This document discusses muscle strains and ligament sprains. It describes the different types and grades of muscle strains, from minor strains involving a small number of fibers to complete tears of the muscle. The healing process for muscle injuries is described in two phases - initial destruction and injury followed by repair and regeneration. Treatment recommendations include RICE initially, followed by early mobilization and exercise like isometrics and stretching within the limits of pain.

1. MUSCLE STRAIN &
LIGAMENT SPRAIN
-Dr. Krupal Modi(MPT)
3/9/2018

2. MUSCLE STRAIN/TEAR
Types of muscle injuries:
• Laceration- cut by external trauma
• Contusion- compressive forces to muscle ,
contact sports
• Strain- when muscle can not withstand
excessive tensile forces placed on them and
are therefore associated with eccentric muscle
action.

3. • Muscles are strained or torn when some or all of
the fibers fail to cope with the demands placed
upon them.
• Muscles that are commonly affected are the
hamstrings, quadriceps and gastrocnemius;
these muscles are all biarthrodial (cross two
joints) and thus more vulnerable to injury.
• A muscle is most likely to tear during sudden
acceleration or deceleration(because muscle in
lengthened state and contracting forcefully).

4. • When the muscle is strained the initial injury is
usually associated with disruption of the distal
myotendinous junction and fibres distal to this
but still near the myotendinous junction.
• Injuries to the musclebelly only occur with the
application of very high forces.
• The contractile elements are the first tissues to be
disrupted; with the surrounding connective tissue
not being damage until high forces are applied.
PATHOPHYSIOLOGY

5. • The contractile elements are relative stiff in
comparison to the surrounding connective tissue
and hence become disrupted at lower forces than
the surrounding connective tissue.

6. • Muscle strains are classified in three grades.
• A grade I strain involves a small number of
muscle fibers and causes localized pain but no
loss of strength.
• A grade II strain is a tear of a significant
number of muscle fibers with associated pain
and swelling. Pain is reproduced on muscle
contraction. Strength is reduced and movement
is limited by pain.
• A grade III strain is a complete tear of the
muscle. This is seen most frequently at the
musculotendinous junction.

9. Healing
• Muscles heal by a repair process that can be
divided into two phases:
• (1) the destruction/injury phase resulting in
rupture and necrosis of the muscle fibres; and
• (2) Repair and regeneration.

10. Destruction/injury phase
• This phase results in damage to the vascular supply and
as oxygen can no longer reach the cells, they die and
release lysosome.
• Excessive force to a musclefibre results in tearing of the
sarcoplasm and the cells respond by forming a
contraction band , creating a protective barrier.
• Within 15 minutes of injury the damaged tissue
consists of disrupted extracellular tissue and dead cells,
platelets and plasma, which themselves release powerful
enzymes such as thrombin thereby setting off an
inflammatory cascade.
• A haematoma is formed to fill the gap between
ruptured muscle fibres.

11. • Clinically tissue inflammation presents as redness,
heat, swelling and pain of the tissues.
• The redness, heat and swelling are due to an
increased blood flow and so blood within vascular
beds in the area, with the swelling developing as a
result of the increased local tissue pressure due to
inflammatory exudates leaking into the interstitial
space.
• The pain is due to the initial damage to local nerves
and irritation of nerves in the area from the
inflammatory chemicals release by the damaged
tissue.

12. Repair and regeneration phase
• The regeneration process starts within 3–6 days
following injury, reaching a peak between day 7 and
14.
• After the initial injury, the inflammatory
chemicals released from the injured tissues attract
lymphocytes and macrophages to the area.
• Macrophage phagocytosis of the necrotic material
then occurs removing the debris.

13. • In response to injury satellite cells proliferate
and differentiate into myoblasts and then
become multinucleated myotubes.
• These then fuse with parts of the muscle fibre
that have survived the initial injury and attempt
to breech the gap in the muscle.

