Groin Pain Syndrome Italian Consensus Conference update 2023.

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).

Achilles Tendon Repair after Tenorraphy Imaging and the Doughnut Metaphor.

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.

Neuropathic pain in athletes: basics of diagnosis and monitoring of a hidden threat.

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.

Prepubic aponeurotic complex injuries: a structured narrative review.

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.

COVID-19 Lockdown: A Global Study Investigating the Effect of Athletes' Sport Classification and Sex on Training Practices.

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.

The Impact of a Precision-Based Exercise Intervention in Childhood Hematological Malignancies Evaluated by an Adapted Yo-Yo Intermittent Recovery Test.

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.

In Professional Male Soccer Players, Time-Loss Groin Injury Is More Associated With the Team Played for Than With Training/Match-Play Duration.

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.

Return to Play in Long-Standing Adductor-Related Groin Pain: A Delphi Study Among Experts.

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.

Injury and illness epidemiology in professional Asian football: lower general incidence and burden but higher ACL and hamstring injury burden compared with Europe.

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.

Long-standing groin pain syndrome in athletic women: a multidisciplinary assessment in keeping with the Italian Consensus Agreement.

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.

Training During the COVID-19 Lockdown: Knowledge, Beliefs, and Practices of 12,526 Athletes from 142 Countries and Six Continents.

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).

A multidisciplinary assessment of 320 athletes with long-standing groin pain syndrome in keeping with the Italian consensus agreement: the high incidence and the multiple causes of inguinal and hip pathologies and pubic osteopathy.

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.

How does sleep help recovery from exercise-induced muscle injuries?

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.

Return to football training and competition after lockdown caused by the COVID-19 pandemic: medical recommendations.

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.

Medical recommendations for home-confined footballers' training during the COVID-19 pandemic: from evidence to practical application.

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.

Harmful association of sprinting with muscle injury occurrence in professional soccer match-play: A two-season, league wide exploratory investigation from the Qatar Stars League.

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.

Italian consensus statement (2020) on return to play after lower limb muscle 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.