Muscle Injuries In Sports
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Muscle Injuries In Sports
In sports-related muscle injuries, the main goal of the sports medicine physician is to return the athlete to competition-balanced against the need to prevent the injury from worsening or recurring. Prognosis based on the available clinical and imaging information is crucial. Imaging is crucial to confirm and assess the extent of sports-related muscle injuries and may help to guide management, which directly affects the prognosis. This is especially important when the diagnosis or grade of injury is unclear, when recovery is taking longer than expected, and when interventional or surgical management may be necessary. Several imaging techniques are widely available, with ultrasonography and magnetic resonance imaging currently the most frequently applied in sports medicine. This state of the art review will discuss the main imaging modalities for the assessment of sports-related muscle injuries, including advanced imaging techniques, with the focus on the clinical relevance of imaging features of muscle injuries. RSNA, 2017 Online supplemental material is available for this article.
Literature does not reveal great consensus when it comes to classifying muscle injuries, despite their clinical importance. However, the most differentiating factor is the trauma mechanism. Muscle injuries can, therefore, be broadly classified as either traumatic (acute) or overuse (chronic) injuries.
Acute injuries are usually the result of a single traumatic event and cause a macro-trauma to the muscle. There is an obvious link between the cause and noticeable symptoms. They mostly occur in contact sports such as rugby, soccer and basketball because of their dynamic and high collision nature[5][6].
Overuse, chronic or exercise-induced injuries are subtler and usually occur over a longer period of time. They result from repetitive micro-trauma to the muscle. Diagnosis is more challenging since there is a less obvious link between the cause of the injury and the symptoms[5]. The below video gives a brief talk on these chronic injuries.
A strain to the muscle or muscle tendon is the equivalent of a sprain to ligaments. It is a contraction-induced injury in which muscle fibres tear due to extensive mechanical stress. This mostly occurs as a result of a powerful eccentric contraction (see EIMD) or over-stretching of the muscle. Muscles will most likely tear during sudden acceleration or deceleration.[15] Therefore, it is typical for non-contact sports with a dynamic character such as sprinting, jumping.[16]
A muscle contusion is usually the result of a direct blow from an opposition player or contact with equipment in collision sports, such as football, rugby and hockey. The blow causes local muscle damage with associated bleeding.[15] A bruise, or contusion, is a type of haematoma of tissue in which capillaries and sometimes venules are damaged by trauma, allowing blood to seep, haemorrhage, or extravasate into the surrounding interstitial tissues. Bruises, which do not blanch under pressure, can involve capillaries at the level of the skin, subcutaneous tissue, muscle, or bone. As a type of haematoma, a bruise is caused by internal bleeding into the interstitial tissues which do not break through the skin, usually initiated by blunt trauma, which causes damage through physical compression and deceleration forces. Trauma sufficient to cause bruising can occur across a wide range of sports. Bruises often induce pain, but small bruises are not normally dangerous alone. Sometimes bruises can be serious, leading to other more life-threatening forms of haematoma, such as when associated with serious injuries, including fractures and more severe internal bleeding. The likelihood and severity of bruising depend on many factors, including type and healthiness of affected tissues.
Muscle cramps are sudden, involuntary muscle contractions or over-shortening. While cramps are generally temporary and non-damaging, they can cause mild-to-excruciating pain and paralysis-like immobility of the affected muscle. The onset is usually sudden, and it resolves on its own over a period of several seconds, minutes, or hours. Cramps may occur in a skeletal muscle or smooth muscle.
Muscle cramps during exercise are very common, even in elite athletes. Muscles that cramp the most often are the calves, thighs, and arches of the foot. Such cramping is associated with strenuous physical activity and can be intensely painful; however, they can even occur while inactive/relaxed. Around 40% of people who experience skeletal cramps are likely to endure extreme muscle pain and may be unable to use the entire limb that contains the "locked-up" muscle group. It may take up to seven days for the muscle to return to a pain-free state.
