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High prevalence of patellar and Achilles tendinopathies in futsal athletes.

Dear Editor-in-chief,

Futsal (indoor version of soccer), in the last decade, has gained popularity all over the world. The game is played 5-a-side, and during the competitions unlimited substitutions are permitted. Body movements, during playing, are characterized by frequent accelerating and stopping, jumping and tackling (Junge et al., 2004; Nogueira Ribeiro and Pena Costa, 2006). Consequently, physical demands are very high (Castagna et al., 2009). Epidemiological studies report a high incidence of knee and ankle injuries, owing to playing characteristics and field hard surface (Junge et al., 2004; Nogueira Ribeiro and Pena Costa, 2006). However, to our knowledge, systematic studies on the structural damage of Patellar patellar

of or pertaining to the patella.

patellar cartilage
a cartilaginous process borne on the medial side of the patella of horses and cattle.
 (PT) and Achilles (AT) tendons have never been performed. Aim of this letter is to report the prevalence and incidence of PT and AT tendinopathies, in the players of a top level futsal team.

Ultrasound (US) examinations were carried out at the beginning and at the end of the regular season. The diagnosis of tendinopathy and peritendinitis was performed using strict US criteria (Salini and Abate, 2011). Neovascularization was estimated by means of Colour Doppler, and graded as (0), (1+), (2++), (3+++), (4++++), according to the appearance of vessels inside the tendon (Alfredson and Ohberg, 2005).

Demographic and anthropometric an·thro·pom·e·try  
The study of human body measurement for use in anthropological classification and comparison.

 data were registered. By self report, information about injuries, suffered in the past, or during the season, were collected. An injury was defined as pain or tendon discomfort regardless of the subsequent absence from match or training. Players who had tendon damage at US evaluation were compared with those free from abnormalities.

Data are reported as mean and standard deviation, frequencies and percentage. Student's t and [chi] 2 tests were used.

At the beginning of the season, 7 players (38.8 %) showed tendon degeneration, associated with neovascularisation in 7 / 9 tendons (Table 1). Out of them, all asymptomatic when observed, 5 had complained injuries in the past. The remaining 11 athletes were asymptomatic and without tendon abnormalities.

At the end of the season, in 3 players, among the ones who did not show tendon damage at the beginning, US revealed the onset of peritendinitis with neovascularisation. In most cases, tendinopathy was observed in the non dominant leg. Therefore, a total of 10 athletes (55.5 %) showed tendon damage at the end of the season. To sum up, 12 tendons had US signs of tendinopathy associated with neovascularisation in 10 (Table 1). Among these players, 8 reported tendon discomfort during regular season, and 4 were forced to stop playing for a short period (~10 days). All the US positive subjects had played for several years and were older (Table 2).

These results show that PT and AT tendinopathies are very frequent among futsal players. The high prevalence of tendon lesions, due to acute traumas and, more frequently, to overuse overuse Health care The common use of a particular intervention even when the benefits of the intervention don't justify the potential harm or cost–eg, prescribing antibiotics for a probable viral URI. Cf Misuse, Underuse.  degeneration, may be explained by the playing characteristics: the frequent accelerating and stopping, jumping, tackling, and abrupt jerking movements can indeed cause significant stress on knee and ankle (Junge et al., 2004, Nogueira Ribeiro and Pena Costa, 2006).

Moreover, the low heel footwear can expose AT to higher straining and stretching, and the hard and adherent adherent /ad·her·ent/ (-ent) sticking or holding fast, or having such qualities.  playing surface, that does not cushion the blows of the heel, can further stress this tendon (Cain et al., 2007). The higher prevalence of lesions in the non dominant leg can be explained by the fact that periods of play are mostly spent in single--leg stance on this leg, while the dominant foot manipulates the ball (Cain et al., 2007). To our knowledge, this is the first US study of tendinopathies in futsal, and, therefore, every comparison with other sports may be misleading. For example, Fredberg and Bolvig (Fredberg and Bolvig, 2002) found, in asymptomatic soccer athletes, at baseline, a percentage of AT and PT degeneration slightly lower than the one we observed in our group (34 % vs 38.8 %). At the end of season, in this study (Fredberg and Bolvig, 2002), US normalization was observed in some athletes, whereas in others, normal at baseline, signs of degeneration were found. In our group, none of degenerated tendons improved, while 3 athletes developed signs of tendinopathy. The comparison, however, is misleading, considering that the main criteria for the diagnosis of degeneration were tendon thickness in Fredberg's study (Fredberg and Bolvig, 2002), and structural abnormalities in our study. Moreover, the discrepancies can be explained by the playing characteristics, and by the demonstration that the exercise intensities are higher in futsal than those found in competitive soccer athletes (Castagna et al., 2009). In our cohort, the main risk factor related to tendon damage was the number of years spent in playing futsal; at a lesser extent, the age was found relevant. Another feature that must be underlined is the frequent observation of neovessels, found in ten tendons (8 subjects, 2 with bilateral tendinopathy). Neovessels ingrowth ingrowth /in·growth/ (-groth) an inward growth; something that grows inward or into.

