bleeding and edema, although an Italian consensus article suggests that compression should not be used for intramuscular hematomas to avoid compartment syndrome. 7 The overall consequences of the PRICE approach are to limit bleeding and tissue damage, reduce pain, and allow early scar formation. The scar acts as a scaffold for satellite cells.…”

“…8 The current German and Italian consensuses are that 3 to 5 days of immobilization are appropriate. 6,7 Mobilization also increases angiogenesis and migration of progenitor cells into the area of injury. 7 Antifibrotic treatments might reduce posttraumatic fibrosis, but there is no clinical evidence that they are effective.…”

“…6,7 Mobilization also increases angiogenesis and migration of progenitor cells into the area of injury. 7 Antifibrotic treatments might reduce posttraumatic fibrosis, but there is no clinical evidence that they are effective. 9 Askling et al 10,11 showed that lengthening exercises, using eccentric muscle contraction, started within 5 days of injury result in a quicker return to play than nonstretching exercises in acute hamstring injuries, but the Italian consensus 7 suggested a less aggressive approach with concentric contraction exercises starting 1 to 2 weeks after injury followed by stretching and eccentric contractions after a further week.…”

“…Oral nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used in the early management (first 2-3 days) of muscle injuries to reduce inflammation and provide analgesia. 6,7 Although there is little in vivo evidence, Järvinen et al 4 reviewed the literature and reported that short-term use of NSAIDS decreases inflammation and does not interfere with healing, although prolonged use (> 7 days in an animal model) may compromise healing. 27 In their review, Hotfiel et al 6 found conflicting results, with some studies reporting increased fibrosis and scar formation and others describing improved satellite cell activation.…”