AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• References

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

Section 3 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• References

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.

DIFFERENTIALS

Section 4 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• References

Other Problems to be Considered

Muscle rupture
Stress fracture
Compartment syndrome
Abuse
DOMS
Muscle cramps

Other conditions that may be considered in certain circumstances include the following:
Hemophilia
Idiopathic thrombocytopenic purpura (ITP)
Leukemia
Thrombocytopenia
Henoch-Schönlein purpura
Erythema multiforme
Phytophotodermatitis
Postinflammatory hyperpigmentation
Mongolian spots

One must also consider coining and cupping, which are cultural remedies employed by traditional Asian families.

WORKUP

Section 5 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• References

Lab Studies

• In most cases, extensive workup is unnecessary and unwarranted. An adequate history and physical usually provides enough information for diagnosis and treatment.
• In the event that massive bleeding occurs or if the patient has a bleeding disorder, coagulation studies and a CBC may be beneficial to track the sequelae of the disease.
• If the patient has extensive bruising and rhabdomyolysis is a consideration, a serum creatine kinase level, serum myoglobin level, and urinalysis may be warranted.

Imaging Studies

• Imaging may be helpful to rule out other significant disease processes.
• • Radiographs
  • If the initial history and physical merit further examination, radiographs of the traumatized region may help rule out a fracture.
  • If treatment fails or symptoms worsen, roentgenogram evaluation helps rule out a missed fracture or the development of myositis ossificans. If myositis ossificans is considered, it may show up radiographically approximately 6 weeks after the injury, though the process actually begins very early after the initial injury. If imaging studies are obtained prior to this time period, this disease process may not have matured and may not show up on radiographic examination.
• MRI
• • MRI is rapidly becoming the imaging modality of choice for soft tissue injuries. However, use of this imaging tool tends to be limited to the professional athlete, to those patients in whom the diagnosis is in doubt, and in those whose symptoms are not responding to therapy.
  • In an MRI study, contusions evidenced a diffuse focus of increased signal intensity within the injured muscle with T2-weighted and short-tau inversion recovery (STIR) sequences. A focus of abnormality is noted within the muscle belly (hematoma and edema), with generally minimal disruption of the muscle architecture. The contusion tends to demonstrate a variable signal intensity presumably reflecting the differences in age and microscopic environment of the collection, though it can appear heterogeneously or homogenously bright.
  • Muscle strain appears as diffuse or patchy bright signals on T2-weighted images with preservation of the muscle architecture. These high-signal regions represent a combination of edema and hemorrhage.
  • Complete muscle tear is a clinical diagnosis. Partial muscle tears range from slight tears to almost complete tears. MRI imaging of a muscle tear reveals a strain pattern with an area of intense focus or brightness where the muscle architecture has been altered.

Other Tests

• Physicians must maintain a high index of suspicion for compartment syndrome, a limb-threatening and life-threatening condition seen when tissue pressure in a closed anatomical space exceeds perfusion pressure. Contused tissue within a confined compartment can rapidly reach elevated or critical pressure levels. Clinicians should have a low threshold for testing compartments for increased pressure if compartment syndrome is suspected.

TREATMENT

Section 6 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• References

Acute Phase

Rehabilitation Program

Physical Therapy

In the acute phase following a muscle contusion, hematoma maturation, inflammation, necrosis of damaged myofibrils, and phagocytosis of the necrotic debris are main features. The goal is to minimize hemorrhage and inflammation and control pain. Limb immobilization with rest, ice, compression, and elevation (RICE) should be performed for the first 24 hours in patients with minor contusions and for 48 hours in patients with moderate or severe contusions.

The general recommendation is to avoid heat during the first 24-48 hours to avoid increasing the extent of hemorrhage and edema. Once the lesion has stabilized, heat may help break up the mass of blood and tissue; however, in the literature, this has been shown to be of limited benefit.

The use of crutches should be emphasized for patients with thigh contusions, as weight bearing following the thigh contusion injury may be extremely painful and may extend the damage. The knee joint should be flexed to pain tolerance in conjunction with the compression dressing. Compression gently increases tension, limiting the extent of the intramuscular hematoma. In addition, the position of flexion stretches the muscle, which increases tension and also facilitates drainage of the edematous fluid from the region.

