Muscle Strain Injury:

Diagnosis and Treatment

Thomas J. Noonan, MD, and William E. Garrett, Jr, MD, PhD

Abstract

Muscle strain is a very common injury. Muscles that are frequently involved sports. The outcome of a muscle
cross two joints, act mainly in an eccentric fashion, and contain a high percent- strain is generally good but de-
age of fast-twitch fibers. Muscle strain usually causes acute pain and occurs pends on the severity of the injury.
during strenuous activity. In most cases, the diagnosis can be made on the A full return to activity with no
basis of the history and physical examination. Magnetic resonance imaging is residual disability is usually possi-
recommended only when radiologic evaluation is necessary for diagnosis. ble after healing of a minor injury.
Initial treatment consists of rest, ice, compression, and nonsteroidal anti- However, a major injury can result
inflammatory drug therapy. As pain and swelling subside, physical therapy in limited range of motion and
should be initiated to restore flexibility and strength. Avoiding excessive weakness. The vast majority of
fatigue and performing adequate warm-up before intense exercise may help to muscle strains fall within the range
prevent muscle strain injury. The long-term outcome after muscle strain of less severe injuries.
injury is usually excellent, and complications are few.
J Am Acad Orthop Surg 1999;7:262-269
Etiology

Certain muscles are injured more

Muscle injuries are very common
in persons who participate in sports.
In addition to the inconvenience
and discomfort associated with
such injuries, they also have a sig-
nificant economic impact if the
work-related costs are considered.
The spectrum of these injuries is
wide and includes contusion, lacer-
ation, delayed-onset muscle sore-
ness, and muscle strain. Contusion
is caused by a direct blow to the
muscle and is treated with a three-
phase treatment program, involving
(1) a short period of immobilization
with the muscle in a lengthened
position, (2) passive and active
range-of-motion exercises, and
(3) strengthening.
Laceration is uncommon and is
seen more often after trauma than
after sports accidents. Treatment
includes thorough irrigation and
debridement followed by suture
repair of the fascia, if possible.
Completely lacerated muscles
recover approximately 50% of their
strength and 80% of their ability to
shorten.
Delayed-onset muscle soreness
is defined as muscular pain that
occurs 24 to 72 hours after vigorous
exercise. It is common following
unaccustomed intense exercise and
is characterized by discomfort
beginning several hours after exer-
cise and peaking after 1 to 3 days.
This entity can be distinguished
from acute muscle strain, which is
characterized by immediate pain
associated with diminished func-
tion. Delayed-onset muscle sore-
ness will resolve in a few days and
requires no specific treatment.
Stretching will help to preserve
range of motion, and nonsteroidal
anti-inflammatory drugs (NSAIDs)
can be used to alleviate pain.
Muscle strain is by far the most
common muscle injury suffered in
often than others. The muscles
most at risk are those in which the
origin and the insertion cross two
joints. One reason for their in-
creased proclivity to injury is that
many of these muscles can limit the
range of motion of a joint they
cross. For example, with the hip
flexed, the hamstring muscles can
limit knee extension; a hurdling
maneuver can place high levels of
Dr. Noonan is in private practice in Charlotte,
NC. Dr. Garrett is Chairman, Department of
Orthopaedic Surgery, University of North
Carolina, Chapel Hill.
Reprint requests: Dr. Noonan, Charlotte
Orthopaedic Specialists, 1915 Randolph Road,
Charlotte, NC 28207.
Copyright 1999 by the American Academy of
Orthopaedic Surgeons.

