Soft Tissue Injuries
Soft tissue injuries include injuries to the muscles, ligaments and tendons. These injuries are extremely common in contact sports and track and field events. Soft tissue injuries can be classified as traumatic or overuse. Some sports have a predilection for certain soft tissue injuries due to the mechanics of the involved sport. For example sports involving agility and single leg landings are associated with ligament injuries of the knee involving the anterior cruciate and medial collateral ligaments. Quadriceps and hamstring strains are also a common feature of these sports. In severe cases day to day activities like walking, climbing up the stairs and running to catch bus can become an ordeal if these injuries are not managed properly with appropriate physiotherapy.
Let’s have a look at the commonest soft tissue injuries and their management:
Sudden or explosive stretching of a muscle results in tearing of its fibres, otherwise known as a muscle strain. Eccentric contraction (where a muscle is lengthening while contracting) is the main cause of a muscle strain. A muscle strain may also occur as an overuse injury when it is unable to cope with increased demands of an exercise or an activity.
Muscle strains are more commonly seen in muscles that cross two joints such as the hamstrings, quadriceps and the calf (gastrocnemius).These injuries are often seen in runners and in contact sports like rugby.
Essentially a combination of three muscles, the hamstrings extend from the ischial tuberosity (bone at the bottom of the glute muscle) to the upper part of the shin bone. Its action includes extending the hip and flexing the knee. As a two-joint muscle, the hamstring is more vulnerable to injury when it gets stretched over the hip and knee (during hip flexion & knee extension) simultaneously. This position is often encountered while sprinting. Hamstring injuries are extremely common in athletes who perform activities involving sudden acceleration sprints such as football, rugby and track and field events.
According to research, hamstring strain injury reoccurred is between 12% and 48% of the players on the English soccer team. Brooks et al. reported that over 68% of hamstring strains occurred during running in English rugby and 10% during the kicking action. Interestingly, hamstring strain sustained while kicking the ball was more severe and required more time off play.
The hamstring is vulnerable to injury in the late swing phase and just before heel strike while running when it is stretched maximally. Poor flexibility, difference in bilateral muscle strength, poor quadriceps to hamstring strength ratio and fatigue are some of the major risk factors for hamstring strain. It has been noted, that poor hamstring flexibility as a result of back pain or increased neural tension may lead to hamstrings strains. Orchard et al. attributes the increased risk of hamstring strain noted with advancing age to a decrease in hamstring strength induced by impingement of the nerves of the low back caused by age-related low lumbar degeneration.
Brooks et al. noticed that, the incidence of hamstring strain injury among African and Caribbean descents was almost four times that of Caucasian players. These results suggest that individuals of difference races may have different muscle fibre compositions that predispose them to injury.
Besides the above-mentioned risk factors, two separate studies by Sherry and Best and also Cibulka et al. showed that poor trunk stabilization and sacroiliac dysfunction may also result in hamstring muscle strain injury. Based on an animal experiment, Nikolaou et al. suggested that scarring and fibrosis observed in the muscle seven days after initial injury may explain the elevated risk for re-injury. This indicates a possibility that previous injury resulted in shortened optimum lengths of hamstring muscles and thus increased the risk for injury.
Quadriceps activation on the other hand opposes the activity to the hamstrings. The muscle originates from the pelvis and upper part of the thigh bone and inserts into the top of the shin bone. It is responsible for flexing the hip and extending the knee. As the name suggests it is composed of four muscles. The rectus femoris is the most vulnerable component as it crosses the hip and the knee joint. It is most likely to get strained when the athlete extends his hip and flexes the knee (thigh and leg move back) at the same time. This is also a common injury in rugby players and sprinters.
Whenever there is a quadriceps strain, it is very important to check the other parts of the leg as well. A stiff hip or ankle prevents the leg from moving optimally which results in the knee joint compensating for the lack of movement. Over time these compensatory movements of the knee result in overuse injury of the quadriceps resulting in quadriceps strain.
In younger skeletally immature athletes, quadriceps strain is more common in the upper (proximal) attachment and may be accompanied by an avulsion of the iliac spine. Older athletes usually present with quadriceps strain that are more distal (i.e. further down at the knee). Usually the strains are seen more in the middle of the belly as the muscle contracts and elongates during the kicking action.
