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  • Writer's pictureDaniel Selin

Muscle strains

Muscle strain, muscle sprain, acute injury, sports injury, overuse, injury, ligament injury


A muscle strain is a injury similar to a ligament tear, but the tear occurs in the muscle fibers instead of the ligaments. On the other hand, a muscle sprain refers to a situation where there is a momentary increased stretch in the muscle, but the muscle fibers are not torn as they are in a muscle strain type of situation. Therefore, a muscle sprain is a milder injury than a muscle strain. Muscle sprains typically heal on their own within a few days and do not usually require specific treatment. In this text, we will primarily focus on muscle strains.


A muscle strain occurs when the muscle fibers cannot withstand the forces exerted on them, resulting in the tearing of muscle fibers. Typically, this happens when a muscle is forcefully contracting while already in a stretched position. In such a scenario, the forces on the muscle fibers are at their highest, increasing the risk of strain. Intense eccentric muscle work and contraction can also create a situation where muscle fibers cannot endure the increased load placed on them. These forces are often encountered in running and jumping sports, but muscle strains can also occur in contact sports or during daly activities.

 

Classification

Muscle injuries are classified into three categories based on clinical and imaging findings:


  • I degree (mild) injuries affect only a limited number of muscle fibers. There is no decrease in strength, and both active and passive range of motion remain normal. Pain and tenderness may typically appear the next day.


  • II degree (moderate) injuries involve the tearing of nearly half of the muscle fibers. Acute and intense pain is accompanied by swelling and a slight decrease in muscle strength. The range of motion may also be affected in a II degree injury.


  • III degree (severe) injuries occur when the muscle tears completely. This can mean that either the tendon separates from the muscle belly or the muscle belly is torn into two parts. Severe swelling, intense pain, and a complete loss of function characterizes this type of injury.


In II- and III-degree injuries, bruising often forms in the injured area within a few days. Grade I injuries usually heal well on their own without treatment or further investigations. However, Grade II and III injuries may require rehabilitation and additional examinations.


The need for imaging is typically determined based on the clinical presentation and history. In this case, plain radiographs are not usually beneficial, except for ruling out possible bone- or joint-related injuries. Therefore, magnetic resonance imaging (MRI), which provides detailed visualization of soft tissues, is often the primary imaging method.


Recovery time depends on the extent of the tear, ranging from a few days to several months. In mild strains, gentle use of the muscle without significant load is recommended to begin as early as possible. For more extensive tears, it may be necessary to refrain from loading the injured area for up to a week.


Intensive training should only resume once muscle strength and flexibility have returned to the pre-injury level, typically taking 2-8 weeks depending on the severity of the injury.

 

Predisposing Factors There are three different types of muscles that are at a greater risk of injury and tearing:

  1. Two-joint muscles: In this case, the stretch and tension applied to the muscle through one joint can more easily lead to a overstretching injury if the joint at the other end of the muscle simultaneously increases the stretch or is already in a stretched position.

  2. Muscles performing eccentric work: Eccentric muscle work refers to a situation where the muscle contracts and lengthens simultaneously. In other words, eccentric muscle work is decelerating muscle work. Muscles can resist greater forces during deceleration than during contraction, but they are also more susceptible to overloads that can lead to tearing.

  3. Muscles with a higher percentage of type II muscle fibers: Type II muscle fibers are rapidly contracting muscle fibers that generate explosive power. Rapidly contracting muscles are typically more prone to tearing compared to slowly contracting muscles. Additionally, rapidly contracting muscles often operate during the eccentric phase of contraction, which further increases the susceptibility to tears. For example, the muscle activity in running and sprinting is mainly eccentric, which is why tears often occur in sprinters or athletes involved in speed-demanding sports.

Typical areas for muscle strains include the hamstrings, calf muscles, quadriceps, hip flexors, hip adductors, back muscles, shoulder muscles, biceps muscle, and the rotator cuff supporting the shoulder joint.

 

Peace & Love In the past, the treatment approach for acute injuries was centered around "R.I.C.E. - Rest, Ice, Compression, and Elevation." Compression and elevation aimed to reduce bleeding and keep swelling in check, while ice was used to calm potential inflammatory changes in the injured tissues.

However, recent research suggests that this model is somewhat outdated. While it is still important to control swelling and bleeding through compression and elevation, anti-inflammatory methods should be avoided in the early stages. It has been shown that overly early intervention to prevent the inflammatory response impairs tissue healing after an acute injury. Hence, the "R.I.C.E" rule for acute tissue injury has evolved into the "Peace & Love" approach:

  • P (Protect): Avoid weight-bearing and limit movement during the first few (1–3) days after the injury to reduce bleeding and prevent additional damage to the injured area.


