a general overview of one one of the most common pathology found in in athlete or a common person..

1. Presented by- Nikhil Govind MPT 1 STYEAR

2.  Contusion?
 Strain in hamstrings
 Strain in calf
 Strain in quadriceps

3.  A contusion happens when an injuried blood
vessel is damaged and leaks blood in the area
of injury
 It can also be defined as the process of a
injury which has occurred due to a blunt force

4.  Contusions can be divided into two
categories that is :-
 1) bone contusions
 2) muscle contusions

5.  Bone contusion is also defined as common
injury which occurs to the bone but less
damaging to that of the fracture
 Bone contusion can occur in any bone and at
any age

6.  A bone bruise has three different types of
bone injuries such as
 Sub perioestal hematoma
 Inter osseous bruising
 Sub condrial lesion
 The only way to say that a bone bruise is
different from a fracture is in the trabculae of
the bone

7.  The most common cause of bone bruise is
trauma
 How ever it is always linked to normal stress
loading and haemophiliaA and B
 It always affects the lower limbs
 Patients who have a bone bruise can see
more bone effusion and slow return to
motion

8.  If we take an example of bone brusing on
such condition where you can see bone
bruising is ACL
 In ACL Rupture , there is concurrent
associated bone bruising at the femoral
condyle and or tibial plateau

10. Bone injury type Characteristics Typical injury/ Mechanism
Sub-periosteal hematoma A concentrated collection
of blood underneath the
periosteal of the bone
Direct high-force trauma
to the bone
Inter-osseous bruising Damage of the bone
marrow.The blood supply
within the bone is
damaged, and this causes
internal bleeding
Repetitive compressive
force on the bone
(extreme pressure on
regular base)
ub-chondral lesion Lesion occurs beneath the
cartilage layer of a joint.
Extreme compressive
force or rotational
mechanism such as testing
(shearing force) that
literally crushes the
cellsForce causes

11.  A Xray would indicate whether there is a
fracture or no
 But the current gold slandered is MRI to
check whether the bone has a bruise or no

12.  Medical management – It includes more of
anti inflammatory medications
 Physical therapy management – RICE
protocol
 Rest
 Icing
 Compression-
 Elevation

13.  So a muscle contusion is a bruise which
happens to a muscle
 Contusions are only secondary to strains
 Most contusions are only minor and heal
quickly
 But in some cases severe contusions, they
can cause severe tissue damage and lead to
complications

14.  Contusions occur when a direct blow or
repeated blows by a blunt object strike part
of the body,
 Thus crushing underlying muscle fibers and
tissue without breaking the skin
 Now A contusion can result from falling or
jamming the body against a hard surface.

15.  swelling
 Pain
 You can also see bluish discoloursiation
 Weakness and stiffness

16.  Physical examination
 CT scan
 MRI

17.  REST ,ICE,COMPRESSION,ELEVATION is
also the treatment for muscle contusion
 REST – the injured area should be protected
from further harm
 ICING- cold packs can be used in the injured
area
 Compression- lightly wrap the injured area
with bandage with a soft bandage
 Elevate the injured limb

18.  It is a contraction-induced injury in which
muscle fibers tear due to extensive
mechanical stress.This mostly occurs as a
result of a powerful eccentric contraction or
over-stretching of the muscle.
 Muscles will most likely tear during sudden
acceleration or deceleration

19.  There are various types of muscle strain but
this class will be more on
 Hamstring muscle strain
 Quadriceps muscle strain
 Calf muscle strain

20.  Hamstring strain

22.  Hamstring strains are caused by a rapid
extensive contraction of the hamstring
muscle which causes high mechanical stress
 This shows in varying degrees of rupture of
the fiber

23.  Hamstring strains are common in sports such
as sprinting, jumping, contact sports such as
Australian Rules football (AFL), where quick
eccentric contractions are seen
 But in football it is quite the common injury

24.  Various factors are seen in hamstring injury such
as
 Older age
 Previous hamstring injury
 Limited hamstring flexibility]
 Increased fatigue
 Poor core stability
 Strength imbalance
 Previous calf injury
 Previous substantial knee injury
 Osteitis pubis

25.  Severe pain can be present in the posterior
thigh
 popping" or tearing impression can be
described.
 Sometimes swelling and ecchymosis can be
present
 Large hematoma or scar tissue can be
presented

26.  Other possible symptoms can be
 Pain
 Tenderness
 Loss of motion
 Decreased strength

27.  They can be divided into 4 classes such as
 Grade 1
 Grade 2
 Grade 3
 Grade 4

28.  Grade 1 (mild): just a few fibres of the muscle
are damaged or have ruptured.This rarely
influences the muscle's power and
endurance.
 Pain and sensitivity usually happen the day
after the injury (depends from person to
person)
 Patient can walk fine.There can be a small
swelling, but the knee can still bend normally

29.  Grade 2 (medium): approximately half of the
fiberes are torn.
 Symptoms are pain, swelling and a mild case
of function loss.
 The walk of the patient will be influenced
 Bending the knee can also be painful

30.  Grade 3 (severe): ranging from more than
half of the fiberes ruptured to complete
rupture of the muscle
 Both the muscle belly and the tendon can
suffer from this injury
 It causes massive swelling and pain
 The function of the hamstring muscle can't
be performed anymore as the muscle shows
more weakness

