eMedicine Specialties > Sports Medicine > Introductory Topics in Sports Medicine

Contusions

Michael A Herbenick, MD, Assistant Professor of Orthopedic Surgery and Sports Medicine, Wright State University School of Medicine; Consulting Surgeon, Department of Orthopedic Surgery, Miami Valley Hospital
Michael S Omori, MD, Attending Staff, Emergency Medicine Residency, St Vincent Mercy Medical Center; Acting Director, Pediatric Emergency Center, Mercy Children's Hospital; Clinical Assistant Professor, Department of Surgery, University of Toledo Medical Center, The University of Toledo College of Medicine; Paul Fenton, MD, Assistant Professor, Department of Orthopaedic Surgery, Division of Sports Medicine, Medical College of Ohio at Toledo

Updated: Apr 17, 2009

Introduction

Background

Muscle contusion indicates a direct, blunt, compressive force to a muscle. Contusions are one of the most common sports-related injuries.^1,2,3 The severity of contusions ranges from simple skin contusions to muscle and bone contusions to internal organ contusions.

Although all tissue and organ contusions can result from traumatic sports injury, this article focuses on muscle contusions. Contusions of internal organs and bone contusions are not discussed in this article (see the eMedicine articles Concussion, Sacroiliac Joint Injury, Femur Injuries and Fractures, and Hip Pointer).

For excellent patient education resources, visit eMedicine's Skin, Hair, and Nails Center and Eye and Vision Center. Also, see eMedicine's patient education articles Bruises and Black Eye.

Frequency

United States

Contusions and strain injuries comprise approximately 60-70% of all sports-related injuries. In addition, most contusion injuries go unreported and untreated. Documented muscle contusions account for one third of all sports injuries. The quadriceps and gastrocnemius muscle groups are most often involved (see Images 1-2).^4,5,6

Athlete with a quadriceps strain. Place knee passively in 120º of flexion and immobilize with a double elastic wrap in a figure-8 fashion. This should occur within minutes of the injury. Used with permission courtesy of John Aronen, MD.

Modified treatment of quadriceps contusion. Used with permission courtesy of John Aronen, MD.

Rotator cuff injury.

In this patient's shoulder radiography, the humeral head no longer matches up with the glenoid because the rotator cuff is torn and the strong deltoid muscle is pulling the head superiorly toward the acromion. Courtesy of Dr Thomas Murray, Orthopaedic Associates of Portland.

International

The international frequency of contusions is similar to that in the United States.

Functional Anatomy

Skeletal muscle constitutes the largest tissue mass in the body, comprising up to 45% of the total body weight. Muscles that cross a single joint are located close to bone, are frequently responsible for postural maintenance, and are most susceptible to contusions. On the other hand, 2-joint muscles, such as the rectus femoris muscle, lie more superficial and are more susceptible to stretch-induced strain injury.

Contusions are caused by blunt trauma to the outer aspect of the muscle, resulting in tissue and cellular damage and bleeding deep within the muscle and between the muscle planes.¹ The resultant tissue necrosis and hematoma lead to inflammation.⁸ Little is known about the role of the inflammatory process and its importance in the healing process. Clearly, too much inflammation is unfavorable, but too little may be just as devastating.

A bruise is caused by blood that has escaped from damaged capillaries into the interstitial tissues. Within a few hours after the injury, the presence of necrotic tissue and hematoma initiates an inflammatory reaction. Because inflammation initiates macrophage action with subsequent phagocytosis of necrotic debris and stimulation of capillary production, it is vital to the process of muscle regeneration. However, inflammation invariably causes edema that leads to anoxia and further cell death.

The extent of the inflammatory response is often considered excessive and detrimental to muscle regeneration. However, controversy exists regarding this theory, because some literature indicates a worsened long-term outcome in patients placed on anti-inflammatory medications. Controversy also surrounds cryotherapy, with some literature touting its benefits, whereas others question its utility.^9,10,11

Clinical

History

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.¹² An inconsistent history provided by the patient and family is the hallmark of child abuse (see Further Reading).

Physical

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.
    

    

    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).
    

    

    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.