  • E (Elevate): Whenever possible, raise the injured area above heart level to facilitate the drainage of potentially increased tissue fluid from the injured area.


  • A (Avoid anti-inflammatory modalities): Use anti-inflammatory methods judiciously. Factors affecting the inflammatory process, such as anti-inflammatory medications, may diminish the beneficial effects of the inflammatory reaction on tissue recovery. There is insufficient evidence supporting the efficacy of cold therapy in the treatment of acute sports injuries, and prolonged cold therapy may interfere with healing. Therefore, use anti-inflammatory drugs and cold therapy judiciously, favoring acetaminophen over anti-inflammatory drugs for pain relief.


  • C (Compress): Mechanical compression on the injured area reduces swelling and internal bleeding of tissues.


  • E (Educate): Encourage the patient to actively and independently participate in their recovery. Passive treatment methods are rarely beneficial in the management of acute injuries.

Once the initial days have passed, soft tissues need a bit of love:

  • L (Load): Replace rest with appropriate loading. The new recommendation emphasizes initiating loading and resuming normal activities as soon as symptoms allow. Appropriate loading helps avoid an increase in pain and strengthens tissue healing through movement. Normal training may need to be replaced with alternative exercises to minimize scar formation and promote resilience.


  • O (Optimism): Support a positive attitude toward recovery while remaining realistic about the healing timeline. Worry, depression, and fear of movement are associated with poorer outcomes during recovery from injury.


  • V (Vascularisation): Starting aerobic exercise a few days after the injury promotes the restoration of normal blood circulation, aiding tissue healing. Early movement improves functionality and reduces the need for pain medication.


  • E (Exercise): Initiate rehabilitative exercises early to restore ranges of motion, strength, and proprioception. Avoid increasing pain, and let pain relief guide the progression of the exercise program. Therapeutic neuromuscular supportive training prevents the occurrence of new injuries. Neglecting active rehabilitation weakens the later tolerance of the injured area to stress, increasing the risk of injury recurrence.

 

Physiotherapy

Following the initial care, muscle strains require progressive training to restore the normal function of the muscle-tendon unit. The treatment approach is determined by the extent and severity of the injury but is generally conservative. Physiotherapy plays a significant role in recovery and the design of a rehabilitation program. In the early stages, the goals often include reducing pain and swelling, maintaining or increasing range of motion, and restoring proprioception.


Once the worst pain and swelling have subsided, rehabilitation is directed towards improving muscle function and strength capacity. For athletes, the specific requirements of their sport are considered in the rehabilitation planning. Rehabilitation is thus always individualized but broadly consists of mobility training, strength training, balance and proprioception enhancement, and plyometric exercises.


The timing of the return to sports depends on the severity of the injury and the functional performance of the torn muscle-tendon unit. The physiotherapist also determines when it is safe to return to sport. Functional tests are employed in the assessment, evaluating control of the area, balance, agility, and tests measuring power production. Adequate mobility and muscle elasticity are also essential for a safe return to sports.

 

Self care

  1. Peace & Love: Following an acute tissue injury, the primary treatment approach should adhere to the "Peace & Love" principles. This ensures a good start to the treatment and promotes the initiation of tissue healing.

  2. Gentle Movement: Move the strained area gently through its full range of motion without causing significant pain. Perform exercises that involve both stretching and contracting forces on the affected muscle. Initially, these exercises can be done without resistance, but as soon as pain allows, resistance should be gradually increased. Gentle movement and light exercises help improve flexibility and prevent stiffness.

  3. Strength Training: Once the injured area can tolerate loading, it should be strengthened. However, pay attention to possible pain and soreness after exercising. Mild or moderate pain that eases within a day is often acceptable, but intense or prolonged pain during or after exercise indicates excessive strain.

  4. Mobility Training: Maintain the mobility of the injured area by performing mobility exercises.

  5. Professional Guidance: Consult a physiotherapist or healthcare professional who can assess your situation and provide appropriate guidance. They can tailor exercises to your individual needs and offer advice on when to progress in your training or when it's safe to return to your specific sport.

Remember, if your pain persists or worsens, it's important to consult a healthcare professional for possible additional examinations and more detailed treatment. For a personalized program, I recommend individuals with discomfort to reach out to a physiotherapist.


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