A higher percentage of fast twitch fibres and chronic fatigue increase the risk of quadriceps strain. It has also been reported that hyperextended knee posture increases the risk for quadriceps strain. Reduced flexibility, poor warm up and sudden increase in training intensity are other modifiable risk factors for a quadriceps injury.
The gastrocnemius component of calf muscle is also a two-joint muscle just like the quadriceps and the hamstrings which makes it more prone to injury. It makes up the bulk of the muscle that in the back of the lower leg. It originates from the lower part of the thigh bone and inserts into the heel. The main action of the calf is to move the foot down and assist in bending the knee. When it gets elongated at the knee (straight knee) and ankle (foot pointing up) at the same time, the stress on the muscle increases.
It has also been noted that since the gastrocnemius consists of a high density of fast twitch fibres involved in power production it more likely to get injured as compared to the deeper calf muscle (the soleus) which have more slow twitch fibres. MRI scans in many athletes have shown that 17% of the calf injuries involve both muscles.
Clinically it is possible to isolate the muscle involved. Pain during a classic straight knee calf stretch suggests gastrocnemius strain whereas pain during the bent knee calf stretch indicates a soleus strain.
Calf strain is seen more in older runners as compared to their younger counterparts. The same is true in footballers as well. Excessive dorsiflexion (foot moving upward) while running or walking could be a reason for chronic calf muscle strain. Those who may have walked uphill (increased upward movement of foot) for years may present with chronic calf strain later in life.
A tight calf is also prone to injury. Recent speculations point towards a link between low back pain and calf strain. However more concrete evidence is needed in this direction.
Biomechanical factors in the lower extremities & trunk may also create a predisposition to calf strain. The gluteal muscles work along with the calf to propel the body forward while walking. Hence weak gluteal muscles require the calf to work more during the push off phase of walking. Certain actions in sports like acceleration and deceleration are likely to strain the calf. These actions are particularly seen in tennis and squash. A calf strain presents a bit differently from achilles tendinitis. In a calf muscle strain the pain is more localised towards the muscle bulk. Secondly continuation of activity increases the pain instead of reducing as is seen in early stages of tendinitis. Calf strains have a nasty habit of reoccuring. Some professionals suspect that strains create scar tissue or muscular adhesions, predisposing the area to re-injury—or preventing proper healing after the initial injury.
How do you grade a muscle tear?
Grade 1- This is a mild muscle strain where less than 5% of the fibres are torn. There is no loss in muscle strength or range of motion. The person is able to walk or continue with his normal activities with minimal pain and discomfort. There may be mild tenderness evident a day after the injury.
Grade 2 – This is a moderate muscle strain where nearly half of the fibres are torn. There is increased pain, tenderness and swelling in the region. The person may experience a significant weakness in the muscle and there may also be a visible limp.
Grade 3- This is a severe muscle strain where there is complete rupture of the muscle fibres. In a few cases the muscle belly may be ruptured into two parts or the tendon may be separated from the muscle. There is severe pain, swelling and tenderness along with a total loss of function.
How do you Diagnose a Muscle Strain?
A physiotherapist can diagnose a muscle strain by examining the site of injury for pain and swelling and correlating this with the mechanism of injury. Resisted contraction of the involved muscle and assessing the range of motion can help to confirm the diagnosis. A grade 3 muscle strain may present as a palpable gap in the muscle. An MRI scan can help visualise the extent of injury and also rule out associated injuries such as an avulsion fracture.
How do you rehabilitate a muscle strain?
Muscle strains, like nearly all soft tissue injuries, are usually managed conservatively (non-surgically). Resting the part and reducing the intensity of training helps to initiate healing in the first 24-48 hours. This is usually followed by range of motion exercises and deep tissue massage to help minimise scar tissue development. This helps to restore optimal muscle length and flexibility and prevent recurrence of injury. Hamstring strains are particularly frustrating as nearly one third may recur within a year of previous injury and these are often more severe than the original.
