Contusions occur by direct or sheer forces applied to the muscle resulting in capillary and venous disruption that causes an intramuscular damage and hematoma. The injury promptly creates a cascade of pathophysiologic changes followed by immediate healing efforts. The acute management strategy focuses on limiting the extent of the hematoma formation. Proper treatment is necessary to avoid potential complications such as compartment syndrome or myositis ossificans.

Rest, ice, compression, and elevation (RICE) principles apply to acute contusion injury . The use of these four principles is recommended because they promote reduction of inflammation and swelling. Resting (relative immobilization) a contusion injury will help prevent further hematoma formation and therefore limit the extent of blood that needs to be reabsorbed and associated changes to the muscle and soft tissue. There is evidence to support immediate muscle immobilization to help limit hematoma formation [2, 3]. Specifically, immobilization while maintaining some muscle tension is suggested. A West Point study investigated a protocol for treating quadriceps contusion. This study found significantly shorter length of disability using an initial treatment protocol that placed the quadriceps on tension by holding the extremity in a knee flexed/hip extended position [3]. Reminiscent of immediate management of quadriceps contusion, resting the gastrocnemius in tension—foot dorsiflexed and knee extended—will theoretically provide an intrinsic tamponade effect by the enveloping fascia . Placing the gastrocnemius in tension will not only limit swelling and hemorrhage but will also minimize scar formation and preserve elasticity, contractility, and strength [3]. While there are no available studies specific to the lower leg, using the data presented in the West Point quadriceps protocol, one can infer that using such a regimen for the gastrocnemius would lead to subsequent accelerated rehabilitation and an ability to achieve full ankle dorsiflexion more rapidly.

While brief immobilization can provide therapeutic benefits as described above, prolonged immobilization is associated with longer periods of disability. Mobilization of the muscle leads to regeneration of its components and restoration of biomechanical strength. It is not possible to reliably determine when immobilization should end, and mobilizations begin since repetitive activation of the muscle too early may incite further connective tissue damage and scarring. The literature suggests that when the hematoma is stable, early restoration of motion can begin as long as the patient is comfortable and pain free at rest. Pain-free or minimally uncomfortable passive range of motion is introduced early and followed by a gradual progression to active range of motion [3].

Ice (cryotherapy) facilitates therapeutic effects on acute soft tissue injuries by decreasing pain and muscle spasm and also limiting inflammation via vasoconstriction mechanisms. This vascular constriction to local tissue reduces reactive hyperemia from the injury and incudes leukocyte recruitment. Using ice for soft tissue injury has long been employed and is a mainstay of acute injury management. However, there is very little consensus regarding the most effective duration, frequency, or mode of application of cryotherapy treatments. The clinician should advise the patient to limit direct contact of cryotherapy treatments to the skin due to possible incidental damage to the soft tissues and give caution regarding signs of frostbite [4–6].

Compression limits local blood flow and can prevent progression of hematoma formation. The literature suggests that the combination of compression and cryotherapy may be more beneficial than either modality used alone. Lastly, elevation takes advantage of gravity and hydrostatic pressure to limit extravasation and thereby reduces edema [6].

Aspiration of hematomas or other fluid collections associated with the contusion should be considered in the acute period. The decision to aspirate is based on the location, extent, and patient factors. Any attempt at aspiration has risks of introducing contamination into the effected tissue and limiting the local tamponade effect. Surgical evacuation of a large hematoma can be considered but is typically deferred unless complications such as acute compartment syndrome are manifest.

During the rehabilitation process , care is necessary to avoid reinjury. Myositis ossificans can develop following the primary injury, however, a reinjured muscle further risks developing this significant complication [2]. Myositis ossificans is a debilitating condition of extra-skeletal ossification of the injured muscle or other soft tissue. Sometimes, the calcifications spontaneously reabsorb and the condition may go unrecognized. Surgical debridement may become necessary if myositis ossificans remains symptomatic and unresponsive to conservative measures such as indomethacin [2].

Use of nonsteroidal anti-inflammatory drugs (NSAIDs) in the setting of muscle contusion is controversial. Given the platelet inhibition effect, NSAIDs may worsen hematoma formation. A safer option may be to use simple analgesics such as acetaminophen. However, a controlled animal study showed that utilization of acetaminophen versus the NSAIDs had similar effects on muscle healing [7]. Conversely, early use of NSAIDs may avert risk of developing myositis ossificans. Evidence for this use is inferred from studies showing a decrease in heterotopic bone formation after total hip replacement in patients receiving indomethacin [8]. Since there are no available randomized controlled studies regarding utilization and timing of various analgesics, the clinician must weigh the risks and benefits when implementing these medications. To supplement the treatment of contusions , one may direct ancillary staff to employ the use of therapeutic ultrasound. It should be noted that although therapeutic ultrasound is commonly used during rehabilitation, it does not appear to effect the regeneration of skeletal muscle following contusion [9].

Acute penetrating trauma from stab or puncture wounds can cause muscular injures in the posterior leg. The focus of treatment for stab or puncture wounds is generally aimed at reducing risk of infection. Thorough irrigation and cleansing of the wound should be performed. The clinician should determine the need for any tissue debridement or surgical repair . Surgical debridement is needed when there is deep tissue involvement and severe contamination. When indicated, tetanus and/or antibiotic prophylaxis should be used [1].