How to treat and prevent Muscle Strains

Andy Chalmers

June 29, 2021

With local sports about to restart again, now is a great time to talk about muscle strain injuries and their prevalence, risk factors, prevention and treatment at a local level. The importance of this topic is particularly enhanced given the shutdown of the 2020 season, and interruptions already during the 2021 season due to the COVID pandemic, with the potential implications of such on muscle injuries particularly at a local and sub-elite level, who aren’t blessed with the same access to resources as those at the elite level. In addition to local team-sports, this even spans further to the recreational runner or the weekend warrior.

Muscle strains:

What?

Muscle strains, occurring most frequently at the musculo-tendon junction, generally occur as a result of muscle fibres being unable to cope with the demand being placed on them, leading to tearing of the fibres (Maffulli & Del Buono, 2015).

Grading systems for muscle injuries vary across the literature, although the foundations remain consistent. The British Athletics muscle injury classification classifies muscular injuries based on the extent of the muscle fibre tear; grades 1 (small), grade 2 (moderate), grade 3 (extensive) and grade 4 (full thickness)). Furthermore, strains are classified in subsets based on the exact tissue injured;

a) myofascial

b) musculotendinous

c) tendinous

Most commonly injured in Australian Rules Football includes the hamstrings, adductors, quadriceps and calf muscles. The latest publicly accessible AFL injury report, of 2018, revealed hamstrings continue as the most common soft tissue injury, followed by the calf, quadriceps and adductors, respectively (AFL Injury Report, 2018).

British Athletics Muscle Injury Classification(Macdonald et al., 2019).

Why? Risk Factors

Various risk factors have been proposed in the literature, but muscle injuries commonly occur concurrently with ‘spikes’ in frequency, intensity or duration of an activity.

Other common risk factors include muscle injury history, age and muscle fibre types (Orchard, 2001). More recently, particularly for the hamstrings, eccentric strength has shown a strong correlation as a protective factor for muscle injury risk (Opar et al., 2015).

How?

Muscle injuries occur most frequently during the eccentric phase of contractions, often during deceleration of activity. Therefore, common tasks where muscle injuries occur include sprinting, jumping and changing of direction.

Type 2 muscle fibres (fast twitch) are the most susceptible to injury as they develop high-speed contractions.

Injury prevention:

Warm-up:

While aimed at soccer, the FIFA-11 is an easily adaptable foundation for a comprehensive sports warm-up. A 2017 systematic review found the FIFA-11 to reduce injuries by up to 30% amongst soccer players (Sadigursky et al., 2017).

Load management:

Gabbett (2016) has produced various research to support load management as a ‘vaccine’ for injury prevention. Effectively, he supports that training needs to be hard enough and long enough to develop the physical qualities to protect against injury, but this needs to be exposed without excessive and rapid increases in these training loads, which are often responsible for a large proportion of non-contact soft tissue injuries.

Strengthening:

Strengthening, particularly now eccentric, continues to be widely researched and supported for injury prevention.

A 2019 systematic review found the Nordic hamstring curl (an eccentric hamstring exercise) was able to reduce hamstring injuries by up to 50% when included in an injury prevention program (Van Dyk et al., 2019). Resultantly, there is preliminary research into similar effects of a ‘reverse Nordic curl’ (an eccentric quadriceps exercise) to elicit similar effects (Alonso-Fernandez et al., 2018). Similarly, the Copenhagen adductor exercise has been shown to reduce groin issues by up to 41% (Harøy et al., 2019).

Management:

Peace & love:

More recently, ‘Peace & Love’ has been proposed as a new acronym for acute injury management to replace the likes of the previous RICE, PRICE or POLICE (Dubois & Esculier, 2020). This acronym proposes that we PROTECT the joint, ELEVATE the joint, AVOID anti-inflammatories, COMPRESS the joint and EDUCATE the patient. Then, we LOAD the injury safely, provide OPTIMISM regarding the injury, prescribe cardiorespiratory exercise to promote VASCULARISATION, as well as other EXERCISE including mobility, strength and proprioception.

Strengthening:

As previously alluded to, strengthening plays a critical role in injury prevention and concurrently as rehabilitation for muscle strain injuries. As such, Physiotherapists can play a critical role in the progression and programming of rehabilitation to the local injury site as well as surrounding musculature. Furthermore, education surrounding the importance of ongoing strengthening is critical to try and assist in preventing re-injuries in the future.