262 Journal of the American Academy of Orthopaedic Surgeons

 Thomas J. Noonan, MD, and William E. Garrett, Jr, MD, PhD

passive tension on the hamstring
muscles and potentially injure
them.
Frequently injured muscles act
in an eccentric fashion (i.e., length-
ening as they contract) as they reg-
ulate motion during sports activi-
ties. During running, for example,
the muscles of the quadriceps
group act primarily to limit knee
flexion after heel strike rather than
to power knee extension. Injury to
these muscles usually occurs dur-
ing an eccentric contraction.
Frequently injured muscles have
a relatively high percentage of type
II (fast-twitch) fibers. The high pro-
portion of such fibers means that
the muscles are used for high-speed
activities, which may predispose to
injury. Not surprisingly, muscle
strain most often occurs in athletes
whose sports require high speeds
or rapid acceleration, such as track
and field, football, basketball, and
soccer. An example of a muscle
that displays all of these risk factors
is the biceps femoris. It crosses two
joints and acts eccentrically at high
speeds to decelerate the leg during
sprinting.
that activation of normal muscle
by nerve stimulation alone did not
cause injury. To produce either
gross or microscopic injury, stretch
of the muscle past its resting length
was also necessary.2
Histology of Muscle Strain
Injury
Histologic studies have shown that
muscle strain injuries cause a dis-
ruption of muscle fibers near the
myotendinous junction. The fibers
do not tear at the junction, but
rather at a short distance from it.
Acutely, the injuries are character-
ized by disruption and some hemor-
rhage within the muscle (Fig. 1). By
day 2, an inflammatory reaction is
evident, with the presence of edema
and inflammatory cells (Fig. 2). By
day 7, fibrous tissue has replaced
the inflammatory reaction. Al-
though some regenerating muscle
fibers are present, the histologic
appearance is abnormal, and scar
tissue is persistent.
Diagnosis
be present. Active and sometimes
passive range of motion of the
joints that the muscle crosses will
also cause discomfort and may be
limited. Strength testing of the
muscle will demonstrate weakness,
but this may be attributable more
to diminished central drive sec-
ondary to pain than to actual mus-
cle damage.
Imaging
Plain radiographs may show
soft-tissue swelling in a case of mus-
cle strain injury but will usually
appear normal. Computed tomog-
raphy has only a limited capability
to depict soft-tissue injury but may
demonstrate hemorrhage into the

Biomechanics of Injury Muscle strain will usually present

Muscle strain occurs as a result of
forcible stretching of a muscle,
either passively or, more common-
ly, when the muscle is activated.1
Most often this is during an eccen-
tric contraction, when the muscle is
being lengthened as it contracts.
This is likely because eccentric con-
traction generates higher forces
than concentric contraction. The
connective tissue framework of the
muscle also produces more force as
it is stretched, although this is usu-
ally quite small until a relatively
large amount of stretch has been
applied.
Experimental data suggest that
strain is crucial to the creation of
injury. Initial studies demonstrated
with an episode of acute pain expe-
rienced during intense activity.
Depending on the severity of the
injury and the intensity of the
activity, the pain may prevent the
patient from continuing. If so, the
pain will be most pronounced dur-
ing eccentric activation of the mus-
cle (e.g., hamstring injury will be
most painful during the swing
phase of gait while running).
Fig. 1 Histologic appearance of an exten-
Physical Examination sor digitorum longus muscle specimen
Localized tenderness over the obtained immediately after strain injury.
Note limited rupture of the most distal
myotendinous junction of the fibers near the myotendinous junction.
injured muscle will be evident on M = intact muscle fibers; T = tendon
physical examination. In the case (Masson stain, original magnification 1.75).
(Reproduced with permission from Noonan
of a complete rupture of the mus- TJ, Garrett WE Jr: Muscle injury of the pos-
cle, a defect may be palpated. terior leg. Foot Ankle Clin 1997;2:457-471.)
Swelling and ecchymosis may also

Vol 7, No 4, July/August 1999 263

Muscle Strain Injury

ate number of fibers, with the fas-

cia remaining intact. A grade 3
injury is a tear of many fibers with
partial tearing of the fascia. A
grade 4 injury is a complete tear of
the muscle and fascia (i.e., a rup-
ture of the muscle-tendon unit).
Recovery is longer with a high-
grade injury, and the long-term
outcome is potentially worse.
T M
Treatment Options