The contusion generally stabilizes by 24-48 hours, and subsequent evaluation should dictate further treatment and prognosis. Reinjury is a significant factor in prolonging disability, and patients must be instructed to avoid retraumatizing the muscle.

Occupational Therapy

In the first phase of rehabilitation, an occupational therapist may become involved by educating the patient about proper crutch use and tailoring the patient's activities of daily living (ADL) to the immobilized limb.

Medical Issues/Complications

The suspicion of compartment syndrome must be high until the hemorrhage, swelling, and pain have subsided (see Miscellaneous).

Surgical Intervention

Surgical intervention should not be necessary unless the diagnosis of compartment syndrome is considered and confirmed.

Consultations

If the diagnosis is in question or if myositis ossificans is confirmed by radiographs, orthopedic consultation can be obtained. Compartment syndrome is a surgical emergency, and an immediate consultation should be made if the diagnosis is confirmed.

Other Treatment

Multiple therapies that have become commonplace in the treatment of contusions exist. However, most therapies have not been proven to provide any benefit, and some may be damaging to the healing tissue.

In a given situation, an injection of epinephrine (with lidocaine) may be considered in the acute phase, along with ice and compression to help limit bleeding.

• Therapeutic ultrasound is a commonly used physical therapy modality that has been claimed to promote tissue repair by enhancing cell proliferation and protein synthesis during the healing of skin wounds, tendon injuries, and fractures. The theory is that of a micromassage effect. However, ultrasound can enhance both myogenic precursor cell and fibroblast proliferation. Prolonging the proliferation phase of fibroblasts during muscle regeneration can add to the amount of permanent scar tissue production, which could outweigh the possible positive effects of ultrasound on satellite cell proliferation. Recent literature questions the utility of ultrasound and notes that some evidence reveals worsening recovery and outcome.

• Heat, whirlpool therapy, and electrotherapy, though pleasing to the patient, have not been shown to influence the rate of recovery.

Recovery Phase

Rehabilitation Program

Physical Therapy

In the second phase of muscle healing, known as the recovery or regeneration phase, the main feature is proliferation of reserve satellite cells and endomysial fibroblasts, followed by active protein synthesis. The main goal of this treatment phase is restoration of mobility and ROM. Early mobilization of the joint and muscle has been shown to dramatically reduce recovery time and increase tensile strength of the muscle. Early pain-free PROM establishes normal tissue planes, maintains uninjured muscle fiber excursion, and pumps excessive detritus from the soft tissue.

The patient is ready to progress to the next level of therapy when ROM has been restored. Jackson et al found that a patient is ready to move on to the next phase of treatment when 90° of knee flexion is achieved.

Pain-free PROM of the knee with emphasis on flexion should be encouraged. Gentle isometric muscle exercises can be performed as tolerated. Weight bearing should be allowed as tolerated. Excessive passive stretching of a previously immobilized limb has been shown to produce myositis ossificans in animal models. This potential complication must be balanced against laboratory evidence showing that mobilization demonstrates faster healing times and increased vascularity of the affected tissue.

Occupational Therapy

Individualized education and instruction to adjust the athlete to ADL and routines with the injured limb may be needed to prevent reinjury and work in conjunction with physical therapy to promote healing.

Medical Issues/Complications

Reinjury is a significant factor in prolonging disability. A fine line exists between a sufficient amount of therapy and too much therapy. Pain tends to be an effective and adequate guide.

Other Treatment (Injection, manipulation, etc.)

Injection of medications into the contused tissue during this phase, and any phase, has not been shown to be beneficial and may in fact be damaging to the tissues; this is especially true of corticosteroids.

Maintenance Phase

Rehabilitation Program

Physical Therapy

The third phase of muscle healing, known as maturation or remodeling, is characterized by a gradual recovery of the functional properties of the muscle, including the recovery of the tensile strength of its connective tissue component. The goal of this phase is to maintain the ROM while restoring full function to the muscle and joint. Progressive resistance exercises are encouraged until full strength and ROM are regained.

Emphasis should be placed on regaining full ROM and restoring strength. Remember that therapy that is too aggressive and too early can result in reinjury caused by muscle strain.

