Muscle strains can occur in many muscle groups, however the most commonly affected during work and exercise are the Lower Back, Hamstrings, Quadriceps, Hip Flexors, Groins and Calf muscles. Each type of injury can range from a slight overstretch and small tears to full-thickness ruptures.
There is a high risk of re-injury if a full rehabilitation program is not completed and appropriate strength and mobility is not restored. Muscle strains can become a frustrating injury to deal with as many people return to sport or work too early, re-injuring the muscle by overloading it before it was ready!
Severity of Muscle Strains – Grading System
Muscle strains are graded as either level I, II or III depending on the severity of injury and amount of damage to the muscle. This means there are varying levels of rehabilitation required as well as a large range in return to sport and/or activity time frames.
Grade I Muscle Strain
In a grade I muscle strain, the muscle or tendon is overstretched. Small tears to the muscle fibres may or may not occur. You may have mild pain with or without swelling. Usually use of the muscle will be sore but most if not all the strength of that muscle still remains.
Grade II Muscle Strain
A grade II muscle strain occurs when the muscle or its’ tendon is overstretched with a large proportion of muscle fibres torn. Symptoms may include significant pain, bruising and swelling. The area of injury can be very tender. Movement may be difficult due to pain and there is normally a loss of strength output as well..
Grade III Muscle Strain
Grade III muscle strains are the most serious among the three grades of muscle strains. Most, if not all (complete ruptures) of the muscle fibres are torn. Pain, swelling, tenderness and bruising are all present and quite significant. Movement is usually difficult with a substantial loss of strength and mobility.
Stages of Rehabilitation for Muscle Strains
There is no specific time frames for when to progress from each stage to the next. Your injury rehabilitation will be determined by many factors during your Physio Fit clinical assessment. You’ll find that in most cases, your physiotherapist will seamlessly progress between the rehabilitation phases as your clinical assessment and function improves.
It is also important to note that each progression must be carefully monitored as attempting to progress too soon to the next level can lead to re-injury and the frustration of a delay in your recovery.
Phase 1 – Injury Protection, Pain Relief & Relative Rest
As with most soft tissue injuries the initial treatment is PRICE – Protect, Rest, Ice, Compression and Elevation.
Protection: First course of management should always be to prevent further injury. For example, an injured leg or foot may be protected by limiting or avoiding weight-bearing through the use of crutches. Partially immobilising the injured area by using a sling, splint, or brace may also be a means of protection.
(Active) Rest: In the early phases you may not be able to use the injured muscle group very well. Your first aim is actively rest from pain-provoking postures and movements. This means that you should stop doing the movement or activity that provokes muscle pain. If able to though, gentle movements or walking may actually be beneficial if there’s minimal pain.
Ice: This is a simple and effective modality to reduce your pain and potentially limit the amount of swelling. Apply for 20 minutes each 2 to 4 hours during the initial phase of injury (normally the first 48 hours).
Compression: A compression bandage (tubigrip compression stocking) will help to both support the injured soft tissue and reduce excessive swelling.
Elevation: Elevating the injured area above your heart will assist with circulation and reducing overall swelling.
Additional to these initial recovery techniques, your physiotherapist will utilise a range of helpful tricks including pain relieving techniques, joint mobilisations, massage and strapping to assist you during this painful phase.
NOTE: Anti-inflammatory Medication: It is best to avoid anti-inflammatory drugs during the initial 48 to 72 hours when they may actually encourage additional bleeding.
Phase 2: Regain Full Range of Motion
During this period, the aim is to regain your full range of motion pain free. This may mean that you have some gentle exercises to complete and need to modify some tasks while the injury heals. During this time, your Physiotherapist will guide you and prescribe the exercises that are best suited to your needs.
Phase 3: Restore Muscle Strength, Endurance & Power
Your injured muscles will require strengthening after any strain. It is important to regain normal muscle strength and endurance to provide normal dynamic control and function. Your strength and power should be gradually progressed from body weight exercises to resistance exercises. You may also require strengthening for your other limb or side of the body depending on assessment findings.
Phase 4: Return to Activity
Depending on the demands of what you are planning on getting back to, you may require work or sport-specific exercises and a progressed training regime to enable a safe and injury-free return to your desired activity. Your Physiotherapist will work with you to help you towards your goals, guiding you through time frames and training schedules to optimise you for a complete and safe return. The perfect outcome will have you performing at full function with the added knowledge that a thorough rehabilitation program has minimised your chance of future injury.
Can Muscle Strains Be Prevented?
Not all injuries can be prevented, however there are always things you can do to help minimise the risk of them occurring. Follow these steps to keep your muscles strong and ready to go at all times!
