eMedicine Specialties > Sports Medicine > Introductory Topics in Sports Medicine

Contusions

Brett J Earl, MD, Consulting Staff, Department of Emergency Medicine, Ogden Regional Medical Center and Davis Hospital and Medical Center
Michael S Omori, MD, Attending Staff, Emergency Medicine Residency, St Vincent Mercy Medical Center; Acting Director, Pediatric Emergency Center, Mercy Children's Hospital; Clinical Assistant Professor, Department of Surgery, University of Toledo Medical Center; Paul Fenton, MD, Assistant Professor, Department of Orthopaedic Surgery, Division of Sports Medicine, Medical College of Ohio at Toledo
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Updated: Dec 8, 2005

Introduction

Background

Muscle contusion indicates a direct, blunt, compressive force to a muscle. Contusions are one of the most common sports-related injuries. The severity of contusions ranges from simple skin contusions to muscle and bone contusions to internal organ contusions. Although all tissue and organ contusions can result from traumatic sports injury, this article focuses on muscle contusions. Contusions of internal organs and bone contusions are not discussed in this article (see Concussion, Sacroiliac Joint Injury, Femur Injuries and Fractures, and Hip Pointer).

Frequency

United States

Contusions and strain injuries comprise approximately 60-70% of all sports-related injuries. In addition, most contusion injuries go unreported and untreated. Documented muscle contusions account for one third of all sports injuries. The quadriceps and gastrocnemius muscle groups most often are involved.

International

International frequency is similar to the frequency in the United States.

Functional Anatomy

Skeletal muscle constitutes the largest tissue mass in the body, comprising up to 45% of the total body weight. Muscles that cross a single joint are located close to bone, are frequently responsible for postural maintenance, and are most susceptible to contusions. On the other hand, 2-joint muscles, such as the rectus femoris muscle, lie more superficial and are more susceptible to stretch-induced strain injury.

Contusions are caused by blunt trauma to the outer aspect of the muscle, resulting in tissue and cellular damage and bleeding deep within the muscle and between the muscle planes. The resultant tissue necrosis and hematoma lead to inflammation. Little is known about the role of the inflammatory process and its importance in the healing process. Clearly, too much inflammation is unfavorable, but too little may be just as devastating.

A bruise is caused by blood that has escaped from damaged capillaries into the interstitial tissues. Within a few hours after the injury, the presence of necrotic tissue and hematoma initiates an inflammatory reaction. Since inflammation initiates macrophage action with subsequent phagocytosis of necrotic debris and stimulation of capillary production, it is vital to the process of muscle regeneration. However, inflammation invariably causes edema that leads to anoxia and further cell death. The extent of the inflammatory response often is considered excessive and detrimental to muscle regeneration. However, controversy exists in this theory because some literature indicates a worsened long-term outcome in patients placed on anti-inflammatory medications. Controversy also surrounds cryotherapy with some literature touting its benefits, while others question its utility.

Clinical

History

Symptoms of a contusion often are nonspecific, and the diagnosis is one of exclusion.

• Symptoms include soreness, pain with active range of motion (AROM) and passive range of motion (PROM), and limited range of motion (ROM). Without a straightforward history of an impact to the area, the diagnosis can be difficult.
• Presentation is characterized by direct trauma to the muscle group with subsequent pain and swelling resulting from bleeding within the muscle.
• A contusion usually can be distinguished from a muscle rupture because residual function remains after a contusion. Muscle ruptures usually are straightforward; sudden intense pain, tightness, and loss of function occur. The patient usually describes a popping sensation. Muscle strains are differentiated by the history of high stress use as opposed to the history of a direct trauma with a contusion.
• Distinguishing contusion from delayed-onset muscle soreness (DOMS) can be difficult in patients with delayed presentation, particularly if the patient is unsure if direct trauma caused the injury (such as in football when multiple traumatic events happen simultaneously). One helpful distinction is that DOMS tends to develop well after the sporting event, or even the next morning, and tends to be distributed symmetrically if muscle groups are used in tandem.
• Ask the patient if he/she has a family history of bleeding disorders or easy or frequent bleeding or bruising.
• A final, yet vital consideration is the possibility of physical abuse. An inconsistent history provided by the patient and family is the hallmark of child abuse.

Physical

Often, the physical examination is most important in excluding other injuries and narrowing the differential. In general, tenderness to palpation and pain with PROM and AROM are the hallmarks of the physical examination. Depending upon the size of the lesion, a hematoma also may be appreciated. A complete examination of the injured area and surrounding areas must be emphasized to identify other possible injuries.

• No objective criteria are available for deciding which athletes should be removed from the field of play and which may return to competition.
  • In general, individuals with injuries involving the larger muscle groups, such as the quadriceps, have to leave the game for immediate attention and evaluation.
  • Each case must be assessed on an individual basis. The first step is to ice the affected area and reassess ROM and swelling within a short period.
  • Documenting the neurovascular status during the initial evaluation and all subsequent evaluations is important.
  • One must always consider the potential for reinjury when deciding if an athlete can return to competition. Reinjury of an injured muscle is a major factor in developing myositis ossificans. Reinjury also significantly increases the healing time for the patient.
• Jackson et al described mild thigh contusions as those having active knee motion greater than 90°, moderate thigh contusions as those having 45-90° of motion, and severe thigh contusions as those having less than 45° of motion. Note that these criteria were based on contusions assessed 48 hours after the event.
• Often the patient presents hours or several days after the event. In these cases, document ROM, extent of swelling, level of function, and neurovascular status.
• Keep in mind the possibility of abuse when performing the physical examination.
  • Accidental bruising and nonaccidental bruising are differentiated by a careful history; age and developmental capabilities of the child; and appearance, location, and number of bruises.
  • Accidental bruising tends to occur in a predictable distribution, such as on the shins, chin, forehead, lower arms and, occasionally, over the hips and spinal prominences.
  • Bruises in the shape of an instrument generally are diagnostic of abuse. Belts and extension cords most frequently are used for abuse.

Causes

Any blunt trauma with sufficient force to propel its energy into the muscle can cause a contusion. Contusions often are the result of sports-related injuries.

References

• Femur Injuries and Fractures
• Quadriceps Injury

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