Role of the Extracellular Matrix in Muscle Injuries. Histoarchitectural Considerations for Muscle Injuries.


In recent years, different classifications of muscle injury have been proposed based on topographic location within the bone-tendon-muscle chain. Furthermore, because the degree and level of extracellular matrix (ECM) involvement might vary greatly, we propose to include histoarchitectural considerations in the gross anatomic description of muscle injuries.

Autores: Balius R, Alomar X, Pedret C, Blasi M, Rodas G, Pruna R, Peña-Amaro J, Fernández-Jaén T.

Revista: Orthopaedic Journal of Sports Medicine

Año de publicación: 2018

A 3-Arm Randomized Trial for Achilles Tendinopathy: Eccentric Training, Eccentric Training Plus a Dietary Supplement Containing Mucopolysaccharides, or Passive Stretching Plus a Dietary Supplement Containing Mucopolysaccharides


Tendinopathy is an overuse tendon injury that occurs in loaded tendons and results in pain and functional impairment. Although many treatments for painful tendons are described, the scientific evidence for most of the conservative and surgical treatments is not always conclusive.

Autores: Balius, R, Álvarez G, Baró F, Jiménez F, Pedret C, Costa E, Martínez-Puig D

Revista: Current Therapeutic Research, Clinical and Experimental

Año de publicación: 2016

Efficacy and Tolerability of Peritendinous Hyaluronic Acid in Patients with Supraspinatus Tendinopathy: a Multicenter, Randomized, Controlled Trial


Physical therapy and peritendinous hyaluronic acid (HA) injections have both shown promising results in the treatment of shoulder tendinopathies. However, the superiority of treatment combining physical therapy and HA is unclear.

Autores: Flores C, Balius R, Álvarez G, Buil MA, Varela L, Cano C, Casariego J

Revista: Sports Med Open

Año de publicación: 2018

Gemelli-obturator complex in the deep gluteal space: an anatomic and dynamic study.



To investigate the behavior of the sciatic nerve during hip rotation at subgluteal space.


Sonographic examination (high-resolution ultrasound machine at 5.0-14 MHZ) of the gemelli-obturator internus complex following two approaches: (1) a study on cadavers and (2) a study on healthy volunteers. The cadavers were examined in pronation, pelvis-fixed position by forcing internal and external rotations of the hip with the knee in 90° flexion. Healthy volunteers were examined during passive internal and external hip rotation (prone position; lumbar and pelvic regions fixed). Subjects with a history of major trauma, surgery or pathologies affecting the examined regions were excluded.


The analysis included eight hemipelvis from six fresh cadavers and 31 healthy volunteers. The anatomical study revealed the presence of connective tissue attaching the sciatic nerve to the structures of the gemellus-obturator system at deep subgluteal space. The amplitude of the nerve curvature during rotating position was significantly greater than during resting position. During passive internal rotation, the sciatic nerve of both cadavers and healthy volunteers transformed from a straight structure to a curved structure tethered at two points as the tendon of the obturator internus contracted downwards. Conversely, external hip rotation caused the nerve to relax.


Anatomically, the sciatic nerve is closely related to the gemelli-obturator internus complex. This relationship results in a reproducible dynamic behavior of the sciatic nerve during passive hip rotation, which may contribute to explain the pathological mechanisms of the obturator internal gemellus syndrome.

Autores: Balius R, Susín A, Morros C, Pujol M, Pérez-Cuenca D, Sala-Blanch X

Revista: Skeletal Radiol

Año de publicación: 2018

Time Course and Association of Functional and Biochemical Markers in Severe Semitendinosus Damage Following Intensive Eccentric Leg Curls: Differences between and within Subjects.


To investigate the extent and evolution of hamstring muscle damage caused by an intensive bout of eccentric leg curls (ELCs) by (1) assessing the time course and association of different indirect markers of muscle damage such as changes in the force-generating capacity (FGC), functional magnetic resonance (fMRI), and serum muscle enzyme levels and (2) analyzing differences in the degree of hamstring muscle damage between and within subjects (limb-to-limb comparison). Methods: Thirteen male participants performed six sets of 10 repetitions of an ELC with each leg. Before and at regular intervals over 7 days after the exercise, FGC was measured with maximal isometric voluntary contraction (MVC). Serum enzyme levels, fMRI transverse relaxation time (T2) and perceived muscle soreness were also assessed and compared against the FGC. Results: Two groups of subjects were identified according to the extent of hamstring muscle damage based on decreased FGC and increased serum enzyme levels: high responders (n = 10, severe muscle damage) and moderate responders (n = 3, moderate muscle damage). In the high responders, fMRI T2 analysis revealed that the semitendinosus (ST) muscle suffered severe damage in the three regions measured (proximal, middle, and distal). The biceps femoris short head (BFsh) muscle was also damaged and there were significant differences in the FGC within subjects in the high responders. Conclusion: FGC and serum enzyme levels measured in 10 of the subjects from the sample were consistent with severe muscle damage. However, the results showed a wide range of peak MVC reductions, reflecting different degrees of damage between subjects (high and moderate responders). fMRI analysis confirmed that the ST was the hamstring muscle most damaged by ELCs, with uniform T2 changes across all the measured sections of this muscle. During intensive ELCs, the ST muscle could suffer an anomalous recruitment pattern due to fatigue and damage, placing an excessive load on the BFsh and causing it to perform a synergistic compensation that leads to structural damage. Finally, T2 and MVC values did not correlate for the leg with the smaller FGC decrease in the hamstring muscles, suggesting that long-lasting increases in T2 signals after FGC markers have returned to baseline values might indicate an adaptive process rather than damage.