The various treatment strategies for

muscle strain injuries have usually
been empirically adapted from
clinical practice. Few clinical or
basic science studies have been per-
formed to determine the effects of
different treatments.
A B Initial treatment usually consists
of rest, ice, and compression for
Fig. 2 Histologic appearance of tibialis anterior muscle specimens (M = intact muscle
fibers; T = tendon). A, Specimen obtained 24 hours after strain injury demonstrates muscle relief of pain and swelling. Non-
fiber necrosis, tissue edema, inflammation, and hemorrhage (Masson stain, original magni- steroidal anti-inflammatory agents
fication 70). B, Specimen obtained 48 hours after strain injury. Higher-magnification may also be used for pain relief for
view of the musculotendinous junction shows the presence of macrophages, multinucleate
cells, and fibroblast cells (Masson stain, original magnification 227.5). (Reproduced with the first 2 to 3 days. As pain and
permission from Nikolaou PK, Macdonald BL, Glisson RR, Seaber AV, Garrett WE Jr: swelling decrease, physical therapy
Biomechanical and histological evaluation of muscle after controlled strain injury. Am J can be initiated to improve range of
Sports Med 1987;15:9-14.)
motion and strength. When full
range of motion and nearly full
strength have been attained, the
muscle. If radiologic evaluation is nosis may be evident from the athlete may return to full activity.
necessary, magnetic resonance physical examination, MR imaging No specific criteria for adequate
(MR) imaging can most accurately can be used to differentiate deep strength have been defined, but a
define the injury site. T1-weighted venous thrombosis from muscle cutoff of 80% of the strength on the
images may show disruption of the strain. This modality may also be contralateral side on isokinetic test-
normal architecture of the muscle- useful in determining the severity ing is recommended. In the early
tendon junction. T2-weighted im- of a muscle strain in cases in which stages of return, it is advisable to
ages will show increased signal in this may be important (e.g., in a avoid excessive fatigue to prevent
the injured muscle due to edema professional athlete). reinjury. In addition, the muscle
(Fig. 3, A). In addition, T2-weighted should be warmed up with low-
images often show collections of level activity plus external heat
high-signal-intensity fluid that track Classification Systems before intense activity.
along the epimysium and escape to Although surgical treatment
the subcutis (Fig. 3, B). There is no universal classification has been recommended for com-
Magnetic resonance imaging is system for muscle strain injuries. plete (grade 4) muscle ruptures,4,5
seldom necessary, however, as the Ryan 3 published a classification most surgeons believe that nonop-
diagnosis is usually evident from system for quadriceps strain in- erative treatment provides equiva-
the history and physical examina- juries that has been applied to lent or superior results. Almekin-
tion. For example, its use may be other muscles. A grade 1 injury is ders6 studied this issue by sever-
warranted if a patient has a a tear of a few muscle fibers, with ing the extensor digitorum longus
swollen calf but a history of only the fascia remaining intact. A muscle in the rat and then treating
minor trauma. Although the diag- grade 2 injury is a tear of a moder- it with either surgical repair or

264 Journal of the American Academy of Orthopaedic Surgeons

 Thomas J. Noonan, MD, and William E. Garrett, Jr, MD, PhD

A B

Fig. 3 A, T2-weighted axial MR image through the middle of the medial gastrocnemius muscle in a patient with documented disruption at
the distal myotendinous junction (m = medial head of gastrocnemius muscle; T = tibia). High-signal changes (arrow) consistent with edema
and inflammation are present throughout the muscle at this level. B, T2-weighted coronal MR image shows injury around the distal
myotendinous junction of the medial head of the gastrocnemius muscle (m). A layer of fluid is present (arrow), with escape into the sub-
cutis. (Reproduced with permission from Noonan TJ, Garrett WE Jr: Muscle injury of the posterior leg. Foot Ankle Clin 1997;2:457-471.)