Causes

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.

Differential Diagnoses

Femur Injuries and Fractures
Quadriceps Injury

Other Problems to Be Considered

• Abuse
• Compartment syndrome
• Delayed-onset muscle soreness (DOMS)
• Muscle cramps
• Muscle rupture
• Stress fracture

Other conditions that may be considered in certain circumstances include the following:

• Erythema multiforme
• Hemophilia
• Henoch-Schonlein purpura
• Idiopathic thrombocytopenic purpura (ITP)
• Leukemia
• Mongolian spots
• Phytophotodermatitis
• Postinflammatory hyperpigmentation
• Thrombocytopenia

One must also consider coining and cupping, which are cultural remedies employed by traditional Asian families.

Workup

Laboratory Studies

• In most cases of contusions, extensive workup is unnecessary and unwarranted. An adequate history and physical examination usually provide enough information for diagnosis and treatment.
• In the event that massive bleeding occurs or if the patient has a bleeding disorder, coagulation studies and a complete blood cell (CBC) count may be beneficial to track the sequelae of the disease.
• If the patient has extensive bruising and rhabdomyolysis is a consideration, a serum creatine kinase level, serum myoglobin level, and urinalysis may be warranted.

Imaging Studies

Imaging studies in patients with contusions may be helpful to rule out other significant disease processes.

• Radiographs
  • If the initial history and physical examination merit further evaluation, radiographs of the traumatized region may help rule out a fracture.
  • If treatment fails or symptoms worsen, roentgenogram evaluation helps rule out a missed fracture or the development of myositis ossificans. If myositis ossificans is considered, it may show up radiographically approximately 6 weeks after the injury, although the process actually begins very early after the initial injury. If imaging studies are obtained before this time period, this disease process may not have matured and may not show up on radiographic examination.
    

    

    Lateral view of the neck showing calcification in the paraspinal muscles. Image contributed by Ajay K. Singh, MD, William Beaumont Hospital, Royal Oak, Mich.

    
    
• MRI^13,14,15
  • MRI is rapidly becoming the imaging modality of choice for soft-tissue injuries. However, use of this imaging tool tends to be limited to the professional athlete, to those patients in whom the diagnosis is in doubt, and in those whose symptoms are not responding to therapy.
  • In an MRI study, contusions evidenced a diffuse focus of increased signal intensity within the injured muscle with T2-weighted and short-tau inversion recovery (STIR) sequences. A focus of abnormality is noted within the muscle belly (hematoma and edema), with generally minimal disruption of the muscle architecture. The contusion tends to demonstrate a variable signal intensity, presumably reflecting the differences in age and microscopic environment of the collection, although it can appear heterogeneously or homogeneously bright.
  • Muscle strain appears as diffuse or patchy bright signals on T2-weighted images, with preservation of the muscle architecture. These high-signal regions represent a combination of edema and hemorrhage.
  • Complete muscle tear is a clinical diagnosis. Partial muscle tears range from slight tears to almost complete tears. MRI imaging of a muscle tear reveals a strain pattern, with an area of intense focus or brightness where the muscle architecture has been altered.

Other Tests

• Physicians must maintain a high index of suspicion for compartment syndrome, a limb-threatening and life-threatening condition that is seen when tissue pressure in a closed anatomic space exceeds perfusion pressure. Contused tissue within a confined compartment can rapidly reach elevated or critical pressure levels. Clinicians should have a low threshold for testing compartments for increased pressure if compartment syndrome is suspected.
  

  

  Picture of compartment pressure measuring device for use when commercial devices are unavailable.

  
  
  

  

  Stryker STIC Monitor. Image courtesy of Stryker Corporation, used with permission.

  
  
  

  

  An illustration that depicts measurement of compartment pressures in the forearm.

