Muscle injuries recovery

Muscle injuries recovery

 

Antonis Papoutsidakis MD, MSc, MFSEM(UK), MECOSEP

Orthopaedic Surgeon

 

MECHANISM OF SKELETAL MUSCLE INJURY

Muscle injuries are one of the most common injuries occurring in sports, their frequency varying from 10–55% of all sustained injuries. Muscle injuries can be caused by contusion, strain or laceration. Over 90% of all sports-related injuries are either contusions or strains, whereas muscle lacerations are uncommon injuries in sports.

THE PATHOBIOLOGY OF MUSCLE INJURY

What distinguishes the healing of injured skeletal muscle from that of fractured bone is that the skeletal muscle heals by a repair process, whereas the bone heals by a regenerative process. When most of the musculoskeletal tissues are being repaired, they will heal with a scar, which replaces the original tissue, whereas when a bone regenerates, the healing tissue is identical to the tissue that existed there before.   The healing of an injured skeletal muscle follows a fairly constant pattern with three phases:

1)     Destruction phase: characterised by the rupture and ensuing necrosis of the myofibres, formation of a haematoma between the stumps of the ruptured myofibres and an inflammatory cell reaction.

2)     Repair phase: consisting of the phagocytosis of the necrotised tissue, regeneration of the myofibres and concomitant production of a connective tissue scar, as well as revascularisation by ingrowth of capillaries into the injured area.

3)     Remodelling phase: a period during which the maturation of the regenerated myofibres, retraction and reorganisation of the scar tissue and recovery of the functional capacity of the muscle occurs.

CLINICAL CLASSIFICATION OF MUSCLE INJURIES

The clinical picture of a muscle injury – strain, contusion or laceration – depends on the severity of the injury and the nature of the haematoma. Mild (first degree) strain/contusion represents a tear of only few muscle fibres with minor swelling and discomfort accompanied with no or only minimal loss of strength and restriction of movement (ability to mobilise). Moderate (second degree) strain/contusion, in turn, involves greater damage to the muscle with a clear loss of function (ability to contract), whereas a tear extending across the entire cross-section of the muscle and, thus, resulting in a virtually complete loss of muscle function, is termed a severe (third degree) strain/contusion.

            DIAGNOSIS OF MUSCLE INJURIES

            The diagnosis of a muscle injury begins with a careful history of the occurrence of the trauma, followed by clinical examination consisting of inspection and palpation of the involved muscles, as well as testing the function of the injured muscles both with and without external resistance. Imaging modalities such as ultrasonography, computed tomography (CT) or magnetic resonance imaging (MRI) provide useful means to more precisely verify and characterise the injury. Ultrasonography has traditionally been considered the method of choice for clinical diagnosis of muscle injuries, as it is a relatively inexpensive examination. However, it has a clear disadvantage of being highly dependent on the experience of the radiologist and, accordingly, MRI has more recently replaced ultrasonography in the imaging of many musculoskeletal disorders. MRI can accurately confirm/rule out the existence of muscle injury and also provides a very detailed characterisation of the lesion, even to the extent of being considered somewhat over-sensitive at times.

TREATMENT PRINCIPLES FOR MUSCLE INJURIES

The current treatment principles for injured skeletal muscle lack a firm scientific basis. A short period of immobilisation following muscle injury is beneficial, but it should be limited to the first few days after the injury only. This allows the scar tissue connecting the injured muscle stumps to gain the required strength to withstand the contraction-induced forces applied on the regenerating tissue without re-rupturing. By restricting the length of immobilisation to a period of less than a week, the adverse effects of immobility per se can be minimised. Re-ruptures at the site of the original muscle trauma are common if active mobilisation is begun immediately after the injury. By placing the injured muscle at rest for the first couple of days after the injury, excessive scar formation and re-rupture at the injury site can be best prevented. Avoiding re-ruptures is important as re-ruptures are actually the most severe skeletal muscle injuries causing the greatest amount of time lost from sporting activity. The practice for the treatment of those of our athletes with an acute muscle injury: the required relative immobility can be achieved simply by applying a firm adhesive taping or similar over the injured muscle, so a cast is naturally not needed. It is highly recommend the use of crutches for those athletes with the most severe lower extremity muscle injuries, as well as when the injury is located at a site where adequate immobilisation is otherwise difficult to attain, such as in the groin area. After this period of relative immobility, more active use of the injured muscle can be started gradually within the limits of pain.

            Immediate treatment – the ‘RICE’ principle

            The immediate treatment of an injured skeletal muscle (or any soft-tissue injury, for that matter) should follow the ‘RICE ’ principle: Rest, Ice (cold), Compression and Elevation. The overall justification for the use of this RICE-principle is very practical, as all these four methods aim to minimise bleeding into the injury site. By placing the injured extremity to rest immediately after the trauma, one can prevent further retraction of the ruptured muscle stumps (and thus the formation of a large gap within the muscle), reduce the size of the haematoma and, subsequently, the size of the connective tissue scar. Regarding the use of ‘cold’ on injured skeletal muscle early use of cryotherapy is associated with a significantly smaller haematoma between the ruptured myofibre stumps, less inflammation and tissue necrosis and somewhat accelerated early regeneration. Although ‘compression’ reduces the intramuscular blood flow into the injured area, it is debatable whether compression applied immediately after the injury accelerates the healing of the injured skeletal muscle. However, according to prevailing understanding, it is recommended that the combination of ice (cryotherapy) and compression are applied in bouts of 15- to 20-minutes in duration, repeated at intervals of 30–60 minutes for at least several hours. Icing of the injured skeletal muscle should continue for an extended period of time (6 hours) to obtain a substantial effect on limitation of the haemorrhaging and tissue necrosis at the site of the injury. Finally, concerning the last component of the RICE, ‘elevation’, the rationale for its use is based on the fundamental principles of physiology and traumatology; the elevation of an injured extremity above the level of the heart results in a decrease in hydrostatic pressure and, subsequently, reduces the accumulation of interstitial fluid.