Occupational Therapy

Reevaluation of the patient' s daily activities and increasing tolerance to normal use of the limb should be emphasized.

Recreational Therapy

Maintain agility by participation in noncontact sports such as squash, tennis, badminton, and swimming.

MEDICATION

Section 7 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• References

The physician needs to make every effort to relieve pain as completely and expeditiously as possible. Distinguishing the intensity of the pain can be difficult because it tends to be subjective; therefore, treatment and therapy should be individualized.

Objective parameters, such as tachycardia, are unreliable. Usually, minor trauma to the muscles is self-limited. An enormous selection of analgesics is available for use by the physician, but pharmacological agents tend to fall into 2 general categories: nonnarcotic and narcotic analgesics. The physician also must consider the best route of delivery of the drug.

Corticosteroids should not be used; they are catabolic, and they inhibit the healing process. These steroids promote overall negative nitrogen balance and loss of muscle. However, they continue to be used clinically to treat muscle contusion injuries and are injected into the site of injury to relieve the pain and to expedite a player's return to active status. This inhibition of the inflammatory response may have a sparing effect on the local muscle tissue and, perhaps, on the athlete as a whole in the short term; however, corticosteroids seem to cause an unwanted atrophy of both injured and uninjured muscles.

Anabolic steroids may be proven useful in the treatment of contusion injuries because of the effects they have on nitrogen and protein balance and on stimulation of cell synthesis; however, research currently is limited. Many sporting governing bodies also control the use of anabolic steroids in their athletes, making their use controversial.

Drug Category: Nonnarcotic analgesics

Pain accompanying minor acute soft tissue injuries may be relieved by a short course of nonnarcotic analgesics with acetaminophen.

Drug Category: Nonsteroidal anti-inflammatory drugs (NSAIDs)

Recent controversial data on NSAIDs exist. By suppressing the initial inflammatory reaction, the NSAID permits improved performance in early time periods but appears to suppress the stimulus that may be needed for cellular remodeling in longer time periods. NSAIDs also may increase the amount of bleeding within the tissue. Currently, there is a lack of compelling evidence for either argument.

Although acetaminophen typically is listed with NSAIDs, it lacks anti-inflammatory properties and is used for its antipyretic and analgesic effects.

A number of NSAIDs are available for use. NSAIDs share a common mechanism of action, inhibiting the production of pain-mediating prostaglandins. Generally, NSAIDs provide a comparable degree of pain and inflammatory relief, but they differ in dosing schedule.

The 5 categories of marketed NSAIDs are acetic acid derivatives, fenamates, oxicams, propionic acid derivatives, and related compounds. Numerous NSAIDs are obtainable over-the-counter (OTC). Choosing a NSAID to prescribe can be difficult because little data exists that compares these agents, and individual responses are inconsistent. With a lack of evidence that one NSAID proves to be clearly superior, base decisions on personal experience, safety profiles, cost, and convenience.

Drug Name	Ketorolac (Toradol)
Description	Has become the choice of parenteral pain medications dispensed in the ED. Frequently overlooked is the fact that this medication is an NSAID, carrying all its attendant risks, and it is almost 20 times the cost of morphine (and 140 times the cost of ibuprofen). Little data supporting its superiority over other analgesics exist.
Adult Dose	10 mg PO q6h prn 15-30 mg IV/IM q6h prn, give IV dose over 15-30 sec; not to exceed 5 d of treatment
Pediatric Dose	<16 years: 0.5 mg/kg/dose IV/IM q6h; not to exceed 30 mg q6h >16 years: Administer as in adults
Contraindications	Documented hypersensitivity; do not administer into CNS; do not administer to patients diagnosed with peptic ulcer disease, recent GI bleeding or perforation, and renal insufficiency or to those patients at high risk of bleeding
Interactions	Administered concurrently with aspirin increases the risk of inducing serious NSAID-related side effects; probenecid may increase the concentrations and possibly the toxicity of NSAIDs; may prolong PT when administered concurrently with anticoagulants; closely monitor PT, and instruct patients to watch for signs and symptoms of bleeding; may increase the risk of methotrexate toxicity (eg, stomatitis, bone marrow suppression, nephrotoxicity); phenytoin levels may be increased when administered concurrently
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases the risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; low WBC counts rarely occur and usually return to normal in ongoing therapy; discontinuation of the therapy may be necessary if persistent leukopenia, granulocytopenia, or thrombocytopenia occur Perform ophthalmologic studies in patients who develop eye complaints during therapy; therapy should be discontinued if changes are noted; changes may include blurred or diminished vision, corneal deposits, retinal disturbances, scotomata, changes in color vision, and macular degeneration