  
  

Related eMedicine topics:
Compartment Syndrome [in the Physical Medicine and Rehabilitation section]
Compartment Syndrome, Extremity [in the Emergency Medicine section]
Compartment Syndrome, Lower Extremity [in the Orthopedic Surgery section]
Compartment Syndrome, Upper Extremity [in the Orthopedic Surgery section]
Compartment Syndromes

Treatment

Acute Phase

Rehabilitation Program

Physical Therapy

In the acute phase following a muscle contusion, hematoma maturation, inflammation, necrosis of damaged myofibrils, and phagocytosis of the necrotic debris are main features. The goal of therapy is to minimize hemorrhage and inflammation and control pain. Limb immobilization with rest, ice, compression, and elevation (RICE) should be performed for the first 24 hours in patients with minor contusions and for 48 hours in patients with moderate or severe contusions.

The general recommendation is to avoid heat during the first 24-48 hours to avoid increasing the extent of hemorrhage and edema. Once the lesion has stabilized, heat may help break up the mass of blood and tissue; however, in the literature, this has been shown to be of limited benefit.

The use of crutches should be emphasized for patients with thigh contusions, as weight bearing following the thigh contusion injury may be extremely painful and may extend the damage. The knee joint should be flexed to pain tolerance in conjunction with the compression dressing. Compression gently increases tension, limiting the extent of the intramuscular hematoma. In addition, the position of flexion stretches the muscle, which increases tension and also facilitates drainage of the edematous fluid from the region.

The contusion generally stabilizes by 24-48 hours, and subsequent evaluation should dictate further treatment and prognosis. Reinjury is a significant factor in prolonging disability, and patients must be instructed to avoid retraumatizing the muscle.

Occupational Therapy

In the first phase of rehabilitation of a contusion, an occupational therapist may become involved by educating the patient about proper crutch use and tailoring the patient's activities of daily living (ADL) to the immobilized limb.

Medical Issues/Complications

The index of suspicion for compartment syndrome must be high until the hemorrhage, swelling, and pain have subsided (see Miscellaneous, Medical/Legal Pitfalls).

Surgical Intervention

Surgical intervention should not be necessary in cases of contusions, unless the diagnosis of compartment syndrome is considered and confirmed.

Consultations

If the diagnosis is in question or if myositis ossificans is confirmed by radiographs, orthopedic consultation can be obtained. Compartment syndrome is a surgical emergency, and an immediate consultation should be made if the diagnosis is confirmed.

Other Treatment

Multiple therapies that have become commonplace in the treatment of contusions exist. However, most therapies have not been proven to provide any benefit, and some may be damaging to the healing tissue.

In a given situation, an injection of epinephrine (with lidocaine) may be considered in the acute phase of a contusion injury, along with ice and compression to help limit bleeding.

• Therapeutic ultrasound is a commonly used physical therapy modality that has been claimed to promote tissue repair by enhancing cell proliferation and protein synthesis during the healing of skin wounds, tendon injuries, and fractures. The theory is that of a micromassage effect. However, ultrasound can enhance both myogenic precursor cell and fibroblast proliferation. Prolonging the proliferation phase of fibroblasts during muscle regeneration can add to the amount of permanent scar-tissue production, which could outweigh the possible positive effects of ultrasound on satellite cell proliferation. Recent literature questions the utility of ultrasound and notes that some evidence reveals worsening recovery and outcome.^16,17
• Heat, whirlpool therapy, and electrotherapy, although pleasing to the patient, have not been shown to influence the rate of recovery from contusions.

Recovery Phase

Rehabilitation Program

Physical Therapy

In the second phase of muscle healing, known as the recovery or regeneration phase, the main feature is proliferation of reserve satellite cells and endomysial fibroblasts, followed by active protein synthesis. The main goal of this treatment phase is restoration of mobility and ROM. Early mobilization of the joint and muscle has been shown to dramatically reduce recovery time and increase tensile strength of the muscle. Early pain-free PROM establishes normal tissue planes, maintains uninjured muscle fiber excursion, and pumps excessive detritus from the soft tissue.

The patient is ready to progress to the next level of therapy when ROM has been restored. Jackson and Feagin found that a patient is ready to move on to the next phase of treatment when 90° of knee flexion is achieved.⁴

Pain-free PROM of the knee with emphasis on flexion should be encouraged. Gentle isometric muscle exercises can be performed as tolerated. Weight bearing should be allowed as tolerated. Excessive passive stretching of a previously immobilized limb has been shown to produce myositis ossificans in animal models. This potential complication must be balanced against laboratory evidence showing that mobilization demonstrates faster healing times and increased vascularity of the affected tissue.