      Treatment after 3-7 days

After the acute phase of the injury the recovery of the injured limb starts gradually. Progressive agility and trunk stabilization exercises reduce re-injury rate and help to rapid return to sport activity.

To avoid muscle atrophy and weakness we suggest to follow:

1. Isometric training (i.e. muscle contractions where the length of the muscle remains constant and the tension changes), first without a resisting/counter load and then later with increased loads, within the limits of pain.

2. Isotonic training (i.e. the length of the muscle changes while the tension remains constant during muscle contraction) can be started once isometric training can be performed pain-free with resisting loads. First without a resisting/counter load and then with progressively increased load.

3. Isokinetic, dynamic training (e.g. done with specialized apparatus that provides a varying amount of resistance to movement so that the movement takes place at constant speed).

In this phase other physical activities aimed at maintaining cardiovascular  fitness can be initiated. This could be done without the risk of re-ruptures by means of stationary bike riding or swimming.

      WARM UP

All physical rehabilitation activities should always start with an adequate warming-up of the injured muscle. Warming-up reduces muscle viscosity and relaxes muscles neurally. Stimulated warm muscles absorb more energy than unstimulated muscles and can thus better withstand loading. When warming up is combined with stretching, the elasticity of the muscle is improved.

      STRETCHING

Stretching distends the maturing scar at a phase where it is still plastic, but already has the required strength to prevent a functionally disabling retraction of the muscle stumps. Painless elongation of the maturing scar can be achieved by gradual stretching, beginning with bouts of 10–15 seconds at a time and then proceeding up to a period of 1 minute. Stretching should also involve repeated stretches of the same muscle because repeated elongation decreases the (counter) resistance of the muscle to stretching.

      RETURNING TO SPORTS-SPECIFIC TRAINING

The decision regarding the appropriate timing of the return to sports-specific training is based on two simple and inexpensive measures: (1) The ability to stretch the injured muscle as much as the healthy contralateral muscle. (2) The pain-free use of the injured muscle in basic movements.

      OPERATION

Indications for operative treatment have the athlete with a large intramuscular haematoma(s), a complete (third degree) strain or tear of a muscle with few or no agonist muscles, or a second degree strain if more than half of the muscle belly is torn. We have to recognize those rare muscle injuries that require surgery very early, because operative treatment performed within 3 weeks of injury provides significantly better outcome than when the operation is postponed beyond that point.

      MEDICATION

A short-term use of different NSAIDs in the early phase of healing has been shown to lead to a decrease in the inflammatory cell reaction with no adverse effects on the healing process or on the tensile strength or ability of the injured muscle to contract. The use of NSAIDs should be restricted to the early phases of muscle repair as their long-term use might have undesired effects on the regenerating skeletal muscle. Delayed elimination of the haematoma and necrotic tissue, retardation of the muscle regeneration process and, ultimately, reduced biomechanical strength of the injured muscle have been reported with the use of glucocorticoids in the treatment of muscle injuries.

      THERAPEUTIC ULTRASOUND

High-frequency US waves works as a pain reliever. US could somehow enhance the initial stage of muscle regeneration. Despite the apparent promotion of the proliferation phase of myofibre regeneration, therapeutic US unfortunately does not seem to have a positive (muscle healing enhancing) effect on the final outcome of muscle healing.

      MYOSITIS OSSIFICANS

Myositis ossificans is a non-neoplastic proliferation of bone and cartilage within the skeletal muscle at the site of a previous single major trauma or repeated injury and/or haematoma. In sports, myositis ossificans is typically associated with prior sports-related muscle injury, the incidence being the highest in the high-contact sports in which the use of protective devices is uncommon (e.g. rugby). Increased susceptibility to myositis ossificans has also been described in individuals with haemophilia or other bleeding disorders in conjunction with a soft-tissue injury. Clinically, myositis ossificans should be suspected if pain and swelling are not clearly subsiding 10–14 days after an injury to a skeletal muscle or if the healing does not seem to progress normally despite the execution of a proper conservative treatment regimen. The treatment principles of myositis ossificans are based on empirical experience rather than on clinical or experimental evidence. First aid for muscle trauma (the prevention of the formation of a large haematoma) naturally creates the foundation for the treatment of this complication. Although indomethacin is quite commonly used in orthopaedics to prevent heterotopic ossification, it has not been validated for the prevention and/or treatment of myositis ossificans. The surgical excision of the bone mass can be considered at later phases, if the symptoms do not subside despite 12 months of watchful waiting. However, according to our experience, surgery should not be performed until the ectopic bone has fully ‘matured’, which is 12–24 months after the onset of the symptoms, as the excision of immature bone often results in local recurrence.

PREVENTION

Passive and active warm-up and muscle stretching have beneficial effects on muscle function and thus they should be advocated also for the prevention of muscle injuries. A critical review of the medical literature reveals that there is limited evidence to demonstrate that these activities actually reduce the incidence of muscle injuries. The focus to the prevention of skeletal muscle injuries has recently shifted from mere stretching to specifically tailored muscle strengthening protocols. Eccentric muscle strengthening exercises (also called Nordic strengthening, strong contraction and then lengthening of the muscle) are being widely advocated to provide additional preventative benefit over the classical strengthening programs.

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