Muscle soreness after exercise is commonly referred to as delayed onset muscle soreness (DOMS). DOMS is common in individuals who engage in strenuous and unaccustomed exercise and physical activity. It is classified as a grade 1 muscle strain injury and is characterised by localised tenderness and soreness. It typically peaks between 24 to 72 hours after a bout of exercise but eventually disappears after five to seven days.[20] Soreness is accompanied by a prolonged strength loss, a reduced range of motion, and elevated levels of creatine kinase in the blood. These are taken as indirect indicators of muscle damage, and biopsy analysis has documented damage to the contractile elements. The exact cause of the soreness response is not known but thought to involve an inflammatory reaction to the damage.[21]
The healing process in the injured skeletal muscle consists of overlapping phases of degeneration, inflammation, regeneration, and fibrosis. Efficient regeneration of the injured muscle is thought to compete with fibrotic healing, and excessive fibrosis is thought to impede regeneration. This balance depends mainly on the cells and factors that are present at the degeneration and inflammation stages of healing[22].Regardless of the underlying cause, the processes occurring in injured muscles tend to follow the same pattern. Functional recovery, however, varies from one type of injury to another. Two phases can be distinguished in the repair process[17][23][24].
Starts with the actual trauma that causes muscle fibres to tear. Immediate necrosis of myofibres takes place due to deterioration of the sarcoplasm, a process that is halted within hours after the trauma by lysosomal vesicles forming a temporary membrane[19]. An inflammatory process takes place as a reaction to the torn blood vessels. Specialised cells start removing necrotised parts of the fibres[25].
The actual repair of the injured muscle takes place. Myofibres start regenerating out of satellite cells (= undifferentiated reserve cells) and a connective tissue scar is being formed in the gap between the torn muscle fibres. In the first 10 days after the trauma, this scar tissue is the weakest point of the affected muscle. After 10 days, however, eventual re-rupture will rather affect adjacent muscle tissue than the scar tissue itself, although full recovery (up to the point of pre-injury strength) can take a relatively long time. Vascularisation of the injured area is a prerequisite for recovering from a muscle injury. New capillaries originate from the remaining injured blood vessels and find their way to the centre of the injured area. Early mobilisation plays a very important role since it stimulates the vascularisation process. Similar wise, intramuscular nerves will regenerate to re-establish the nerve-muscle contact[26][27].
After a trauma, skeletal muscles have the capacity to regenerate and repair in a complex and well-coordinated response. This process required the presence of diverse cell populations, up and down-regulation of various gene expressions and participation of multiples growth factors. Regeneration Strategies based on the combination of stem cells (satellite cells), growth factors and biological scaffolds have already shown promising results in animal models. A better understanding of the cellular and molecular pathways as well as a better definition of the interactions (cell-cell and cell-matrix) that are essential for effective muscle regeneration, should contribute to the development of new therapies in humans[3].
Both for acute and chronic injuries, thorough subjective examination is primary in identifying muscle injuries. Particular attention to the history of occurrence of the trauma is needed. A clinical examination and testing of the muscle function together with the patient's recollection of what happened, are mostly sufficient for making the right diagnosis. In some cases, additional tests (MRI, X-ray, Ultrasound, CT Scan) may be required to determine the extent of the injury or to identify possible additional injuries.
The past few years the POLICE principle (an updated version of RICE-principle) has generally been considered as being the best method to minimise swelling and relief pain within the first 24 to 48 hours. Although the different components of the RICE-principle have each shown their effectiveness in experimental studies, the use of the all-round concept is yet to be proved in randomised clinical trials[17]. These methods focus on the acute management and do not really provide any information on the sub-acute and chronic stages of soft tissue healing. More recently Dubois and Esculier (2019) proposed two new acronyms to optimise soft tissue recovery: PEACE and LOVE.[29]These two acronyms (PEACE and LOVE) include the full range of soft tissue injury management from immediate care to subsequent management. It also highlights the importance of patient education and addressing the psychosocial factors involved that will aid recovery. It also highlights the potentially harmful effects of using anti-inflammatory medication for recovery.[29] Read more about the Peace and Love principle in the management of soft tissue injuries here. 59ce067264
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