Nordic Curl (Muscle and Strength, 2021).
Copenhagen Adductor exercise (long lever)
Reverse Nordic Exericse

Return to play (control/chaos):

This is most critical phase in the re-integration of our athletes back into the sport they love. Taberner et al. (2019) proposes this is a balancing act between ‘control’ and ‘chaos’, and as such presents the ‘control/chaos continuum’. This continuum guides an athlete to return to play via phases of high-control, moderate-control, control>chaos, moderate chaos and finally high chaos. Effectively, this involves slowly re-integrating the athlete into controlled running, while progressing to change of direction, involving balls and unpredictability, then integration into levels of training drills where ‘chaos’ is evoked.

Final note:

The prevention and management of muscle strains in athletes at a local level is multi-faceted and complex in nature given the variability in access to resources on a club-to-club basis. An adequate foundation in respect to a thorough dynamic warm-up before sessions as well as particularly a solid pre-season that forms the base from which to work on throughout the season.  As such, Physiotherapists play an important role in educating patients on these facets as well as the importance of strengthening as a means of both injury prevention and completing a thorough rehabilitation, as critical in achieving positive outcomes in these athletes to keep them playing the sport they love.

About the Author:

Andy Chalmers graduated from Latrobe University and has special interests in utilising exercise based rehabilitation, acute and chronic sporting injuries, lower limb tendinopathies and loading issues. Andy currently works with AFL team Western Bulldogs as a trainer and is the head physiotherapist for the North Geelong Warriors (NPL). He also holds qualifications in strength and conditioning (ASCA) and Clinical Pilates.

References:

AFL. Injury Report. (2018). AFL Injury Report 2018. Retrieved from: https://s.afl.com.au/staticfile/AFL%20Tenant/2018-AFL-Injury-Report.pdf

Alonso-Fernandez, D., Fernandez-Rodriguez, R., & Abalo-Núñez, R. (2018). Changes in rectus femoris architecture induced by the reverse nordic hamstring exercises. The Journal of sports medicine and physical fitness59(4), 640-647.

Dubois, B., & Esculier, J. F. (2020). Soft-tissue injuries simply need PEACE and LOVE.

Gabbett, T. J. (2016). The training—injury prevention paradox: should athletes be training smarter and harder?. British journal of sports medicine50(5), 273-280.

Harøy, J., Clarsen, B., Wiger, E. G., Øyen, M. G., Serner, A., Thorborg, K., … & Bahr, R. (2019). The adductor strengthening programme prevents groin problems among male football players: a cluster-randomised controlled trial. British journal of sports medicine53(3), 150-157.

Macdonald, B., McAleer, S., Kelly, S., Chakraverty, R., Johnston, M., & Pollock, N. (2019). Hamstring rehabilitation in elite track and field athletes: applying the British Athletics Muscle Injury Classification in clinical practice. British journal of sports medicine53(23), 1464-1473.

Maffulli, N., & Del Buono, A. (2015). Muscle strains: Pathophysiology and new classification models. In Nuclear Medicine and Radiologic Imaging in Sports Injuries (pp. 939-948). Springer, Berlin, Heidelberg.

Muscle and Strength. (2021). Nordic Hamstring Curl (Bodyweight) Video Exercise Guide. Retrieved from: https://www.muscleandstrength.com/exercises/nordic-hamstring-curl-bodyweight

Opar, D., Williams, M., Timmins, R., Hickey, J., Duhig, S., & Shield, A. (2015). Eccentric hamstring strength and hamstring injury risk in Australian footballers. Medicine and Science in Sports and Exercise47(4), 857-865.

Orchard, J. W. (2001). Intrinsic and extrinsic risk factors for muscle strains in Australian football. The American journal of sports medicine29(3), 300-303.

Patel, A., Chakraverty, J., Pollock, N., Chakraverty, R., Suokas, A. K., & James, S. L. (2015). British athletics muscle injury classification: a reliability study for a new grading system. Clinical radiology70(12), 1414-1420.

Sadigursky, D., Braid, J. A., De Lira, D. N. L., Machado, B. A. B., Carneiro, R. J. F., & Colavolpe, P. O. (2017). The FIFA 11+ injury prevention program for soccer players: a systematic review. BMC sports science, medicine and rehabilitation9(1), 1-8.

Taberner, M., Allen, T., & Cohen, D. D. (2019). Progressing rehabilitation after injury: consider the ‘control-chaos continuum’.

Van Dyk, N., Behan, F. P., & Whiteley, R. (2019). Including the Nordic hamstring exercise in injury prevention programmes halves the rate of hamstring injuries: a systematic review and meta-analysis of 8459 athletes. British journal of sports medicine53(21), 1362-1370.