1.2.1

Patients

Between January 2nd and December 15th 2006, a physician (Y.G.) at the Questel Sports Medicine Surgery included all patients consulting for sudden muscle pain that had appeared during sporting activity (whether in training or competition) and had led to sporting incapacity.

Patients with a history of trauma in the same muscle group in the preceding 12 months and/or chronic muscle pain in that muscle group were excluded from the study.

The study was approved by the local independent ethics committee.

1.2.2

Methods

1.2.3

Statistical analysis

The date of full resumption of sport (as stated in the telephone interview) was considered as the date of recovery from the injury. On this basis, we classified the patients into two groups :

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  Group 1: patients having been able to resume full sporting activity within 40 days of the injury (and thus considered as having suffered from minor muscle trauma);

  
  
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  Group 2: patients having been able to resume full sporting activity but more than 40 days after the date of injury (considered as having suffered from major muscle trauma) .

We compared the two groups in order to identify any factors associated with the recovery outcome. Although our classification into two groups (minor and major trauma with a cut-off at 40 days) may appear somewhat arbitrary, the classification of muscle trauma is subject to much debate. Common terms such as “muscle strain” and “muscle tear” do not portray the severity of the condition and only the presence of a haematoma in an ultrasound or MRI scan testifies to macrostructural muscle trauma. Furthermore, the extent of the haematoma and/or other pathological signs revealed by imaging do not provide the physician with any discriminant information on the severity of the muscle trauma and thus the likely sporting incapacity. Likewise, a recent study by Schneider-Kolsky et al. reported that clinical evaluation is better than MRI in predicting the duration of incapacity.

Some published studies on muscle trauma have used histological and/or anatomical criteria to define muscle strain severity grades. Jarvinen et al. suggested three groups but Levine et al. suggested only two. The two-group classification chosen here facilitates statistical analysis and is pertinent in clinical practice (as is the 40-day cut-off, as shown by Askling et al. ).

1.3.1

The study population

In all, 93 patients (87 men and six women; mean age 29.4 ± 10.1 years; range: 14 to 57) were included in the study and gave rise to 95 cases, since two patients suffered from two different injuries each (and not recurrence of prior trauma) during the inclusion period.

The sport practiced at the time of the injury was mainly football (64 cases), followed by running (10 cases).

Sixteen cases (17%) involved people performing sport as a leisure activity and 79 cases (83%) corresponded to competitive sportspeople; three of the latter injuries occurred during training and 76 occurred during competition (96%). Of the 79 competitive sportspeople, 24 were county-level performers, 38 performed at the regional level and 17 were national-level.

Trauma was rarely caused by a blow: only nine cases of extrinsic trauma were reported. There was a history of muscle trauma in 23 of the 86 cases of intrinsic trauma cases (27%). The injury occurred when running in 58 cases (67.5%), when performing a sport-specific act (kicking a ball, tackling, etc.) in 26 cases (30.2%) and when jumping in two cases (2.3%). Forewarnings (e.g., slight pain in the days or hours preceding the injury) were present in 31 cases (36%).

The mean time interval between the beginning of the sporting session and occurrence of the injury was 37 minutes (range: 5–90 min; S.D.: 21.11).

The average, self-assessed fitness level at the time of the injury was 7.02 on a scale from 0 to 10 (range: 4–9; S.D.: 1.13).

1.3.2

Clinical and ultrasound examinations

None of the patients displayed normal clinical check-up results and only seven displayed ultrasound scan results that were considered to be normal.

Only one case of arm muscle trauma was recorded. Of the 94 leg injuries, 48 cases concerned the hamstring muscles (i.e., 51.5% of all leg injuries), 19 concerned the quadriceps, eight concerned the adductors and 19 concerned the triceps surae.

1.3.3

Initial treatment

Sporting activity was ceased immediately upon injury in 90 cases and shortly afterwards in the remaining five cases. Ice was applied in 57 cases (60%). Compression was applied in 17 cases (17.8%). In one case, the patient had given himself a massage with an anti-inflammatory gel.

1.3.4

Distribution of the population

Thirty-four patients (35.8%) had minor muscle trauma (Group 1) with, on average, resumption of gentle sporting activity (e.g., jogging) on day 11 post-injury and full resumption of their sport on day 23.

Sixty-one patients (64.2%) suffered from major trauma (Group 2) with, on average, a resumption of gentle sporting activity on day 39 and full resumption of their sport on day 69.

1.3.5

Rehabilitation

Patient compliance with the prescribed rehabilitation program was observed in 62 cases (64.5%). There were no significant differences between Groups 1 and 2 in terms of the patients who decided not to perform the prescribed rehabilitation program ( Tables 1 and 2 ).

Compliance with the prescription by the physiotherapist: of the 62 patients who attended physiotherapy sessions, 40 performed some type of muscle exercise, 29 did some cycling and 58 were given advice on resuming their sport.

Resumption of sport: in both Groups 1 and 2, the period of sporting incapacity did not differ in a statistically significant manner according to whether or not rehabilitation was performed and regardless of whether muscle exercise was included or not.

1.3.6

Recovery

In 75 cases, the patients considered that they had made a full recovery. In 20 cases, the patients considered that they had not fully recovered (despite having resumed their sport at the same level in 19 cases). In fact, only one patient (a leisure runner) decided not to resume his sport because of injury.

1.3.7

Recurrence (second phone interview)

We obtained 84 answers (a response rate of 88%). Seven patients (8%) had suffered recurrence of trauma in the same muscle group (with no difference between the minor and major trauma groups) and 22 patients (26%) had suffered a different muscle injury.