Autores: Carmona G, Mendiguchía J, Alomar X, Padullés JM, Serrano D, Nescolarde L, Rodas G, Cussó R, Balius R, Cadefau JA.

Revista: Front Physiol. 2018 Feb 5; 9:54. doi: 10.3389/fphys.2018.00054. eCollection 2018.

Año de publicación: 2018

Validation of the range of dry needling with the fascial winding technique in the carpal tunnel using ultrasound.



To use ultrasound imaging to show how the needles in dry needling applied in the carpal tunnel can reach the transverse carpal ligament, acting on it in the form of traction-stretching when the fascial winding technique is performed. The potential associated risks are also assessed.


Validation study.


Healthy volunteers (n = 18).


Four dry needling needles were applied to the carpal tunnel, only using anatomical references, according to the original approach known as «four-pole carpal dry needling», and manipulating the needles following the so-called fascial winding technique according to the authors, in the form of unidirectional rotation. An ultrasound recording of the distance reached was then performed, and compared with the mechanical action achieved on the transverse carpal ligament.


93.1% of the needles placed came into contact with the transverse carpal ligament with traction-stretching of the ligament observed when the needles were manipulated with the fascial winding technique in 80.6%. The mean distance from the tip of the needle to the median nerve was 3.75 mm, with CI95% [3.10, 4.41] and it was 7.78 mm with CI95% [6.64, 8.91] to the ulnar artery. Pain immediately after the technique concluded was of mild intensity, almost nil 10 min later, and non-existent after one week.


Dry needling with fascial winding technique in the carpal tunnel using the four-pole carpal dry needling approach is valid for reaching and traction of the transverse carpal ligament, and may stretch it and relax it. It is also safe with regard to the median nerve and ulnar artery, with a very mild level of pain.

Autores: Gascon-Garcia J, Bagur-Calafat C, Girabent-Farr M. Balius R.

Revista: Journal of Bodywork & Movement Therapies 22 (2018) 348e353

Año de publicación: 2018

Spanish Consensus Statement: Clinical Management and Treatment of Tendinopathies in Sport.


On October 15, 2016, experts met at Clínica CEMTRO in Madrid, Spain, under the patronage of the Spanish Society for Sports Traumatology (SETRADE), the Spanish Society of Sports Medicine (SEMED), the Spanish Association of Medical Services for Football Clubs (AEMEF), the Spanish Association of Medical Services for Basketball Clubs (AEMB), F.C. Barcelona, and Clínica CEMTRO. The purpose was to consider the most appropriate clinical management and treatment of tendinopathies in sports, based on proven scientific data described in the medical literature as well as on each expert’s experience. Prior to the meeting, each expert received a questionnaire regarding clinical management and treatment of tendinopathies in sports. The present consensus document summarizes the answers to the questionnaire and the resulting discussion and consensus regarding current concepts on tendinopathies in sports.

Autores: Spanish Group for Tendon Consensus, Fernandez-Jaén T, Rey GÁ, Angulo F, Cuesta JA, Loureda RA, España FÁ, Ayala J, Balius Matas R, Pazos FB, de Dios Beas Jiménez J, Rosell JC, Fernandez CC, Del Pilar Doñoro Cuevas M, Ros FE, Colmenero JE, de Prado JF, García Cota JJ, Garrido González JI, de Vega CG, Santander MG, Herrador Munilla MÁ, Ruiz FI, Díaz FJ, Fernandez AM, Marqueta PM, Muñoz Benito JJ, Vilás RO, Pedret C, Teres XP, Amaro JP, Grifell JP, San Roque JP, Parenteu CR, Serna JR, Rodas G, Álvarez MS, Marchori CS, Perez LT, Durán RU, Del Valle Soto M, Villalón Alonso JM, García PG.