immobilization. At 7 days postin- Rest Seven days after injury, load to

jury, the surgically repaired mus-
cles were stronger. However, by
14 days, there were no differences
between the two treatment groups.
In contrast, a recent study7 evalu-
ated the results of treatment of
experimentally created laceration
in the gastrocnemius muscle of the
mouse and found that suture re-
pair yielded significantly greater
tetanus strength at 1 month com-
pared with treatment by immobi-
lization. Whether these results are
applicable to the clinical situation
is unclear. Another consideration
is that muscle repair is technically
difficult, as there is no way to
securely fix the muscle to itself.
For these reasons, nonoperative
treatment of muscle strain injury is
almost universal.
The time frame for healing of
muscle strain injuries is directly
related to the severity of injury.
Minor muscle strain injuries may
be healed in 1 week, whereas se-
vere injuries may require 4 to 8
weeks.
In the acute inflammatory
phase (days 1 to 5 after injury),
rest promotes pain control. After
the resolution of acute inflamma-
tion, only submaximal activity is
recommended, to prevent further
injury or reinjury. The tensile pro-
perties and contractile ability of
the muscle-tendon unit are altered
after injury, and an early return to
full activity predisposes to addi-
tional injury.
Several researchers have dem-
onstrated changes attributable to
stretch-induced nondisruptive
strain injuries. Taylor et al8 tested
the extensor digitorum longus
muscle in the New Zealand white
rabbit and found that the postin-
jury load to failure was 63% that of
the control value and length to fail-
ure was 79% of control. Contrac-
tile ability was diminished as well.
Obremsky et al9 also studied rabbit
skeletal muscle and found that 1
day after injury, load to failure was
65% of control and maximum con-
tractile force was 59% of control.
failure had returned to only 77% of
the control value, while maximum
contractile force was 91% of the
control value.
Some authors recommend im-
mobilization of the muscle-tendon
unit to limit hemorrhage and edema
in the acute postinjury phase.
However, prolonged immobiliza-
tion is discouraged because of de-
trimental long-term effects. Long-
term immobilization in either a
lengthened or a shortened position
will result in a change in sarcomere
number (i.e., sarcomeres will be
added or deleted until the sarco-
mere length in the position of
immobilization equals the sarco-
mere length before immobilization).
The addition of sarcomeres occurs
at the muscle-tendon junction. Im-
mobilization in a lengthened posi-
tion results in the reorganization of
the passive elements of the muscle
as well; the connective tissue is
rearranged as the resting length of
the muscle adjusts to its position of
immobilization. Therefore, immo-