Occupational Therapy

Individualized education and instruction to adjust the athlete to ADL and routines with the injured limb may be needed to prevent reinjury, and working in conjunction with physical therapy to promote healing is advised.

Medical Issues/Complications

Reinjury is a significant factor in prolonging disability. A fine line exists between a sufficient amount of therapy and too much therapy. Pain tends to be an effective and adequate guide.

Other Treatment (Injection, manipulation, etc.)

Injection of medications into the contused tissue during the recovery phase, and any phase, has not been shown to be beneficial and may in fact be damaging to the tissues; this is especially true of corticosteroids.

Maintenance Phase

Rehabilitation Program

Physical Therapy

The third phase of muscle healing, known as maturation or remodeling, is characterized by a gradual recovery of the functional properties of the muscle, including the recovery of the tensile strength of its connective tissue component. The goal of this phase is to maintain the ROM while restoring full function to the muscle and joint. Progressive resistance exercises are encouraged until full strength and ROM are regained.

Emphasis should be placed on regaining full ROM and restoring strength. Remember that therapy that is too aggressive and too early can result in reinjury caused by muscle strain.

Occupational Therapy

Reevaluation of the patient' s daily activities and increasing tolerance to normal use of the contused limb should be emphasized.

Recreational Therapy

Maintain agility by participation in noncontact sports such as squash, tennis, badminton, and swimming.

Medication

The physician needs to make every effort to relieve pain as completely and expeditiously as possible. Distinguishing the intensity of the pain can be difficult, because it tends to be subjective; therefore, treatment and therapy should be individualized.

Objective parameters, such as tachycardia, are unreliable. Usually, minor trauma to the muscles is self-limited. An enormous selection of analgesics is available for use by the physician, but pharmacologic agents tend to fall into 2 general categories: nonnarcotic and narcotic analgesics. The physician also must consider the best route of delivery of the drug.

Corticosteroids should not be used; they are catabolic, and they inhibit the healing process. These steroids promote overall negative nitrogen balance and loss of muscle. However, these agents continue to be used clinically to treat muscle contusion injuries and are injected into the site of injury to relieve the pain and to expedite a player's return to active status. This inhibition of the inflammatory response may have a sparing effect on the local muscle tissue and, perhaps, on the athlete as a whole in the short term; however, corticosteroids seem to cause an unwanted atrophy of both injured and uninjured muscles.^18,22,24

Anabolic steroids may be proven useful in the treatment of contusion injuries because of the effects they have on nitrogen and protein balance and on stimulation of cell synthesis; however, research currently is limited.¹⁸ Many sporting governing bodies also control the use of anabolic steroids in their athletes, making the use of these agents controversial.

Nonnarcotic Analgesics

Pain accompanying minor acute soft-tissue injuries may be relieved by a short course of nonnarcotic analgesics with acetaminophen.

Acetaminophen (Tylenol, Feverall, Aspirin Free Anacin)

Ordinarily, the most commonly ingested pain reliever. Also marketed in combination with other drugs to provide analgesia. Advantages include availability, cost, and relatively high safety profile. The onset of relief is usually within 20-30 min. Extended release preparations do not appear to offer major benefits (other than dosing convenience) and may increase the incidence of toxicity. For children, acetaminophen is available as drops (80 mg/0.8 mL), elixirs (160 mg/5 mL), tablets (80 mg, 160 mg, 325 mg), and suppositories (125 mg, 325 mg).

Dosing

Adult

650-1000 mg PO q4h; not to exceed 4,000 mg/d PO

Pediatric

10-15 mg/kg/dose PO q4-6h

Interactions

Rifampin can interact to reduce the analgesic effects of acetaminophen; conversely, barbiturates, carbamazepine, alcohol, hydantoins, zidovudine, and isoniazid may increase acetaminophen hepatotoxicity

Contraindications

Documented hypersensitivity; known G6PD

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Use with care in patients who are malnourished; hepatotoxicity can occur in those with chronic alcoholism following various dosage levels

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

Controversial data exist on NSAIDs. By suppressing the initial inflammatory reaction, the NSAID permits improved performance in early time periods but appears to suppress the stimulus that may be needed for cellular remodeling in longer time periods. NSAIDs also may increase the amount of bleeding within the tissue. Currently, there is a lack of compelling evidence for either argument.

