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. [22, 23]
-
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. [5]
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.
Return to Play
Contusions, in particular quadriceps contusions, [24] 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. See the images below.
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.
No objective data indicate when an athlete may safely return to competition. Each case must be evaluated on an individual basis, and the clinician's best judgment must act as a guide. In general, if athletes have 90% of strength on the affected side and are able to perform the required activity without any pain or obvious deficits, they are ready to return to the field.
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 indomethacin can help in decreasing heterotopic bone formation. To date, the data are inconclusive, but indomethacin may be considered when selecting a medication with which to treat a patient. See the images below.
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.
-
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.
-
Lateral view of the neck showing calcification in the paraspinal muscles. Image contributed by Ajay K. Singh, MD, William Beaumont Hospital, Royal Oak, Mich.
-
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.
-
Stryker STIC Monitor. Image courtesy of Stryker Corporation, used with permission.
-
An illustration that depicts measurement of compartment pressures in the forearm.
-
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.