Vol 7, No 4, July/August 1999 265

Muscle Strain Injury
bilization of an injured muscle such
that it is held at its resting length is
recommended.
Immobilization also alters the
biomechanical properties of the
muscle-tendon unit. Laboratory
studies have shown that immobi-
lized muscle has a lower load to
failure and a lower total deforma-
tion to failure compared with nonim-
mobilized muscle.10 Clinical stud-
ies also support using immobiliza-
tion for only short periods of time;
a 20% decline in muscle strength
has been measured after 1 week of
immobilization.10
The only exception may be the
complete rupture, in which case im-
mobilization may allow some reap-
proximation of the torn muscle ends.
Even in this instance, however, im-
mobilization should be used for no
more than 10 to 14 days.
Early tensile loading of muscle,
tendon, and ligament can stimulate
collagen fiber growth and realign-
ment. Early motion also limits the
formation of adhesions between
healing muscle and adjacent tissue.
Proprioception also recovers faster
with early motion.
Cryotherapy
Application of ice, or cryotherapy,
is recommended to ameliorate the
effects of the inflammatory reaction
to strain injury by reducing edema
and hematoma formation and
diminishing pain. 11 It has been
hypothesized that cryotherapy
retards hematoma formation be-
cause it constricts the capillaries and
thereby decreases blood flow.
Although a number of studies attest
to these effects, there is also evi-
dence that cryotherapy results in
periodic vasoconstriction and vaso-
dilation, known as the hunting
reaction.11
Cryotherapy can either increase
or decrease swelling. Several stud-
ies have documented increased
swelling with cold application to
temperatures below 15C due to
266
the increase in the permeability of
superficial lymph vessels that oc-
curs at this temperature. With less
extreme cooling, diminished swell-
ing has been observed. McMaster
et al12 studied crush injury of the
rabbit forelimb and found reduced
limb volume at 24 hours with cool-
ing to 30C. Similarly conflicting
data relative to the inflammatory
response have been reported. Stud-
ies have shown that cold can in-
hibit as well as enhance inflamma-
tion.
Cryotherapy also provides an
analgesic effect. Numerous studies
have shown an analgesic effect of
cold application with cooling to
10C to 15C. The mechanism of
pain relief is believed to be due to
breaking of the pain cycle by show-
ering the central nervous system
with impulses, which makes the
receptors momentarily refractory
to pain.
In summary, the effects of cryo-
therapy on inflammation and
swelling after muscle strain injury
are unclear. The analgesic effect is
well substantiated. Although the
duration of the effect is not well
defined, even the temporary estab-
lishment of analgesia is helpful for
early mobilization of the injured
extremity. However, caution is ne-
cessary, as the theoretical possibility
of worsening swelling exists with
the application of extreme cold.
Nonsteroidal Anti-inflammatory
Drugs
Nonsteroidal anti-inflammatory
agents have been used to reduce
the inflammatory response seen in
muscle strain injury. This response
involves vasodilation and extrava-
sation of blood into the surround-
ing tissue. Inflammatory cells are
recruited in this process, which
results in increased swelling, ery-
thema, pain, and impaired func-
tion.13
Although these effects are detri-
mental, an inflammatory response
Journal of the American Academy of Orthopaedic Surgeons
is not absolutely undesirable after a
strain injury. This response may be
the only means by which the body
can remove necrotic tissue. There-
fore, a certain level of inflammation
may be necessary to allow healing
to take place.13 Healing of a muscle
injury occurs in two ways. First,
muscle can regenerate from intact
viable muscle fibers and from satel-
lite cells that act as muscle stem
cells. Second, the defect can heal
with bridging scar tissue. It is un-
clear whether treatment aimed at
inhibiting the initial inflammatory
response can blunt the scarring
response and allow increased
amounts of muscle regeneration.
In two studies, 9,14 the effect of
NSAIDs on muscle strain injury
was investigated, but no significant
effect on tensile strength was
demonstrated. Contractile force
was also evaluated in one study9
and found to be unaltered. How-
ever, both studies showed histo-
logic evidence of delayed healing
with NSAID use.
Another study evaluated the
effect of NSAIDs on rabbits with
exercise-induced muscle injuries.15
The group that received NSAIDs
had a more complete functional
recovery than untreated control ani-
mals at 3 and 7 days, but showed
deficits in pertinent measurements
when tested at 28 days. Evaluation
of histologic and ultrastructural
properties also suggested that the
long-term effects of NSAIDs could
be potentially harmful.
In summary, NSAIDs offer the
potential benefits of analgesia and
inflammation reduction when used
to treat muscle strain injury. How-
ever, many questions remain re-
garding the long-term effects of
these drugs on the recovery pro-
cess. In addition, the choice of
NSAID and the optimal timing and
dosing schedules have not yet been
established. The current recom-
mendation of most authors is to
use an NSAID immediately after