14. • A number of factors predispose to muscle
strains:
• inadequate warm-up
• insufficient joint range of motion
• excessive muscle tightness
• fatigue/overuse/inadequate recovery
• muscle imbalance
• previous injury
• faulty technique/biomechanics
• spinal dysfunction.

15. SIGNS AND SYMPTOMS
• Pain
• Muscle spasm
• Muscle weakness
• Swelling
• cramp

16. Treatment of muscle injuries
• It is frequently cited within the sports medicine
literature that the initial treatment of musculoskeletal
injuries should be rest, ice, compression and
elevation (RICE).
• However, this acrimony is likely to be more valid in the
less metabolically active tissues such as ligament and
bone.
• Muscle with its capacity for rapid regeneration due to the
nature of its constituent tissues requires a modified
approach. This modification is based around the
balance between absolute rest and the absolute
level of loading to stimulate appropriately the
rapidly developing tissues.

17. Rest and mobilisation
• Early mobilisation, rather than immobilisation or
complete rest, has been advocated .
• Studies have shown early mobilisation aids with
regeneration of muscle fibres.
• The exact level of loading is difficult to judge, it must
be sufficient to stimulate and challenge the
developing tissues, but not so great that it causes
tissue breakdown .
• This includes early weight bearing to help
promote scar tissue re-alignment and
controlled running to reduce muscle
inhibition.

18. • Immobilisation and poorly controlled early
loading (low or high), have been shown to lead
to the development of contracted scar tissue,
which blocks the linking of myotubes across the
injury, thereby stopping the formation of a
functional contractile element, and the
surrounding areas then become more
susceptible to further injury.

19. Ice
• Studies have shown that ice results in a significantly
smaller haematoma and less inflammation in the
initial stages of the injury.
• Reducing tissue temperature results in
vasoconstriction, thereby limiting the amount of
bleeding in the area .
• It also reduces the metabolic rate of the tissue and
therefore reduces the demand for oxygen ,
decreasing the hypoxic damage.
• 5–10 minutes in the initial stages and repeat every
60minutes within the first24–48hour to reduce the
inflammatory effects.

20. Compression and elevation
• Compression is an area where research is lacking, it
has been stated that it results in a reduction in the
severity of bleeding and swelling following an injury
, though the only evidence often present in support
of this theory is from studies involving ligament
injuries.
• A recent clinical study by Thorsson et al. (2007)
utilising 40 athletes with calf injuries found
compression resulted in no significant
difference in reducing muscle haematoma, or
speed of recovery of the injury using compression.

21. • Elevation is still one of the preferred and easiest
methods of immediate management used in sports
medicine for muscular injuries.
• It simply relies on the use of gravity to promote
venous return and lymphatic flow to drive
swelling/oedema from the area.
• It would appear that the greatest benefit that comes
from compression and elevation is that it ensures
that the athlete rests during the acute inflammatory
phase of the first 72 hours following injury.

22. Strengthening exercise
• Isometric exercise can begin after 2–5 days and
should be performed within the limits of pain .
• Frequency, duration and intensity are limited by the
patients’pain.
• Some therapists advocate three sets of 10 repetitions
using 5–10 second holds to begin with at intensity
within pain tolerance.
• These then are undertaken at multiple angles,
beginning in mid range then progressing to inner
range (shortened position) then outer range
(lengthened position).

23. • Once these can be undertaken in a pain-free
manner throughout the available range, then
isotonic exercises can commence.
• Dynamic movement and isotonic contraction is
then incorporated again starting in the strongest
position (mid range, close to a 90◦ joint angle)
progressing to and finishing in the functionally
most relevant (outer range with eccentric and
concentric contractions most often).

