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Management of a Muscle Tear
Cameron Bulluss – Advanced Physiotherapy Warners Bay www.advancedphysio.com.au
Summary • This presenta<on is an internal document designed to educate Sports Physiotherapists on the current best prac<ce for muscle tear management.
• The presenter is a Physiotherapist located in Newcastle NSW and has treated pa<ents at Olympic level, na<onal and interna<onal level
• His team consists of 8 sports physiotherapists, 3 of whom are formally <tled (APA)
• Muscle tears are extremely common and are oKen recurrent. They are not as simple as we used to think and the advent of beMer imaging has proven that the site, size and loca<on of the tear, together with the presence or otherwise of the tendon is crucial informa<on especially for elite or professional athletes, who need accurate informa<on about return to play. Tradi<onal treatments of electrotherapy are simply placebos. The challenge ahead is to op<mise treatments for the various diagnos<c categories.
Muscle Tears • Most common spor<ng injury • 31% of all injuries in elite football
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5
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Hamstring Adductors Quadriceps Calf Upper limb
Frequency/muscle %
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12
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16
Muscle Injury ACL rupture
Frequency/season
Challenges Re-‐injury Rate is high • Common up to 16% of muscle tears will reoccur with the season
• Recovery <me of these is 30% longer than ini<al injury • Previous hamstring strain has 4x increased risk of delayed return to sport (Warren et al 2010)
• Not all muscle tears are as simple as we used to think • Op<mal management of the different types has not been established
• Clinical tes<ng does not always predict outcome • Predic<ng recovery <me is difficult
Case Study 24 year old soccer player presents with anterior thigh pain following a kicking a ball over the weekend. Unable to con<nue to play, Clinical assessment shows local tenderness mid thigh, swelling, antalgic gait. Grand final in 2 weeks.
Question 1 What is the ini<al advice regarding • Weight-‐bearing • Ice, compression and eleva<on • Medica<on • Referral on
• Imaging? • sports physician? • orthopaedic surgeon? • Physio?
Referral on • Imaging? • This has some value • MRI probably beMer than ultrasound • The loca<on of the tear and • To a lesser extend the size of the tear and • Presence or otherwise of a central tendon injury is good to know
• Sports physician? • Orthopaedic surgeon? • Physio?
Referral on • Sports Physician • Perhaps to assist with imaging referral • Physios can refer for MRI and Ultrasound but need interpre<ve skills • These are not taught at undergraduate level
• Orthopaedic surgeon? • As per Sports Physician • Would need a special interest in this area to be involved as the injury is
generally non-‐operable
• Physio? • Choose wisely • Post-‐graduate (or Titled) sports or musculoskeletal is preferable • They must have access to equipment to test muscle func<on and an
exercise space with equipment for rehabilita<on • Small clinic with curtains and no gym can’t do this
Question 2 What to expect from the physio? • Electrotherapy e.g. Ultrasound, laser, interferen<al -‐ NO • Dry needling – NO, this is contraindicated • Progressive exercise aKer a period of acute care – YES • Op<mal programming has s<ll not been established
Question 3 Is imaging useful to us?
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MRI normal 1 joint muscle 2 joint muscle muscle around central tendon
Central tendon injury
Mean Days to return to play (add 30% for recurrent injury)
18%
Hamstrings Central Tendon -‐18% of all hamstring tears
Tendon of Indirect Head of Rectus Femoris (central tendon)
Lack of information • Most of literature assumes that all “muscle tear” presenta<ons are ubiquitous
• Informa<on regarding muscle around central tendon from Tom Cross found in powerpoints on web
• Central tendon of hamstring concept appears to be valid but I could only find one good study
Central tendon
Central tendon
Question 4 • The pa<ent can not afford Physio – what then?
Question 5. Can he play in the grand Jinal?
With MRI Informa<on • If central tendon or muscle around the central tendon is injured = no
• Otherwise a good chance If no MRI • Assess for single or mul<ple joint muscle • If single joint = good chance • If mul<ple joint muscle possibly, should be clearer aKer a 1 week review. Poor response to rehabilita<on = suspect muscle around central tendon or central tendon injury
Question 6. If MRI is negative does this mean it is not a muscle tear?
• Unknown • MRI nega<ve muscle disorders are responsible for 50% of <me lost
• Can imaging be done too early? • Could other pain generators be possible e.g. Femoral nerve?
Question 7. What terminology or grading systems do we use
• No good consensus recommenda<ons • Pulled muscle is a lay term • Strain is a biomechanical term • Tear is not always supported by imaging • ? Func<onal muscle disorder = clinical muscle injury but nega<ve imaging
• Structural muscle disorder = clinical muscle injury plus posi<ve imaging
• Grading systems of limited use
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