1.4.1

Population

All the treated sportspeople had stopped their sporting activity due to the sudden appearance of muscle pain. All displayed unambiguous muscle trauma in a clinical examination. In 88 cases (92.5%), an ultrasound scan performed on the same day as the clinical examination also gave an abnormal result. For the seven cases in which the ultrasound result was normal, the patients were able to resume their sport at the same level between days 14 and 24 post-injury.

In line with literature reports, the muscle trauma mainly occurred in young men and, above all, in the hamstrings . In general, injuries appeared to occur after a good warm-up and in sportspeople considering themselves to be in “good shape”, which rather goes against conventional sporting wisdom.

1.4.2

Initial treatment

Our first objective was to establish whether the RICE protocol (recommended for minimizing haematoma immediately after muscle trauma ) was well known and actually applied by sportspeople confronted with suspected muscle trauma, given that this protocol is not even applied frequently enough by physicians in certain emergency services .

Cessation of sport was immediate for the great majority of the sportspeople in the study population.

Ice had been applied in 60% of cases. However, it is still difficult to explain the rules for application of this first-line treatment, since there are no real guidelines on its mode of use, duration and frequency .

In only one case, the patient massaged himself with an anti-inflammatory gel (a common practice amongst sportspeople a few years ago). Hence, is clear that the message on not massaging an injured muscle is now well known and correctly adopted in the field.

Our sportspeople were less familiar with compression (18%). However, the appropriateness of this technique is not accepted by all experts , except in cases of rupture of the distal musculotendinous junction of the medial gastrocnemius (“tennis leg”) , which accounted for 18% of the injuries in our series.

Lastly, we did not question our patients on elevation.

Hence, we believe that sportspeople should receive more education on the value of compression in the event of injury (notably for triceps surae trauma).

1.4.3

Rehabilitation

Our second objective was to determine the nature of the rehabilitation program actually implemented by the physiotherapists.

Only two thirds of the patients complied with the physician’s prescription and visited the physiotherapist; the minor and major trauma groups did not differ significantly in this respect.

Therapeutic compliance was defined as the match between the patient’s actions and the physician’s prescription. Compliance is primarily an issue in the drug treatment of chronic disease , where it barely exceeds 50% . Here, we were dealing with acute trauma treated by a paramedical health professional. Hence, the moderate level of compliance observed here (64.5%) cannot be explained by problems in understanding the treatment and potential side effects. In terms of the main factors usually cited in the explanation of poor compliance, we rather suspect the rapidly asymptomatic nature of the injury (with perhaps a combination of little or no day-to-day pain and a long wait for an initial appointment with a physiotherapist), the potential lack of information from the prescriber on the benefits of treatment and, perhaps, the cost (including travel, time and availability constraints for young professionals with busy schedules).

In addition to patient compliance, we also looked at the physiotherapist’s compliance with the physician’s prescription.

A third of physiotherapists did not implement the prescribed weight training – despite the strong consensus within the sports medicine community that this form of training (especially in an eccentric mode) is of value in the recovery from muscle trauma. In fact, weight training enables true mechanical rehabilitation of the muscle by avoiding uncontrolled scarring – a cause of pain and/or re-injury. From laboratory experiments, it is known that muscle traction enables better orientation of new muscle fibres and increases conjunctive healing by decreasing the risk of fibrosis . Conversely, immobilisation worsens fibre orientation and decreases local vascularisation and innervation, both of which are essential for wound healing . Eccentric weight training in the gym can be followed by plyometric work on the field . However, the value of weight training in the rehabilitation of muscle trauma is also subject to debate and there is a lack of well-designed and well-performed studies. In fact, in his recent meta-analysis of rehabilitation for hamstring injuries, Mason et al. only identified three appropriate studies and did not draw any conclusions on the efficacy of weight training. However, isokinetic evaluation may provide information on persistent muscle problems and may optimize rehabilitation, notably when performed in an eccentric mode .

Half of the surveyed physiotherapists did not make their patients perform any cycling – despite the fact that this activity enables a risk-free transition between rehabilitation per se and the resumption of jogging.

In contrast, the great majority of physiotherapists (94%) gave their patients advice on the resumption of sport activities.

One can legitimately ask why the physiotherapists did not comply with the physician’s prescription; was this due to poor knowledge of muscle problems or because their own experience had taught them otherwise? Physiotherapists often dispense other treatments that lack proven efficacy – notably muscle massage and ultrasound treatment .

Regardless of these factors, we nevertheless observed that rehabilitation (such as performed by the physiotherapists here, at least) does not enable quicker recovery from either minor or major trauma. Of course, in Group 2, resumption of sport was more rapid for patients who had performed a rehabilitation program and weight training (whereas the opposite was true in Group 1) but this difference was not statistically significant. Moreover, rehabilitation did not protect rehabilitation-compliant patients from (admittedly rare) recurrence of injury to the same muscle (8%), when compared with patients who did not follow any treatment program at all.

Our descriptive study focused on a population at all sporting levels and did not exclude particular muscle groups or trauma aetiologies. Nevertheless, given the number of patients included, we believe that this situation faithfully reflects the sportsperson’s attitude when confronted with muscle trauma. Initial management can still be optimized, notably by increasing the use of compression. Furthermore, a third of the patients did not comply with the prescribed rehabilitation program. But were these injured sportspeople wrong to do so, given that rehabilitation (such as prescribed by the study physician and performed by the private practice physiotherapists consulted by the study patients) does not enable more rapid resumption of the sport?

Further studies with a more homogenous set of muscle groups and rehabilitation protocols must be performed in order to establish the value of this type of therapy.