24. • There is preferential atrophy of type 1 muscle
fibres with disuse.
• Therefore, initially an endurance based
programme should be used, (three sets of 15
repetitions at 40–60% of one repetition
maximum) this would be progressed to
strength (4–6 sets of 3–6 repetitions at 85–
95% of one repetition maximum and then
power training (3–5 sets of 3-5 repetitions at
75–85% of one repetition maximum) or
plyometrics depending on the specific
requirements of the muscle.

25. Stretching
• Passive stretching (at the end of available range) should be
avoided for the first 72 hours as a minimal period, possibly
the athlete should not stretch for the first 7–10 days following
injury.
• The reasons for this are twofold.
• Firstly, the healing tissue is weak and intolerant of tensile
loading and so is likely to be damaged by uncontrolled
stretching.
• The second reason is there is no physiological need in the
early stages to stretch, as the scar does not beginning to
shrink until around the tenth day post injury when
fibroblasts begin to be converted to myofibroblasts and
contract and draw the wound ends together.

26. • Prior to the tenth day post injury it would be more
appropriate to take the muscle through its full
available pain-free range without any attempt to
force the muscle beyond this point.
• Each stretch should be held at the end of
available range within the limits of pain.
Time, frequency, duration and intensity of stretch
remain debateable in the literature. Some research
suggests passive stretching should be held for a
minimum of 15 seconds with 6–8 sets per day.

27. Electrotherapy
• Pulsed shortwave diathermy is particularly
helpful for enabling re-absorption of the
muscular haematoma as it is particularly
effective in more vascularised tissues such as
skeletalmuscle.
• It is thought to work at the cell membrane level,
resulting in an ‘up regulation’ of cellular behaviour.
This results in an improved rate of oedema
dispersion,resolution of the inflammatory
process and promotes a more rapid rate of
fibrin fibre orientation and deposition of
collagen.

28. • Therapeutic ultrasound
• This is the use of high intensity
soundswaves,which research has been shown
can help recovery of tissues at a cellular level by
increasing ion transport across cells and
increasing metabolism within the cell and
increasing fibroblastic and angiogenic activity.

29. • Muscle stimulation may prove a further useful
electrotherapeutic adjunct for the treatment of
muscle injuries.
• It has been shown to decrease oedema, muscle
inhibition and the rate of strength loss with
inactivity .
• However, muscle stimulation has not been shown
to be useful in the regaining of strength in the
injured athlete.

30. Summary key points of muscle healing
and rehabilitation
• RICE should be implement as soon as possible following acute
injury.
• Early mobilisation and weightbearing should also be
encouraged
• Stretching and strength exercises can start within pain-free
range as soon as possible
• Fitness and conditioning of the athlete should be incorporated
within the early rehabilitation programme without
compromising the injury
• Specificity, and functional fitness are imperative to help
return the athlete back to sport without recurrence.

31. LIGAMENT
SPRAINS
4/9/2018

32. LIGAMENT SPRAINS
• The stability of a joint is increased by the
presence of a joint capsule of connective tissue,
thickened at points of stress to form ligaments.
• The ends of the ligament attach to bone.
Ligament injuries range from mild injuries
involving the tearing of only a few fibers to
complete tears of the ligament, which may lead
to instability of the joint.
• Most common ???

33. Pathology
• Pathological changes in ligaments may occur due to
structural and functional failure.
• Any strain to a ligament may cause a long-term
joint instability.
• Following a strain, ligaments do not heal by
producing an identical tissue; instead, a scar tissue
is formed. (The scar tissue presents with an
uneven matrix, smaller in diameter collagen fibers,
weaker collagen crosslinking and a limited creep.)

35. • The blood circulation is also affected with a long
term reduction in blood circulation to the scar
tissue.
• Although scar tissue is formed relatively fast, there
are still mechanical and chemical changes months
and years after the injury, though it never has a
normal appearance or function again,
resulting in a high level of reoccurrences.
• Ankle sprains, for example, reoccur in 73% of all
athletes (Yeung et al. 1994).
• As ligaments provide the proprioceptive sensory
nerve supply to the central nervous system, any
ligament injury may cause further problems in the
neuromuscular system.