Although acetaminophen is typically listed with NSAIDs, this agent lacks anti-inflammatory properties and is used for its antipyretic and analgesic effects.

A number of NSAIDs are available for use. NSAIDs share a common mechanism of action, inhibiting the production of pain-mediating prostaglandins. Generally, NSAIDs provide a comparable degree of pain and inflammatory relief, but they differ in dosing schedule.

The 5 categories of marketed NSAIDs are acetic acid derivatives, fenamates, oxicams, propionic acid derivatives, and related compounds. Numerous NSAIDs are obtainable over the counter (OTC). Choosing an NSAID to prescribe can be difficult because few data exist that compare these agents, and individual responses are inconsistent. With a lack of evidence that one NSAID proves to be clearly superior, base prescribing decisions on personal experience, safety profiles, cost, and convenience.

Indomethacin (Indocin)

Rapidly absorbed; metabolism occurs in liver by demethylation, deacetylation, and glucuronide conjugation; inhibits prostaglandin synthesis.

Dosing

Adult

25-50 mg PO bid/tid
75 mg SR PO bid; not to exceed 200 mg/d

Pediatric

1-2 mg/kg/d divided PO bid/qid; not to exceed 4 mg/kg/d or 150-200 mg/d

Interactions

Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Contraindications

Documented hypersensitivity; GI bleeding or renal insufficiency

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; reversible leukopenia may occur, (discontinue if there is persistent leukopenia, granulocytopenia, or thrombocytopenia)

Ketorolac (Toradol)

Has become the choice of parenteral pain medications dispensed in the ED. Frequently overlooked is the fact that this medication is an NSAID, carrying all its attendant risks, and it is almost 20 times the cost of morphine (and 140 times the cost of ibuprofen). Few data supporting its superiority over other analgesics exist.

Dosing

Adult

10 mg PO q6h prn
15-30 mg IV/IM q6h prn, give IV dose over 15-30 sec; not to exceed 5 d of treatment

Pediatric

<16 years: 0.5 mg/kg/dose IV/IM q6h; not to exceed 30 mg q6h
>16 years: Administer as in adults

Interactions

Administered concurrently with aspirin increases the risk of inducing serious NSAID-related side effects; probenecid may increase the concentrations and possibly the toxicity of NSAIDs; may prolong PT when administered concurrently with anticoagulants; closely monitor PT, and instruct patients to watch for signs and symptoms of bleeding; may increase the risk of methotrexate toxicity (eg, stomatitis, bone marrow suppression, nephrotoxicity); phenytoin levels may be increased when administered concurrently

Contraindications

Documented hypersensitivity; do not administer into CNS; do not administer to patients diagnosed with peptic ulcer disease, recent GI bleeding or perforation, and renal insufficiency or to those patients at high risk of bleeding

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases the risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; low WBC counts rarely occur and usually return to normal in ongoing therapy; discontinuation of the therapy may be necessary if persistent leukopenia, granulocytopenia, or thrombocytopenia occur
Perform ophthalmologic studies in patients who develop eye complaints during therapy; therapy should be discontinued if changes are noted; changes may include blurred or diminished vision, corneal deposits, retinal disturbances, scotomata, changes in color vision, and macular degeneration

Ibuprofen (Motrin, Advil, Nuprin)

This prevalently used NSAID, also available OTC, is a derivative of the propionic class of NSAIDs and is considered the safest of the NSAIDs. Available as tablets of 200 mg, 400 mg, 600 mg, and 800 mg. Pediatric dosage forms are available as both a tablet and oral suspension (20 mg/mL). Advise taking ibuprofen with food or milk, if possible. Prescribe with caution in children with flulike illnesses.

