A recent survey by pain relieving gel, Polar Frost found that a fifth of UK adults injure themselves playing sport and leave it untreated. The survey also revealed a significant knowledge gap of how to treat basic sports injuries. Of the 2,000 Brits included in the study 39% used pain relief as their default form of treatment, 14% used only rest and a further 14% used no action at all. So how do we identify and treat muscle injuries for the best result?
First we need to determine the nature of the muscle injury. Mueller-Wolfhart et al. (2013) propose a detailed classification system to guide diagnosis and management;
The initial, important distinction to make is between functional muscle disorder and structural muscle injury. Functional muscle disorder involves pain without a muscle tear, while structural muscle injury involves an actual tear (that can vary in severity). Further sub-classifications can be made, for physiotherapists and clinicians I recommend reading the paper linked above for full details.
Functional muscle disorder is very common in runners, especially fatigue induced muscle pain. An example of this is calf pain when running. The calf gradually starts to ache and tighten and worsens if you continue running. In most cases the symptoms settle fairly rapidly after the run and there is no swelling or bruising. Over time these symptoms can occur more frequently and at an earlier stage of the run and symptoms can linger with tightness remaining after a run.
Management of functional muscle disorder involves modifying training and addressing the cause of the muscle fatigue. Training volume and intensity should be reduced to a comfortable level. In many cases athletes can continue to train as long as they don't push through pain and recognise their limits. Ekstrand et al. (2013) found that footballers with fatigue-induced muscle disorder missed on average, just 8 days of sport. If running is too painful then cross-training with cycling, swimming or gym work is often well tolerated.
Addressing the cause means asking the question what has increased the load on this particular muscle? It can be training error, particularly a rapid increase in running mileage or intensity. For example developing quadriceps pain and tightness after running on hills as descending hills places a high load on the quads. The cause can also be an underlying muscle weakness, altered biomechanics or running gait. Changes in running shoes, especially moving to barefoot or minimalist styles, can also change loading patterns when running. Calf pain is common in runners transitioning to barefoot due to the increase load on the calf compared to 'shod' running.
Many treat functional muscle disorders with massage, foam rollers and stretching. Intuitively this would make sense, it feels tight therefore stretch it! These approaches may be valuable to improve symptoms but may not address the underlying cause. If the muscle is tight because it's weak and over-worked then stretching, prodding and poking won't change that! While symptoms will improve in the short term with this approach they often recurr on returning to running. A better long term solution is to strengthen the muscle to cope with the demands of sport and modify aspects of running that may lead to an increased load.
Case example: we recently treated a runner with calf pain which started when he switched from his usual heel-strike pattern to fore foot running. On assessment he had profoundly weak calf muscles and wasn't able to perform a single leg calf raise. He had a previous history of calf tear that had been left untreated. It does make you wonder why someone advised him to fore foot strike! We suggested he returned to his usual foot strike pattern, worked on calf strength and gradually returned to running with a good outcome.
Structural muscle injury is less common, research in elite football reported that 70% of muscle injuries were not found to have evidence of a muscle tear on MRI and yet resulted in 56% of the absence from sport. While many runners present to clinic assuming they have torn a muscle it is often functional muscle disorder rather than a true muscle tear. The symptoms are quite different, with a muscle tear people usually report a 'snap' or tearing sensation followed by a sudden onset of localised pain, rather than more gradual tightening and diffuse muscle ache. Tears vary in severity, Mueller-Wolfhart et al. (2013) categorise them as minor partial tear, moderate partial tear and subtotal/ complete muscle tear. Structural muscle injury can result in haematoma which is unlikely with functional muscle disorder. This haematoma may not be visible in deeper muscles and swelling can move with gravity, sometimes you see oedema further down the limb.
The sudden onset of pain following a muscle tear is characterised by an athlete suddenly pulling up, which is commonly seen with a hamstring injury. When I worked pitch side during football matches if a player 'pulled a hammy' fellow footballers on the bench used to quip, “there's a sniper in the crowd” as the player would stop suddenly and collapse to the ground like they'd been shot! This video from tornhamstring.org shows some great examples of this;
Treatment of a structural muscle injury should first involve seeking medical advice for accurate diagnosis and treatment. Rest from running until advised otherwise as early return to sport can result in recurrence of the injury. Ice, cold gels and compression can be helpful, especially in the first 2-3 days but avoid heat and massage during this period. For more information on managing acute injury see our posts on POLICE (which replaces RICE as the acronym to guide acute injury management) and HARM.
Following the initial stage of inflammation and pain you can gradually strengthen the muscle and restore flexibility. This is important to prevent recurrence. Where possible exercises should be included that replicate the function of the muscle involved. For example the hamstrings work eccentrically* during running to control extension of the knee during the swing phase so hamstring exercises with a strong eccentric component are recommended.
*eccentric exercise is where the muscle lengthens during activity, often it's a controlled lowering process. For example if you bring your hand up to touch the front of your shoulder the bicep contracts to bend your arm, this is concentric activity. As you lower the arm again the bicep gradually lengthens to slowly straighten the arm, this is eccentric muscle activity. In the example in the text above there is a controlled lengthening of the hamstring muscle when the knee straightens during the swing phase of running.
There is no recipe for managing muscle tears, every individual will have different needs and goals. For more on specific muscle injuries see our previous work;
Our selection of articles on calf pain and calf injury.
Return to sport should be guided by your physio, timescales can vary considerably depending on the severity and nature of the muscle tear. Work by Ekstrand et al. (2013) in professional footballers reported an average of 16 days absence from sport following a minor tear, 38 days with a moderate tear and 62 days with a subtotal/ complete tear. This gives some indication of prognosis but results are likely to be different in recreational runners without access to the facilities and health care resources available in elite football.
Why seek medical advice and treatment?
The survey from Polar Frost indicates that a considerable amount of people don't seek medical advice following a sports injury and don't use effective treatments for managing muscle injuries. Is this an issue or are we just over-medicalising something that will heal naturally? While muscle injuries can heal without any medical help it is their tendency to recur that makes treatment important. What's more is that re-injury can be more serious and results in 30% longer absence from sport than the original tear. In addition evidence based treatment can quicken recovery. Research by Askling et al. (2013) reported that recovery time following hamstring injury was significantly shorter with exercise that replicated hamstring function (eccentric/ lengthening protocol). Time to return to sport was an average of 28 days in the eccentric group, compared to 51 days in the concentric exercise group.
As ever with recommendations for injury treatment there are limitations. There is still a great deal we don't know about treating muscle injuries and Mueller-Wolfhart et al. (2013) point out that, “scientific data are limited for muscle injury in general”. Their work provides guidance on classification which, when applied by Ekstrand et al. (2013) appeared to be effective to determining prognosis following muscle injury. However, to our knowledge, treatment for these specific classifications is yet to be studied in detail. Also, I'm aware that the Polar Frost study isn't likely to be highly reliable scientific data, I am grateful to them however for sharing some of their findings with us to give some indication of injury prevalence and management. Also without them we wouldn't know that 5% of muscle injuries occur during sex!
In conclusion: muscle injuries can occur without structural damage in the form of functional muscle disorders, or with structural damage with an actual muscle tear. Rehab of both will benefit from physiotherapy assessment and guidance to ensure quick return to sport without re-injury.
As ever with injury on RunningPhysio – if in doubt, get checked out!