Revista: Orthop J Sports Med.

Año de publicación: 2017

Muscle Injuries in Sports: A New Evidence-Informed and Expert Consensus-Based Classification with Clinical Application.


Muscle injuries are among the most common injuries in sport and continue to be a major concern because of training and competition time loss, challenging decision making regarding treatment and return to sport, and a relatively high recurrence rate. An adequate classification of muscle injury is essential for a full understanding of the injury and to optimize its management and return-to-play process. The ongoing failure to establish a classification system with broad acceptance has resulted from factors such as limited clinical applicability, and the inclusion of subjective findings and ambiguous terminology. The purpose of this article was to describe a classification system for muscle injuries with easy clinical application, adequate grouping of injuries with similar functional impairment, and potential prognostic value. This evidence-informed and expert consensus-based classification system for muscle injuries is based on a four-letter initialism system: MLG-R, respectively referring to the mechanism of injury (M), location of injury (L), grading of severity (G), and number of muscle re-injuries (R). The goal of the classification is to enhance communication between healthcare and sports-related professionals and facilitate rehabilitation and return-to-play decision making.

Autores: Valle X, Alentorn-Geli E, Tol JL, Hamilton B, Garrett WE Jr, Pruna R, Til L, Gutierrez JA, Alomar X, Balius R, Malliaropoulos N, Monllau JC, Whiteley R, Witvrouw E, Samuelsson K, Rodas G

Revista: Sports Med

Año de publicación: 2016

Spanish Consensus Statement: The Treatment of Muscle Tears in Sport.


On the 21st of March, 2015, experts met at Clínica CEMTRO in Madrid, Spain, under the patronage of The Spanish Society for Sports Traumatology (SETRADE), The Spanish Federation of Sports Medicine (FEMEDE), The Spanish Association of Medical Services for Football Clubs (AEMEF), and The Spanish Association of Medical Services for Basketball Clubs (AEMB) with the aim of establishing a round table that would allow specialists to consider the most appropriate current general actions to be taken when treating muscle tears in sport, based on proven scientific data described in the medical literature. Each expert received a questionnaire prior to the aforementioned meeting comprising a set of questions concerning therapeutic indications generally applied in the different stages present during muscle repair. The present Consensus Document is the result of the answers to the questionnaire and resulting discussion and consensus over which are the best current indications in the treatment of muscle tears in sport. Avoiding immobilization, not taking nonsteroidal anti-inflammatory drugs (NSAIDs) randomly, fostering early mobilization, increasing vascularization of injured, site and regulating inflammatory mechanisms-without inhibiting these from the early stages of the recovery period-all stood out as main points of the Consensus Document. Additionally, there is controversy concerning cell stimulation techniques and the use of growth factors or cell inhibitors. The decision concerning discharge was unanimous, as was the criteria considered when it came to performing sport techniques without pain.

Autores: Fernandez-Jaén TF, Rey GÁ, Cuesta JA, Loureda RA, España FÁ, Balius Matas R, Pazos FB, de Dios Beas Jiménez J, Rosell JC, Fernandez CC, Ros FE, Colmenero JE, de Prado JF, Cota JJ, González JI, Santander MG, Munilla MÁ, Ruiz FI, Díaz FJ, Marqueta PM, Fernandez AM, Benito JJ, Vilás RO, Teres XP, Amaro JP, Roque JP, Parenteu CR, Serna JR, Álvarez MS, Marchori CS, Soto Mdel V, Alonso JM, García PG, de la Iglesia NH, Alcorocho JM.

Revista: Orthop J Sports Med

Año de publicación: 2016

Ultrasound-Guided Fasciotomy for Anterior Chronic Exertional Compartment Syndrome of the Leg.


Chronic exertional compartment syndrome is characterized by exertional pain and elevated intracompartmental pressures affecting the leg in physically active young people. In patients who have failed conservative measures, fasciotomy is the treatment of choice. This study presents a new method for performing fasciotomy using high-resolution ultrasound (US) guidance and reports on the clinical outcomes in a group of these patients. Over a 3-year period, 7 consecutive patients with a total of 9 involved legs presented clinically with anterior compartment chronic exertional compartment syndrome, which was confirmed by intracompartmental pressure measurements before and after exercise. After a US examination, fasciotomy under US guidance was performed. Preoperative and postoperative pain and activity levels were assessed as well as number of days needed to “return to play.” All patients had a decrease in pain, and all except 1 returned to presymptomatic exercise levels with a median return to play of 35 days.

Autores: Balius R, Bong DA, Ardèvol J, Pedret C, Codina D, Dalmau A. J

Revista: Ultrasound Med, 35:823-9.

Año de publicación: 2016.