Dosing

Adult

400-600 mg PO q6h
Alternative dosing: 800 mg PO q8h

Pediatric

30-50 mg/kg/d PO divided qid; not to exceed 2400 mg/d

Interactions

Increased toxicity if used with oral hypoglycemic agents, phenytoin, and warfarin; interferes with ACE inhibitors and beta-blockers; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of loop diuretics when administered concurrently; PT may increase when administered concurrently with anticoagulants; closely monitor PT, and instruct patients to watch for signs and symptoms of bleeding; ibuprofen and other NSAIDs may increase serum phenytoin and lithium levels as well as risk of methotrexate toxicity

Contraindications

Documented hypersensitivity; because of potential cross-sensitivity to other NSAIDs, do not give these agents to patients in whom aspirin, iodides, or other NSAIDs induce hypersensitivity; do not administer to patients diagnosed with peptic ulcer disease, recent GI bleeding or perforation, and renal insufficiency or to those patients at high risk of bleeding

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in patients with congestive heart failure, hypertension, and decreased renal and hepatic function

Narcotic Analgesics

Patients complaining of inadequate pain relief from NSAIDs may benefit from short-term supplementation with an opioid compound. A wide array of products is available.

Orally (PO), hydrocodone (eg, Lortab, Lorcet, Vicodin, Anexsia), a schedule III narcotic, and oxycodone (eg, Roxicet, Percodan, Tylox), a schedule II substance, usually provide additional pain relief. Codeine-containing products (schedule III drugs) are not as reliable for alleviating pain. Although the relative potency for oxycodone and hydrocodone is approximately 0.33 (compared with parenteral morphine), that for oral codeine is 0.05. Mixed agonist-antagonist oral agents, such as butorphanol, nalbuphine, and pentazocine, offer no real advantages to opioid agents; yet, they cause a higher incidence of adverse effects. Common side effects include constipation, nausea, respiratory depression, sedation, and urinary retention.

Generally, the approved dosage of hydrocodone is 5-10 mg, combined with 500-750 mg of acetaminophen and taken PO every 6 hours as needed (q6h prn). Oxycodone analgesic preparations typically combine 2.5-5 mg of oxycodone with 325 mg of acetaminophen. They are dosed as 1-2 tablets PO q4h prn for moderate to severe pain. Acetaminophen with codeine (Tylenol #3) contains 30 mg of codeine with 325 mg of acetaminophen. Usually, 1-2 pills q4h prn is recommended.

Elixirs containing hydrocodone (Hycodan) are convenient for children older than 6 years who have moderate to severe pain and who are unable to swallow pills. One teaspoon (5 mL) of Hycodan contains 5 mg of hydrocodone; the dose usually is 1.25-2.5 mg q4h, depending on the child's size and the severity of pain. The elixir of Tylenol with codeine for children contains 120 mg of acetaminophen and 12 mg/5 mL of codeine in an alcohol base (7%).

Generally, orally administered drugs impart a slower onset of action. For patients in severe pain or for those patients who must take nothing by mouth (NPO), parenteral agents may be necessary. Although the intramuscular (IM) route may be more convenient for the staff, the intravenous (IV) route offers a number of advantages. Narcotics given IV provide a rapid and predictable onset of action and are easier to titrate. Morphine and meperidine are the most commonly used parenteral narcotic agents.

Hydrocodone and acetaminophen (Vicodin, Lorcet, Lortab, Anexsia)

A drug combination indicated for the relief of moderate to severe pain.

Dosing

Adult

1-2 tab or cap PO q4-6h prn

Pediatric

<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d of acetaminophen
>12 years: 750 mg acetaminophen PO q4h
Single dose not to exceed 10 mg of hydrocodone bitartrate; do not exceed 5 doses in 24 h

Interactions

Phenothiazines may decrease its analgesic effects; conversely, the toxicity increases when administered concurrently with CNS depressants or tricyclic antidepressants

Contraindications

Documented hypersensitivity to acetaminophen or hydrocodone bitartrate; patients with elevated intracranial pressure

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Tablets contain metabisulfite, which may cause allergic reactions; administer with caution in patients dependent on opiates since this substitution may result in acute opiate withdrawal symptoms; exercise caution when patients have severe renal or hepatic dysfunction; use with caution in elderly persons

Oxycodone and acetaminophen (Percocet, Tylox, Roxicet)

Drug combination indicated for the relief of moderate to severe pain.

