Muscle tears are extremely common and are often recurrent. They are not as simple as we used to think and the advent of better imaging has proven that the site, size and location of the tear, together with the presence or otherwise of the tendon is crucial information especially for elite or professional athletes, who need accurate information about return to play. Traditional treatments of electrotherapy are simply placebos. The challenge ahead is to optimise treatments for the various diagnostic categories.

1. Management
of
a
Muscle
Tear
Cameron
Bulluss
–
Advanced
Physiotherapy
Warners
Bay
www.advancedphysio.com.au

2. 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.

3. Muscle
Tears
• Most
common
spor<ng
injury
• 31%
of
all
injuries
in
elite
football
40
35
30
25
20
15
10
5
0
Frequency/muscle
%
Hamstring
Adductors
Quadriceps
Calf
Upper
limb
16
14
12
10
8
6
4
2
0
Frequency/season
Muscle
Injury
ACL
rupture

4. 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

5. 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.

6. 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?

7. 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?

8. 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

9. 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

10. Question
3
Is
imaging
useful
to
us?

11. 100
90
80
70
60
50
40
30
20
10
0
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%

12. Hamstrings
Central
Tendon
-­‐18%
of
all
hamstring
tears

13. Tendon
of
Indirect
Head
of
Rectus
Femoris
(central
tendon)

14. 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

15. Central
tendon

16. Central
tendon

17. Question
4
• The
pa<ent
can
not
afford
Physio
–
what
then?

18. 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

19. 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?

20. 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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