injury but to continue administra-
tion for only a short period to pre-
vent interference with the healing
response.
Compression and Elevation
The use of compression and ele-
vation in the treatment of muscle
strain injury is thought to decrease
pain and swelling. Although there
are no studies that address the use
of these modalities in muscle strain
injury, their employment is gener-
ally recommended.
Physical Therapy
After the resolution of the acute
pain and swelling, most authors
recommend the institution of a pro-
gram of physical therapy. This is
beneficial for restoring normal
muscle strength and flexibility to
the muscle.
Restoration of muscle strength is
important to prevent further injury
or reinjury because of the role of
muscle as an energy-absorbing
structure. The ability of the muscle
to resist lengthening is a measure
of its capacity for energy absorp-
tion. Muscle can do this in two
ways: passively, by the resistance
of the connective tissue elements
within the muscle, and actively, by
contraction against the lengthening
force.
These concepts have been dem-
onstrated in a laboratory study of
rabbit muscles stretched to failure
in the activated and nonactivated
states.16 In that study, the force to
failure was 15% higher and the
energy absorbed was 100% higher
in muscles stretched to failure
while activated. At small deforma-
tions of the muscle, most of the
energy absorption was due to the
active component rather than the
passive component. Most physio-
logic activity in eccentrically con-
tracting muscle occurs at relatively
small deformations. Thus, muscle
weakness should significantly
impair the ability of the muscle to
Vol 7, No 4, July/August 1999
Thomas J. Noonan, MD, and William E. Garrett, Jr, MD, PhD
absorb energy, making it more sus-
ceptible to muscle strain injury.
Continuing this logic, returning an
injured muscle to full strength is
important in preventing additional
injury.
Passive stretching of muscle is
thought to be beneficial because it
reduces muscle stiffness. A labora-
tory study showed that much of
the decreased stiffness is due to
viscoelastic properties rather than
reflex changes.17 Because of visco-
elasticity, prolonged stretching can
lead to diminished stress within
the muscle for a given length
change. Although the temporal
characteristics of this effect are un-
clear, this property represents a
plausible mechanism by which
stretching might prevent further
muscle strain injury in the postin-
jury setting.
Prevention of Muscle
Strain Injury
Precautions can be taken to prevent
the occurrence of muscle strain
injury. A strong, flexible muscle is
less likely to be injured than a
weak, stiff muscle. Any factor that
impairs the contractile function of
the muscle will lead to a reduction
in its energy-absorbing capabilities,
making it more susceptible to
strain injury. For example, fatigue
has been associated with muscle
strain; laboratory studies have
shown that when fatigued muscle
is failure-tested, it has diminished
load to failure, total deformation,
and energy absorbed prior to fail-
ure. Therefore, a warmed-up, non-
fatigued muscle is more resistant to
injury than a fatigued muscle that
has not been adequately prepared
for competition.
Mair et al 18 examined rabbit
muscle pulled to failure after being
fatigued. In a simulated stretch to
muscle failure, a decrease in energy
absorption of 42% was seen in the
first 70% of the length change
(when most muscle injury occurs);
there was only a 6% difference in
the last 30% of the stretch.
Although it is impossible to
eliminate fatigue in the competitive
situation, it makes sense to limit
fatigue in the postinjury rehabilita-
tion period. At this time, not only
is the muscle at less than full
strength, but the athlete may also
be deconditioned due to inactivity.
As the athletes conditioning and
muscle strength improve, exposure
to intense activity in a relative state
of fatigue may be increased. Re-
habilitation should, therefore, focus
on muscular endurance as well as
strength. This can be accomplished
by training with low levels of resis-
tance for many repetitions.
Athletes commonly participate
in warm-up routines to enhance
performance and minimize the
chance of injury. The benefit of
such routines has been widely
debated. Many authors believe
that warm-up is protective because
it increases the range of motion and
reduces stiffness secondary to an
increase in muscle.
Safran et al19 studied isometrical-
ly preconditioned rabbit muscle ver-
sus nonstimulated control muscle.
The experimental muscle failed at a
greater deformation and greater
load than the control muscle, imply-
ing that a protective effect may have
been gained from the warm-up