Something that grows inward or into a part of the body.
 in tendinopathies is dependent by a hypoxic hypoxic

a state of hypoxia.

hypoxic cell sensitizers
compounds that selectively sensitize hypoxic tumor cells to the effects of radiation.
 environment, with subsequent production of Vascular Endothelial Growth Factor Vascular endothelial growth factor (VEGF) is an important signaling protein involved in both vasculogenesis (the de novo formation of the embryonic circulatory system) and angiogenesis (the growth of blood vessels from pre-existing vasculature).  (Abate et al., 2009). In futsal, the hypoxia hypoxia

Condition in which tissues are starved of oxygen. The extreme is anoxia (absence of oxygen). There are four types: hypoxemic, from low blood oxygen content (e.g., in altitude sickness); anemic, from low blood oxygen-carrying capacity (e.g.
 contribution may be enhanced. Indeed, the analysis of activities during the game shows the existence of sprint bouts sequences (3-4 bouts) with very short recovery time (20-30 sec of lower intensity), anaerobic anaerobic /an·aer·o·bic/ (an?ah-ro´bik)
1. lacking molecular oxygen.

2. growing, living, or occurring in the absence of molecular oxygen; pertaining to an anaerobe.
 metabolism and high levels of lactate Lactate

A salt or ester of lactic acid (CH3CHOHCOOH). In lactates, the acidic hydrogen of the carboxyl group has been replaced by a metal or an organic radical. Lactates are optically active, with a chiral center at carbon 2.
 production (Castagna et al., 2008).

The relevance of asymptomatic tendinopathies in athletes is well known because, in most cases, tendon ruptures may occur without warning symptoms, but only when tendinopathic changes are present. When symptoms develop, the athlete is warned and therefore he should avoid further overload.

In conclusion, this preliminary study shows a high prevalence of tendinopathies in futsal professional athletes, frequently associated with neovascularisation.

Strengths of this study are the accurate US examination and the homogeneity of players evaluated. However, the small number of subjects has to be considered an important limitation and therefore our findings must be confirmed on larger samples, both in professional and amateur players of different ages.

Received: 02 September 2011 / Accepted: 01 December 2011 / Published (online): 01 March 2012


Abate, M., Silbernagel, KG., Siljeholm, C., Di Iorio, A., De Amicis, D., Salini, V., Werner, S. and Paganelli, R. (2009) Pathogenesis of tendinopathies: inflammation or degeneration? Arthritis Research & Therapy 11(3), 235.

Alfredson, H. and Ohberg, L. (2005) Sclerosing injections to areas of neo--vascularisation reduce pain in chronic Achilles tendinopathy : a double--blind randomised Adj. 1. randomised - set up or distributed in a deliberately random way

irregular - contrary to rule or accepted order or general practice; "irregular hiring practices"
 controlled trial. Knee Surgery Sports Traumatology traumatology /trau·ma·tol·o·gy/ (-tol´o-je) the branch of surgery dealing with wounds and disability from injuries.

 Arthroscopy 13(4), 338-344.

Cain, LE., Nicholson, LL., Adams, RD. and Burns, J. (2007) Foot morphology and foot / ankle injury in indoor football. Journal of Science and Medicine in Sport 10(5), 311-319.

Castagna, C., D'Ottavio, S., Granda Vera, J. and Barbero Alvarez, JC. (2009) Match demands of professional Futsal: A case study. Journal of Science and Medicine in Sport 12(4), 490-494.

