Contusions Clinical Presentation

Symptoms of a contusion are often nonspecific, and the diagnosis is one of exclusion.

• Contusion symptoms include soreness, pain with active range of motion (AROM) and passive range of motion (PROM), as well as limited range of motion (ROM). Without a straightforward history of an impact to the area, the diagnosis can be difficult.
• Presentation of a contusion is characterized by direct trauma to the muscle group, with subsequent pain and swelling resulting from bleeding within the muscle.
• A contusion usually can be distinguished from a muscle rupture, because residual function remains after a contusion. Muscle ruptures are usually straightforward; sudden intense pain, tightness, and loss of function occur. The patient usually describes a popping sensation. Muscle strains are differentiated by the history of high stress use as opposed to the history of a direct trauma with a contusion.
• Distinguishing a contusion from delayed-onset muscle soreness (DOMS) can be difficult in patients with delayed presentation, particularly if the patient is unsure if direct trauma caused the injury (such as in football when multiple traumatic events happen simultaneously). One helpful distinction is that DOMS tends to develop well after the sporting event, or even the next morning, and tends to be distributed symmetrically if muscle groups are used in tandem.
• Ask the patient if he/she has a family history of bleeding disorders or easy or frequent bleeding or bruising.
• A final, yet vital consideration is the possibility of physical abuse.^[13] An inconsistent history provided by the patient and family is the hallmark of child abuse (see Further Reading).

Often, the physical examination in a patient with a suspected contusion is most important to exclude other injuries and narrowing the differential diagnosis. In general, tenderness to palpation and pain with PROM and AROM are the hallmarks of the physical examination. Depending upon the size of the lesion, a hematoma may also be appreciated. A complete examination of the injured area and surrounding areas must be emphasized to identify other possible injuries.

• No objective criteria are available for deciding which athletes should be removed from the field of play and which may return to competition.

  • In general, individuals with injuries involving the larger muscle groups, such as the quadriceps, have to leave the game for immediate attention and evaluation.
  • Each case must be assessed on an individual basis. The first step is to ice the affected area and reassess ROM and swelling within a short period.
  • Documenting the neurovascular status during the initial evaluation and all subsequent evaluations is important.
  • One must always consider the potential for reinjury when deciding if an athlete can return to competition. Reinjury of an injured muscle is a major factor in developing myositis ossificans. Reinjury also significantly increases the healing time for the patient. See the image below. Lateral view of the neck showing calcification in the paraspinal muscles. Image contributed by Ajay K. Singh, MD, William Beaumont Hospital, Royal Oak, Mich.
• Jackson and Feagin described mild thigh contusions as those having active knee motion greater than 90°, moderate thigh contusions as those having 45-90° of motion, and severe thigh contusions as those having less than 45° of motion.^[4] Note that these criteria were based on contusions that were assessed 48 hours after the event.
• Often the patient with a contusion presents hours or several days after the event. In these cases, document the ROM, extent of swelling, level of function, and neurovascular status.
• Keep in mind the possibility of abuse when performing the physical examination.

  • Accidental bruising and nonaccidental bruising are differentiated by a careful history; the age and developmental capabilities of the child; and the appearance, location, and number of bruises (see Further Reading). See the image below. A 6-year-old girl who presents a few days after being disciplined on the buttocks with a wooden spoon by her mother. This pattern of bruises is of suspicious shape, number, and location.
  • Bruises in the shape of an instrument are generally diagnostic of abuse. Belts and extension cords most frequently are used for abuse (see Further Reading).
  • Accidental bruising tends to occur in a predictable distribution, such as on the shins, chin, forehead, lower arms and, occasionally, over the hips and spinal prominences.

Any blunt trauma with sufficient force to propel its energy into the muscle can cause a contusion. Contusions are often the result of sports-related injuries.