36. healing process
• Following a strain injury, the gap within the ligament
fills with blood to start the inflammation phase.
• Fibroblasts proliferate, the ligaments revascularise and
the gap becomes filled with scar tissue .
• Fibroblasts start producing scar tissue made by type III
collagen. This collagen-type material creates a rapid,
disorganised structure with weaker cross links to
fill the gap between the ligament’s edges quickly.
• Followed is the long remodelling period, which can take
months or even years as the matrix and collagen fibres
are rearranged to have stronger bonds.

37. • Ligament injuries are divided into three grades.
• A grade I sprain represents some stretched fibers
but clinical testing reveals normal range of motion
on stressing the ligament.
• A grade II sprain involves a considerable
proportion of the fibers and, therefore, stretching of
the joint and stressing the ligament show increased
laxity but a definite end point.
• A grade III sprain is a complete tear of the
ligament with excessive joint laxity and no firm end
point. Although they are often painful conditions,
grade III sprains can also be pain-free as sensory
fibers are completely divided in the injury.

39. SIGNS AND SYMPTOMS
• Pain
• Swelling
• Bruising
• Joint instability
• Not be able to move the joint

40. Treatment
• The viewpoints of the main two treatments are
1) the immobility, long rest and braces versus
2) the sooner-than-later active treatment.
• A systematic review finds no data to support any benefits
from using braces in sprained ligament (Pietrosimone et
al. 2008).
• Another study found that early activity, rather than
long immobility, would make
the healing time shorter,
more complete and that
the ligaments would appear stronger.

41. MANAGEMENT
• For grades I–II a non-operative active treatment
approach is the most common and usually
comprises rest(for a limited period),ice,
compression and elevation (RICE), isometric and
isotonic exercises and proprioceptive training.
• RICE therapy (Rest, Ice, Compress, Elevate) for
the first 24 to 48 hours.
• 1. Rest the injured area (reduce regular exercise or
activities as needed)

42. • 2. Ice the injured area, 20 minutes at a time,
four to eight times a day (cold pack, ice bag, or
plastic bag filled with crushed ice and wrapped
in a towel can be used)
• 3. Compress the injured area, using bandages,
casts, boots, elastic wraps or splints to help
reduce swelling.
• 4. Elevate the injured area, above the level of
the heart, to help decrease swelling while you are
lying or sitting down.

43. Proprioceptive training
• Proprioceptive training concentrates mostly on the
lower limb, in particularly post sprain in the ankle
joint.
• To maintain the proprioceptive neural
function by continuously using the joint in a
challenged position.
• It has been found that even the use of unsupervised,
home proprioceptive exercises reduces the rate of
reoccurance in atheletes.
Example: balanced and coordination training performed
on the wobble board, both as a treatment and
preventative measurements.

44. • For grade I and II sprains, treatment aims to
promote tissue healing, prevent joint stiffness,
protect against further damage and strengthen
muscle to provide additional joint stability.
• The treatment of a grade III sprain may be either
conservative or surgical.

45. PREVENTION
• Although we cannot prevent all sprains and
strains from occurring, there are some tips on
how to avoid them:
• Stretch before you workout with heavy items
• Use proper footwear for the activity you are
doing
• Warm up adequately before activities

46. Summary key points of ligaments
• Ligaments offer joints stability with sensory
feedback to the central nervous system.
• Ligaments’ blood supply is the limiting factor in
many healing process of sprain.
• Ligaments heal by the process of laying down
scar tissue, which exhibits structurally different
tissue organisation and is weaker compared to
the original ligament.

47. • Most frequent treatment for grade I–II sprains
are RICE, early mobilisation, isometric and
isotonic strengthening exercise, neuromuscular
rehabilitation and return to normal function as
soon as possible.
• For grade III injury, reconstructive surgery is an
option.