Dosing

Adult

1-2 tab or cap PO q4-6h prn

Pediatric

0.05-0.15 mg/kg/dose oxycodone PO; not to exceed 5 mg/dose of oxycodone q4-6h prn

Interactions

Phenothiazines may decrease the analgesic effects of this medication; conversely, its toxicity increases when administered concurrently with either CNS depressants or tricyclic antidepressants

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Duration of action may increase in elderly persons; be aware of the patient's total daily dose of acetaminophen; maximum dose of acetaminophen is 4000 mg/d, higher doses may cause liver toxicity

Acetaminophen and codeine (Tylenol #3)

A drug combination indicated for the treatment of mild to moderate pain.

Dosing

Adult

30-60 mg/dose PO (based on codeine content) q4-6h or 1-2 tab q4h; not to exceed 12 tab/24h

Pediatric

0.5-1 mg/kg/dose PO (based on codeine content) and 10-15 mg/kg/dose PO q4h (based on acetaminophen content); not to exceed 2.6 g/24h

Interactions

Toxicity increases when administered concurrently with CNS depressants or tricyclic antidepressants

Contraindications

Documented hypersensitivity to acetaminophen or codeine phosphate

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Administer with caution in patients dependent on opiates since this substitution may result in acute opiate withdrawal symptoms; exercise caution when patients have severe renal or hepatic dysfunction

Follow-up

Return to Play

Contusions, in particular quadriceps contusions, should be observed closely after injury until the hemorrhage has stopped, which usually occurs 24-48 hours after the injury. It is important to consider compartment syndrome or muscle rupture if the pain or girth of the affected area has not stabilized by 48 hours postinjury.

Athlete with a quadriceps strain. Place knee passively in 120º of flexion and immobilize with a double elastic wrap in a figure-8 fashion. This should occur within minutes of the injury. Used with permission courtesy of John Aronen, MD.

Modified treatment of quadriceps contusion. Used with permission courtesy of John Aronen, MD.

Complications

Myositis ossificans occurs in 9% of all contusions, 4% of mild contusions, 13% of moderate contusions, and 18% of severe contusions. Development of myositis ossificans is a multifactorial problem. Reinjury is a significant factor in prolonging disability.

Rhabdomyolysis must be considered if the contusions are extensive or multiple.

The most serious complication is compartment syndrome. Pain out of proportion to the injury or increasing pain over time are red flags that should alert and prompt the physician to measure the compartment pressures.

Picture of compartment pressure measuring device for use when commercial devices are unavailable.

Stryker STIC Monitor. Image courtesy of Stryker Corporation, used with permission.

An illustration that depicts measurement of compartment pressures in the forearm.

Prevention

The use of protective equipment has helped reduce the incidence of contusions, and the athlete must be instructed on the proper use of protective equipment.

Some data indicate Indocin can help in decreasing heterotopic bone formation. To date, the data are inconclusive, but Indocin may be considered when selecting a medication with which to treat a patient.

Anteroposterior radiograph of the right hip in a 16-year-old boy who had suffered trauma to the hip 2 years previously (same patient in Images 10-11). The patient is currently experiencing hip pain. Mature heterotopic ossification (arrowheads) projects over and lateral to the femoral head.

Corresponding lateral view of the right hip (same patient in Images 10-11). Distal to the mature heterotopic ossification (HO) seen on the anteroposterior view (arrowheads) is a subtle area of early mineralization (arrows) consistent with early HO.

Prognosis

For most muscle contusions, the prognosis is excellent. Jackson and Feagin's research on thigh contusions found the average disability time was 13 days for mild contusions, 19 days for moderate contusions, and 21 days for severe contusions.⁴

Risk factors for a more unfavorable prognosis include injuries that occur during football, previous contusion in the same muscle, delay in treatment for more than 3 days, and large muscle involvement. Reinjury is a significant factor in prolonging disability.