Drug Name	Ibuprofen (Motrin, Advil, Nuprin)
Description	This prevalently used NSAID, also available OTC, is a derivative of the propionic class of NSAIDs and is considered the safest of the NSAIDs. Available as tablets of 200 mg, 400 mg, 600 mg, and 800 mg. Pediatric dosage forms are available as both a tablet and oral suspension (20 mg/mL). Advise taking ibuprofen with food or milk, if possible. Prescribe with caution in children with flulike illnesses.
Adult Dose	400-600 mg PO q6h Alternative dosing: 800 mg PO q8h
Pediatric Dose	30-50 mg/kg/d PO divided qid; not to exceed 2400 mg/d
Contraindications	Documented hypersensitivity; because of potential cross-sensitivity to other NSAIDs, do not give these agents to patients in whom aspirin, iodides, or other NSAIDs induce hypersensitivity; do not administer to patients diagnosed with peptic ulcer disease, recent GI bleeding or perforation, and renal insufficiency or to those patients at high risk of bleeding
Interactions	Increased toxicity if used with oral hypoglycemic agents, phenytoin, and warfarin; interferes with ACE inhibitors and beta-blockers; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of loop diuretics when administered concurrently; PT may increase when administered concurrently with anticoagulants; closely monitor PT, and instruct patients to watch for signs and symptoms of bleeding; ibuprofen and other NSAIDs may increase serum phenytoin and lithium levels as well as risk of methotrexate toxicity
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Caution in congestive heart failure, hypertension, and decreased renal and hepatic function

Drug Category: Narcotic analgesics

Patients complaining of inadequate pain relief from NSAIDs may benefit from short-term supplementation with an opioid compound. A wide array of products is available.

Orally, hydrocodone (eg, Lortab, Lorcet, Vicodin, Anexsia), a schedule III narcotic, and oxycodone (eg, Roxicet, Percodan, Tylox), a schedule II substance, usually provide additional pain relief. Codeine-containing products (schedule III drugs) are not as reliable for alleviating pain. While the relative potency for oxycodone and hydrocodone is approximately 0.33 (compared with parenteral morphine), oral codeine is 0.05. Mixed agonist-antagonist oral agents, such as butorphanol, nalbuphine, and pentazocine, offer no real advantages to opioid agents; yet, they cause a higher incidence of adverse effects. Common side effects include constipation, nausea, respiratory depression, sedation, and urinary retention.

Generally, the approved dosage of hydrocodone is 5-10 mg, combined with 500-750 mg of acetaminophen and taken PO q6h prn. Oxycodone analgesic preparations typically combine 2.5-5 mg of oxycodone with 325 mg of acetaminophen. They are dosed as 1-2 tab PO q4h prn for moderate to severe pain. Acetaminophen with codeine (Tylenol #3) contains 30 mg of codeine with 325 mg of acetaminophen. Usually, 1-2 pills q4h prn is recommended.

Elixirs containing hydrocodone (Hycodan) are convenient for children older than 6 years who have moderate to severe pain and who are unable to swallow pills. One teaspoon (5 mL) of Hycodan contains 5 mg of hydrocodone; the dose usually is 1.25-2.5 mg q4h, depending on the child's size and the severity of pain. The elixir of Tylenol with codeine for children contains 120 mg of acetaminophen and 12 mg/5 mL of codeine in an alcohol base (7%).

Generally, orally administered drugs impart a slower onset of action. For patients in severe pain or for those patients who must take nothing by mouth (NPO), parenteral agents may be necessary. Although the IM route may be more convenient for the staff, the IV route offers a number of advantages. Narcotics given IV provide a rapid and predictable onset of action and are easier to titrate. Morphine and meperidine are the most commonly used parenteral narcotic agents.