Fredberg, U. and Bolvig, L. (2002) Significance of ultrasonographically detected asymptomatic tendinosis in the patellar and achilles tendons of elite soccer players: a longitudinal study. The American Journal of Sports Medicine 30(4), 488-491.

Junge, A., Dvorak, J., Graf-Baumann, T. and Peterson, L. (2004) Football injuries during FIFA FIFA International Association Football Federation [French Fédération Internationale de Football Association]

FIFA n abbr (= Fédération Internationale de Football Association) → FIFA f 
 tournaments and the Olympic Games, 1998-2001: development and implementation of an injury--reporting system. The American Journal of Sports Medicine 32(Suppl. 1), 80S-89S.

Nogueira Ribeiro, R. and Pena Costa, LO. (2006) Epidemiological analysis of injuries occurred during the 15th Brazilian Indoor Soccer (Futsal) Sub20 Team Selection Championship. Revista Brasileira de Medicina do Esporte 12 (1), Jan-Feb, 1-4. Available from URL URL
 in full Uniform Resource Locator

Address of a resource on the Internet. The resource can be any type of file stored on a server, such as a Web page, a text file, a graphics file, or an application program.
: en_v12n1a01.pdf

Salini, V. and Abate, M. (2011) Percutaneous steroidal treatment in relapses of chronic tendinopathies: a pilot study. International Journal of Immunopathology and Pharmacology 24(1), 211-216.

Michele Abate (1) [mail], Cosima Schiavone (2) and Vincenzo Salini (3)

(1) Department of Clinical Sciences and Bioimaging, Infrared Imaging Laboratory, Institute of Advanced Biomedical bi·o·med·i·cal
1. Of or relating to biomedicine.

2. Of, relating to, or involving biological, medical, and physical sciences.
 Technologies (ITAB), (2) Echography echography /echog·ra·phy/ (e-kog´rah-fe) ultrasonography.

See ultrasonography.


ultrasonography; the use of ultrasound as a diagnostic aid.
 Unit, Department of Medicine and Sciences of Ageing, (3) Department of Human Movement Science, University G. d' Annunzio", Chieti--Pescara, Chieti Scalo (CH), Italy,

[mail] Michele Abate

Department of Clinical Sciences and Bioimaging, Infrared Imaging Laboratory, Institute of Advanced Biomedical Technologies (ITAB), "University G. d' Annunzio", Chieti--Pescara, Via dei Vestini 31, 66013 Chieti Scalo (CH), Italy

Table 1. Tendinopathies in futsal athletes.

                     No. of      Achilles      Patellar       Total

                              Dom   Non dom   Dom   Non dom
Beginning of the     7/18 *    1       5       1       2       9
New onset             3/18     0       1       0       2       3
End of the season     10/18    1       6       1       4      12
Neovascularization             1       5       1       3
1+                                     **      **     **
2++                            **     ***            ***
3+++                                  ***


Dom = Dominant side; Non dom = Non dominant side.
* = two players had two tendons affected.

Table 2. Characteristics of US positive and negative athletes
(data are reported as mean [+ or -] SD and range).

                            All players               Players with
                               (18)                    US damage

Age                   26 [+ or -] 5.3 (18-37)      28.2 [+ or -] 5.6
Weight               70.5 [+ or -] 4.8 (62-80)     70.2 [+ or -] 4.2
Height             175.1 [+ or -] 3.3 (170-182)    175.4 [+ or -] 3.9
BMI                 22.9 [+ or -] 1 (21,2-24,9)    22.8 [+ or -] 0.7
  Years of           12.2 [+ or -] 4.6 (5-22)      14.3 [+ or -] 4.6
Futsal practice

                    Players without       p
                       US damage

Age                23.3 [+ or -] 3.5      ns
Weight              71 [+ or -] 5.6       ns
Height             174.8 [+ or -] 2.5     ns
BMI                23.1 [+ or -] 1.3      ns
  Years of          9.7 [+ or -] 3.4    < 0.03
Futsal practice
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Author:Abate, Michele; Schiavone, Cosima; Salini, Vincenzo
Publication:Journal of Sports Science and Medicine
Article Type:Report
Geographic Code:1USA
Date:Mar 1, 2012
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