period. It is unclear whether this
effect occurred because of the tem-
perature increase from the contrac-
tion (about 1C) or because of
stretching at the myotendinous
junction.
In another study,20 the effects of
muscle temperature on failure
properties were evaluated. Rabbit
skeletal muscle was studied at 25C
and 40C, temperatures considered
to represent the extremes in human
muscle temperature. Mean stiff-
ness (load to failure/total deforma-
tion) was higher in the cold muscle,
267
Muscle Strain Injury
implying that warming of muscle
may be protective.
The functional aspects of muscle
in relation to temperature have also
been investigated. The temporal
characteristics of contraction are
significantly altered: time to peak
tension and time to relaxation are
decreased with increasing tempera-
ture, and maximum and sustained
power generation are increased.
Therefore, in the rehabilitation of a
muscle strain injury, the use of heat
is recommended before exercise to
decrease the likelihood of reinjury.
In addition, a period of low-intensity
exercise is recommended before
high-intensity activity to allow the
body and muscle temperatures to
rise.
Complications
Complications of muscle strain
injury are relatively few. Most
injuries heal with little, if any,
residual defect. Potential complica-
tions include fibrosis, weakness,
pain, and reinjury. Generally, only
the most severe injuries will be
associated with any of these prob-
lems. We are not aware of any
study in which the incidence of
References
1. Zarins B, Ciullo JV: Acute muscle and
tendon injuries in athletes. Clin Sports
Med 1983;2:167-182.
2. Garrett WE Jr, Nikolaou PK, Ribbeck
BM, Glisson RR, Seaber AV: The effect
of muscle architecture on the biome-
chanical failure properties of skeletal
muscle under passive extension. Am J
Sports Med 1988;16:7-12.
3. Ryan AJ: Quadriceps strain, rupture,
and charlie horse. Med Sci Sports 1969;
1:106-111.
4. Miller WA: Rupture of the musculo-
tendinous juncture of the medial head
of the gastrocnemius muscle. Am J
Sports Med 1977;5:191-193.
5. ODonoghue DH: Treatment of Injuries
268
these complications has been eluci-
dated.
Reinjury is the most frequent
complication. It can occur even in
minor muscle strain injuries. Gene-
rally, this is the result of returning
to sport too soon. Athletes can
develop chronic muscle strain
injuries that last several months,
with reinjury occurring each time a
return to high-level sports activity
is attempted. In this situation, the
athlete has usually attempted to
return despite a persistent deficit in
strength and/or flexibility.
Symptomatic fibrosis occurs less
frequently. In some athletes, how-
ever, a severe muscle strain injury
will result in a painful fibrotic area.
Initial treatment should involve
aggressive physical therapy with
stretching and perhaps the use of
modalities such as ultrasound and
deep-tissue massage. Occasionally,
the area remains painful; in a few
cases, symptoms have been so
severe that resection of the fibrotic
portion of the muscle has been nec-
essary. Although experience with
this procedure is limited, our re-
sults have been good. Myositis os-
sificans may develop after a muscle
contusion, but rarely occurs after a
muscle strain.
to Athletes, 4th ed. Philadelphia: WB
Saunders, 1984, pp 51-63.
6. Almekinders LC: Results of surgical
repair versus splinting of experimen-
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tural deficits and the increased risk for
reinjury. Am J Sports Med 1993;21:190-194.
Journal of the American Academy of Orthopaedic Surgeons
Summary
Despite the high prevalence of mus-
cle strain, treatment regimens have
generally been based on empirical
data. Initial treatment is aimed at
reducing the inflammatory response.
Compression and elevation are used
to limit swelling and hematoma. Ice
is effective as an analgesic, but its
anti-inflammatory effects are unclear.
Similarly, the use of NSAIDs helps to
reduce pain acutely, but their role in
reduction of inflammation has not
yet been defined. Limitation from
full activity is important to prevent
reinjury. Although immobilization
may be indicated, its use should be
limited, as early mobilization is bene-
ficial in the healing process.
With resolution of pain and
swelling, the treatment emphasis
changes to rehabilitation. Physical
therapy is initiated, with the goal of
restoration of muscle strength and
flexibility. A full return to activity
should not occur before these goals
have been met. In the early stages
of return, extreme fatigue should
be avoided, and a thorough warm-
up should always be performed.
Adherence to these principles
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