Drug Name	Oxycodone and acetaminophen (Percocet, Tylox, Roxicet)
Description	Drug combination indicated for the relief of moderate to severe pain.
Adult Dose	1-2 tab or cap PO q4-6h prn
Pediatric Dose	0.05-0.15 mg/kg/dose oxycodone PO; not to exceed 5 mg/dose of oxycodone q4-6h prn
Contraindications	Documented hypersensitivity
Interactions	Phenothiazines may decrease the analgesic effects of this medication; conversely, its toxicity increases when administered concurrently with either CNS depressants or tricyclic antidepressants
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Duration of action may increase in elderly persons; be aware of the patient's total daily dose of acetaminophen; maximum dose of acetaminophen is 4000 mg/d, higher doses may cause liver toxicity

Drug Name	Acetaminophen and codeine (Tylenol #3)
Description	A drug combination indicated for the treatment of mild to moderate pain.
Adult Dose	30-60 mg/dose PO (based on codeine content) q4-6h or 1-2 tab q4h; not to exceed 12 tab/24h
Pediatric Dose	0.5-1 mg/kg/dose PO (based on codeine content) and 10-15 mg/kg/dose PO q4h (based on acetaminophen content); not to exceed 2.6 g/24h
Contraindications	Documented hypersensitivity to acetaminophen or codeine phosphate
Interactions	Toxicity increases when administered concurrently with CNS depressants or tricyclic antidepressants
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Administer with caution in patients dependent on opiates since this substitution may result in acute opiate withdrawal symptoms; exercise caution when patients have severe renal or hepatic dysfunction

FOLLOW-UP

Section 8 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• References

Return to Play

Contusions, in particular quadriceps contusions, should be observed closely after injury until the hemorrhage has stopped, which usually occurs 24-48 hours after the injury. Considering compartment syndrome or muscle rupture is important if the pain or girth of the affected area has not stabilized by 48 hours postinjury.

No objective data indicate when an athlete may safely return to competition. Each case must be evaluated on an individual basis, and the clinician' s best judgment must act as a guide. In general, if athletes have 90% of strength on the affected side and are able to perform the required activity without any pain or obvious deficits, they are ready to return to the field.

Complications

Myositis ossificans occurs in 9% of all contusions, 4% of mild contusions, 13% of moderate contusions, and 18% of severe contusions. Development of myositis ossificans is a multifactorial problem. Reinjury is a significant factor in prolonging disability.

Rhabdomyolysis must be considered if the contusions are extensive or multiple.

The most serious complication is compartment syndrome. Pain out of proportion to the injury or increasing pain over time are red flags that should alert and prompt the physician to measure the compartment pressures.

Prevention

The use of protective equipment has helped reduce the incidence of contusions, and the athlete must be instructed on proper use of protective equipment.

Some data indicate Indocin can help in decreasing heterotopic bone formation. To date, the data is inconclusive, but this may be considered when selecting a medication with which to treat a patient.

Prognosis

For most muscle contusions, prognosis is excellent. Jackson's research on thigh contusions found the average disability time was 13 days for mild contusions, 19 days for moderate contusions, and 21 days for severe contusions.

Risk factors for a more unfavorable prognosis include injuries that occur during football, previous contusion in the same muscle, delay in treatment for more than 3 days, and large muscle involvement. Reinjury is a significant factor in prolonging disability.

Education

Education about proper use of protective equipment and aggressive early treatment of contusions is essential.

For excellent patient education resources, visit eMedicine's Skin, Hair, and Nails Center and Eye and Vision Center. Also, see eMedicine's patient education articles Bruises and Black Eye.

MISCELLANEOUS

Section 9 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• References

Medical/Legal Pitfalls

• The key to diagnosing acute compartment syndrome is a high index of suspicion.
• • The 5 P's of compartment syndrome include (1) pain out of proportion to the injury, (2) pain on PROM, (3) pulselessness, (4) paresthesia, and (5) pallor. These symptoms are not diagnostic of compartment syndrome, and several of them present late in the disease process.
  • Compartment syndrome can occur 12-24 hours following the initial injury.
  • Pain out of proportion to the examination is the most common clinical finding, but pain on PROM with stretching of the affected muscle groups is the most sensitive finding (eg, pain with passive dorsiflexion of the toes is passively testing the posterior calf flexor compartment). Any suspicion on the part of the clinician should prompt measurement of the compartment pressures.