Recent research suggests that optimal rehabilitation should incorporate neuromuscular control and eccentric strength training exercises.Optimising biomechanics (movement quality), improving quadriceps to hamstring strength ratio and incorporating trunk stabilisation exercises have helped to reduce the frequency of lower extremity muscle strains. Sports specific agility drills like figure of 8 and zigzag running can be incorporated to facilitate return to sports scenarios. Exercises that help improve muscle strength and endurance are also an important element of early & late stage rehabilitation.
What are Ligament sprains?
Ligaments are tough bands of fibrous tissue that supports a joint. Research shows that one of the most common musculoskeletal complaints that accounts for approximately 48 out of 1,000 injuries presenting clinically are knee related.
Approximately nine percent of these knee complaints are related to anterior cruciate ligament (ACL) injuries.
A rupture of anterior cruciate ligament is a major cause of knee pain and instability in athletes participating in contact sports. The cut and plant action or sudden change in direction to avoid tackle in rugby is a classic mechanism for ACL injury. Sports involving sudden stopping or landing as in downhill skiing or tennis also causes ACL injury. The ACL ligament is present at the centre of the knee. The ACL prevents the forward slide of the shin bone on the thigh bone. It is also responsible for 80% of rotational stability of the knee while it bends. The other ligaments provide rotational stability at the extremes of flexion.
The medial collateral ligament(MCL) is thick band on the inner side of the knee. It is responsible for side-to-side stability of the knee. A sudden inward movement of the knee while the foot is fixed on the ground is the typical mechanism of injury for MCL. The MCL is also frequently injured in contact sports like rugby, hockey or soccer which require sudden side to side movements or twisting.
Apart from the knee, the lateral collateral ligamentinjury in the ankleis another commonly injured ligament in sports people. Twisting the ankle in a downward and inward movement fashion i.e. an inversion sprain while running is the most common mechanism of injury. The foot is most vulnerable to injury when plantar flexed (toes pointed down). There is pain and tenderness on the outer side of the ankle. An MRI can help diagnose the extent of the injury or rule out a fracture of the surrounding bone. Incomplete rehabilitation may lead to persistent or chronic ankle pain and can have significant long-term consequences in athletes who wish to return to sport.
How do you grade a ligament injury?
- Grade 1- This is the least severe form of ligament injury. The ligament is usually stretched but fibres are still intact. The individual complains of pain and mild swelling around the injured area.
- Grade 2: This is a more severe form of ligament injury. The ligament fibres are partially torn. The individual complains of pain and swelling and may also have a slight limp or feeling of instability while walking.
- Grade 3: This is a most severe form of injury. The ligament fibres are fully torn. The individual complains of relatively less pain and swelling but there may be increased instability while walking.
A detailed history and physical examination by a physiotherapist or chiropractor reveals the mechanism of injury. Special tests for ligament instability, reduced range of motion, decreased muscle strength and tenderness around the joint help to diagnose ligament injury. The patient may also recall an audible pop or giving way of the knee in grade 2 and grade 3 sprains. They may also find it difficult to bear weight on the affected leg. There may be episodes of locking where the person is unable to bend or straighten his knee fully. Additional tests like MRI can help identify the extent of injury and any concomitant injuries. A grade 3 ACL rupture is usually accompanied by injury to the MCL and medial meniscus. This is known as the “unhappy triad”.
A grade 3 ligament rupture usually requires reconstructive surgery. Grade 1 and Grade 2 sprains usually heal in 3-12 weeks with the athlete returning to sports in 3-4 months following intensive rehabilitation. It takes around 6-14 months for an athlete to return to competitive sports following a surgical repair.
How do you rehabilitation a Ligament Injury?
Initial rehabilitation of soft tissue injuries involving the ligament usually entails it being kept in a shortened position to allow healing during which the muscles are put through isometric and short arc exercises.
The hamstrings are considered to work synchronously with the ACL while the quadriceps are antagonists (they work to oppose this action). Thus, in the early phases, hamstrings strengthening is emphasised over quadriceps strengthening. In case of MCL injury however, quadriceps strengthening is emphasised to achieve early knee extension.
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