- Warm ups before and cool downs after any exercise or physical activity to ensure muscles are prepared as well as recovering appropriately
- Working on muscle strength and endurance to ensure there are no imbalances between sides
- Having good recovery habits such as stretching, foam rolling, good nutrition and adequate sleep.
Many athletes will suffer a muscular strain of some degree. Despite their high incidence, advances in clinical diagnostic criteria and imaging, their optimal management and rehabilitation strategies are still debated in literature.
Furthermore, re-injury rate is high after a muscle lesion, and an improper treatment or an early return to sports can increase the rate of re-injury and complications. Most muscle injuries are managed conservatively with excellent results, and surgery is normally advocated only for larger tears.
Mechanism of Injury
A muscle strain is any physical trauma to a muscle caused by force applied along the length of the muscle. When a ‘load’, applied to a tissue outweighs it capacity of the tissue, break down occurs. Patients often coin their strain has a “pulled muscle” or “muscle tear”.
While there are many forms of muscle strains, typically they will involve a high speed contraction (sprinting), high speed deceleration (kicking or change of direction) and sometimes a physical blunt trauma (tackling).
Other forms of muscle strains may be over longer periods of time where micro-trauma begin to build up. Fatigue related muscle strains for example occur with poor sustained postures. But likewise overuse of a tissue can lead to break down such a repetitive strain injury (RSI)
Symptoms of a muscular strain
The symptoms of a muscular strain may include:
- Pain – especially when using or when pressure is applied to the affected muscle
- Swelling – across the affected area
- Stiffness – over the joint that the muscle crosses
- Reduced function – the limb becomes difficult to move because of pain and swelling
Grades Of muscular strains
Acute soft tissue injuries are graded according to their severity and include:
Grade I – some fibres are torn and the site is moderately painful and swollen, but function and strength are mostly unaffected
Grade II – many fibres are torn and the site is painful and swollen, with some loss of function and strength
Grade III – the soft tissue is totally torn, with considerable loss of function and strength. Grade III injuries often need surgical repair.
Muscle strains respond well to conservative management. Typically categorised in phases, management of a muscle strain can be straightforward with goals defining each phase.
The first-line treatment for a muscular strain in the acute phase include five steps commonly known as P.O.L.I.C.E.
(P) Protection: Apply soft padding to minimise impact and further trauma
(O.L) Optimal Load: Injured muscles require rest, but a balanced and progressive program should gradually reintroduce controlled stress to reduce muscle contracture, neural tension and increase flexibility
(I) Ice: Apply ice to induce vasoconstriction, which will reduce blood flow to the site of injury. Never ice for more than 20 minutes at a time.
Compression: Wrap the strained area with a soft-wrapped bandage to promote lymphatic drainage.
Elevation: Keep the strained area as close to the level of the heart as is possible in order to promote venous blood return to the systemic circulation.
In the initial phase, treatment will usually involve the use of NSAIDs and cold compression (icing). Cold compression therapy acts to reduce swelling and pain by reducing inflammatory cells into the injured area.
A new treatment for acute strains is the use of platelet rich plasma (PRP) injections. Blood is drawn from the client, which is then put through a process of centrifuge in order to concentrate the platelets which are then injected into the site of the injury. These platelets contain several growth factors that may stimulate healing and muscle regeneration, and limit the amount of scar tissue that forms. There continues to be an increasing body of research in this field so watch this space!
In the sub acute phase, mobilisation must begin as soon as possible but gradually and within the limits of pain. Tissue mobilisation is completed with the goal of facilitating muscle movement, promote blood circulation and tissue regeneration.
Low impact cardio is encouraged as soon as possible. Since core stability programmes have been shown to improve results in terms of lower re-injury rates and enhanced return to play, they are introduced as soon as possible in this phase.
Proprioceptive and endurance training are used in the advanced stages of rehabilitation. Exercises that challenge balance, body awareness and stability are commonly prescribed. Goals in this phase look to regain the remaining range of motion, return to full strength and begin to participate in sport specific exercises and trainings.
Return to sport
Following most muscle strains, most athletes return to their previous level of competition. While each case is individual, the process to return to sport will be based heavily on the athlete returning to symmetry in all aspects of range of motion, strength, balance, biomechanics and function. In the early stages,milestones centre around returning athletes to baseline performance values that, if available, would have been tested in the pre- or off- season. Later stage milestones prior to return to sport will involve 2-3 pain free full trainings before being cleared to return to sport.
- You can expect a full recovery from a muscular strain
- Early mobilisation is recommended to reduce muscle contracture, neural tension, and increase flexibility
- Muscle and performance imbalances are key indicators for return to sport