ACKNOWLEDGMENTS

Section 10 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• References

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• References

• Beiner JM, Jokl P, Cholewicki J, Panjabi MM. The effect of anabolic steroids and corticosteroids on healing of muscle contusion injury. Am J Sports Med. Jan-Feb 1999;27(1):2-9. [Medline].
• Bencardino JT, Rosenberg ZS, Brown RR, et al. Traumatic musculotendinous injuries of the knee: diagnosis with MR imaging. Radiographics. Oct 2000;20 Spec No:S103-20. [Medline].
• Best TM. Soft-tissue injuries and muscle tears. Clin Sports Med. Jul 1997;16(3):419-34. [Medline].
• Deal DN, Tipton J, Rosencrance E, et al. Ice reduces edema. A study of microvascular permeability in rats. J Bone Joint Surg Am. Sep 2002;84-A(9):1573-8. [Medline].
• Farges MC, Balcerzak D, Fisher BD, et al. Increased muscle proteolysis after local trauma mainly reflects macrophage-associated lysosomal proteolysis. Am J Physiol Endocrinol Metab. Feb 2002;282(2):E326-35. [Medline].
• Hubbard TJ, Denegar CR. Does Cryotherapy Improve Outcomes With Soft Tissue Injury?. J Athl Train. 9 2004;39(3):278-279. [Medline].
• Jackson DW, Feagin JA. Quadriceps contusions in young athletes. Relation of severity of injury to treatment and prognosis. J Bone Joint Surg Am. Jan 1973;55(1):95-105. [Medline].
• Kasemkijwattana C, Menetrey J, Somogyl G, et al. Development of approaches to improve the healing following muscle contusion. Cell Transplant. Nov-Dec 1998;7(6):585-98. [Medline].
• Kneeland JB. MR imaging of sports injuries of the hip. Magn Reson Imaging Clin N Am. Feb 1999;7(1):105-15, viii. [Medline].
• Kneeland JP. MR imaging of muscle and tendon injury. Eur J Radiol. Nov 1997;25(3):198-208. [Medline].
• MacAuley D. Do textbooks agree on their advice on ice?. Clin J Sport Med. Apr 2001;11(2):67-72. [Medline].
• Mishra DK, Friden J, Schmitz MC, Lieber RL. Anti-inflammatory medication after muscle injury. A treatment resulting in short-term improvement but subsequent loss of muscle function. J Bone Joint Surg Am. Oct 1995;77(10):1510-9. [Medline].
• Powell JW, Barber-Foss KD. Injury patterns in selected high school sports: a review of the 1995-1997 seasons. J Athlet Train. 1999;34(3):277-84.
• Rahusen FT, Weinhold PS, Almekinders LC. Nonsteroidal anti-inflammatory drugs and acetaminophen in the treatment of an acute muscle injury. Am J Sports Med. Dec 2004;32(8):1856-9.
• Rantanen J, Thorsson O, Wollmer P, et al. Effects of therapeutic ultrasound on the regeneration of skeletal myofibers after experimental muscle injury. Am J Sports Med. Jan-Feb 1999;27(1):54-9. [Medline].
• Rothwell AG. Quadriceps Hematoma. A prospective clinical study. Clin Orthop Relat Res. Nov-Dec 1982;(171):97-103. [Medline].
• Ryan JB, Wheeler JH, Hopkinson WJ, et al. Quadriceps contusions. West Point update. Am J Sports Med. May-Jun 1991;19(3):299-304. [Medline].
• Schwartz AJ, Ricci LR. How accurately can bruises be aged in abused children? Literature review and synthesis. Pediatrics. Feb 1996;97(2):254-7. [Medline].
• Thorsson O, Rantanen J, Hurme T, Kalimo H. Effects of nonsteroidal antiinflammatory medication on satellite cell proliferation during muscle regeneration. Am J Sports Med. Mar-Apr 1998;26(2):172-6. [Medline].
• Wilkin LD, Merrick MA, Kirby TE, Devor ST. Influence of therapeutic ultrasound on skeletal muscle regeneration following blunt contusion. Int J Sports Med. 25(1):73-7.

Article Last Updated: Dec 8, 2005