Education

Education about the proper use of protective equipment and aggressive early treatment of contusions is essential.

Miscellaneous

Medicolegal Pitfalls

• The key to diagnosing acute compartment syndrome is a high index of suspicion.
  • The 5 P's of compartment syndrome include (1) pain out of proportion to the injury, (2) pain on PROM, (3) pulselessness, (4) paresthesia, and (5) pallor. These symptoms are not diagnostic of compartment syndrome, and several of them present late in the disease process.
  • Compartment syndrome can occur 12-24 hours following the initial injury.
  • Pain out of proportion to the examination is the most common clinical finding, but pain on PROM with stretching of the affected muscle groups is the most sensitive finding (eg, pain with passive dorsiflexion of the toes is passively testing the posterior calf flexor compartment). Any suspicion on the part of the clinician should prompt measurement of the compartment pressures.

Multimedia

Media file 1: Athlete with a quadriceps strain. Place knee passively in 120º of flexion and immobilize with a double elastic wrap in a figure-8 fashion. This should occur within minutes of the injury. Used with permission courtesy of John Aronen, MD.

Media file 2: Modified treatment of quadriceps contusion. Used with permission courtesy of John Aronen, MD.

Media file 3: Rotator cuff injury.

Media file 4: In this patient's shoulder radiography, the humeral head no longer matches up with the glenoid because the rotator cuff is torn and the strong deltoid muscle is pulling the head superiorly toward the acromion. Courtesy of Dr Thomas Murray, Orthopaedic Associates of Portland.

Media file 5: Lateral view of the neck showing calcification in the paraspinal muscles. Image contributed by Ajay K. Singh, MD, William Beaumont Hospital, Royal Oak, Mich.

Media file 6: 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.

Picture of compartment pressure measuring device for use when commercial devices are unavailable.

Media file 8: Stryker STIC Monitor. Image courtesy of Stryker Corporation, used with permission.

Media file 9: An illustration that depicts measurement of compartment pressures in the forearm.

Media file 10: Anteroposterior radiograph of the right hip in a 16-year-old boy who had suffered trauma to the hip 2 years previously (same patient in Images 10-11). The patient is currently experiencing hip pain. Mature heterotopic ossification (arrowheads) projects over and lateral to the femoral head.

Media file 11: Corresponding lateral view of the right hip (same patient in Images 10-11). Distal to the mature heterotopic ossification (HO) seen on the anteroposterior view (arrowheads) is a subtle area of early mineralization (arrows) consistent with early HO.

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Keywords

contusions, bruises, bruising, muscle contusions, hematomas, soft-tissue injuries, ecchymosis, myositis ossificans, heterotopic ossification, compartment syndrome

Contributor Information and Disclosures

Author

Michael A Herbenick, MD, Assistant Professor of Orthopedic Surgery and Sports Medicine, Wright State University School of Medicine; Consulting Surgeon, Department of Orthopedic Surgery, Miami Valley Hospital
Michael A Herbenick, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, and American Orthopaedic Society for Sports Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Michael S Omori, MD, Attending Staff, Emergency Medicine Residency, St Vincent Mercy Medical Center; Acting Director, Pediatric Emergency Center, Mercy Children's Hospital; Clinical Assistant Professor, Department of Surgery, University of Toledo Medical Center, The University of Toledo College of Medicine
Michael S Omori, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Paul Fenton, MD, Assistant Professor, Department of Orthopaedic Surgery, Division of Sports Medicine, Medical College of Ohio at Toledo
Paul Fenton, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Joseph P Garry, MD, FACSM, FAAFP,, Director of Sports Medicine and Sports Medicine Fellowship, Associate Professor of Family Medicine and Exercise and Sport Science, Department of Family Medicine, East Carolina University Brody School of Medicine
Joseph P Garry, MD, FACSM, FAAFP, is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Heart Association, American Medical Society for Sports Medicine, and North American Primary Care Research Group
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

CME Editor

Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital
Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD, Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago
Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Brett J Earl, MD, to the development and writing of this article.

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