31.  On examining the patient , the physio can
misinterpret the posterior thigh pain into
various problems such as
 Adductor strains
 Piriformis injury
 Sacroiliac dysfunction
 Sciatica
 Ischial bursitis

32.  The only way to isolate the hamstring injuries
from other injuries is to perform diagnostic
procedures
 Radiographs
 Ultrasounds
 MRI scan

33.  The FASH(Functional assessment scale for
acute Hamstring injuries) questionnaire is a
self-administered questionnaire which now
can only be used in Greek, English and
German languages.
 Some other outcome measures which can be
used are :-

34.  LEFS: lower extremity functional scale
 SFMA:-The Selective Functional Movement
Assessment (SFMA) is a clinical assessment
system designed to identify musculoskeletal
dysfunction
 PSFS: Patient specific function scale
 VAS:Visual analog scale
 NPRS: Numerical pain rating scale

37.  Running gait:The physical examination
begins with an examination of the running
gait. Patients with a hamstring strain usually
show a shortened walking gait.
 Observation:- The posterior thigh is
inspected for asymmetry, swelling,
ecchymosis and deformity.

38.  Palpation of the posterior thigh is useful for
identifying the specific region injured through
pain provocation, as well as determining the
presence/absence of a palpable defect in the
musculo tendon unit.
 With the knee maintained in full extension,
the point of maximum pain with palpation
can be determined and located relative to the
ischial tuberosity

39.  the more proximal the site of maximum pain,
the greater the time needed to return to pre-
injury level.The proximity to the ischial
tuberosity is believed to reflect the extent of
involvement of the proximal tendon of the
injured muscle, and therefore a greater
recovery period.[

40.  Range of motion: Range of motion tests should
consider both the hip and knee joints. Passive straight
leg raise (hip) and active knee extension test (knee)
are commonly used together to estimate hamstring
flexibility and maximum length
 typical hamstring length should allow the hip to flex
80° during the passive straight leg raise and the knee
to extend to 20° on the active knee extension test
 so In the acutely injured athlete, these tests are often
limited by pain and thus may not provide an accurate
assessment of musculotendon extensibility

41. There are a certain tests in which you can
confirm that a person is having a hamstring
strain or no .
There are as folllows
 Puranen-Orava test – Actively stretching the
hamstring muscles in standing position with
hip flexed at about 90*, the knee fully
extended and foot on a solid surface. Positive
– exacerbation of symptoms.

42.  Bent-Knee stretch test
 Modified Bent-knee stretch test
 Taking off the shoe test/hamstring-drag test

43.  Only in chronic cases of hamstring strain
where one of the muscle fiber is toren surgery
is recommended
 Otherwise most of the cases are managed by
physiotherapy

44.  eccentric strengthening, at long muscle
length exercises, as a rehabilitation
tool worked wonders for the patient and
showed a positive effect
 PATS which stands for progressive ability of
trunk and stabilisation exercises
 It helps in promoting the return to sports and
preventing injury recurrence in athletes
suffering an acute hamstring strain.

45.  Deep stripping massage is another technique
used as rehabilitation for hamstring strain
injury
 DSMS increases hamstring length in less than
3 min but has no effect on strength.
Furthermore, combining DSMS with
eccentric resistance exercise produces more
hamstring flexibility gains than DSMS alone

46.  Functional dry needling is a technique that
has been reported to be beneficial in the
management of pain and dysfunction after
muscle strains and in combination with an
eccentric training program,
 The impact of kinesiology tape has been
demonstrated to be efficient at improving
muscle flexibility, which can prevent or
improve the risk of having injuries

47.  Now lets see how a rehab protocol is set for
hamstring strain
 It contains the following phases
 Phase 1
 Phase 2
 Phase 3

48.  Phase I (week 0-3)
 1-Goals
 Protect healing tissue
 Minimize atrophy and strength loss
 Prevent motion loss

49.  2-Precautions
 Avoid excessive active or passive lengthening
of the hamstrings
 Avoid antalgic gait pattern

50.  3- Rehab
 Ice – 2-3 times daily
 Stationary bike
 Sub-maximal isometric at 90, 60 and 30
 Single leg balance
 Balance board
 Soft tissue mobs/IASTM
 Pulsed ultrasound (Duty cycle 50%, 1 MHz, 1.2W/cm2)
 Progressive hip strengthening
 Painfree isotonic knee flexion
 Active sciatic nerve flossing
 ConventionalTENS

51.  Phase 2 (week 3-12)
 Goals
 Regain pain-free hamstring strength,
progressing through full ROM
 Develop neuromuscular control of trunk and
pelvis with a progressive increase in
movement and speed preparing for
functional movements

52.  Precautions
 Avoid end-range lengthening of hamstring if
painful

53.  Rehab
 Ice – post-exercise
 Stationary bike
 Treadmill at moderate to high-intensity pain-free speed and stride
 Iso kinetic eccentrics in the non-lengthened state
 Single limb balance windmill touches without weight
 Single leg stance with perturbations
 Supine hamstring curls on thera ball
 STM/IASTM
 Nordic hamstring Ex
 Shuttle jumps
 Prone leg drops
 Lateral and retro band walks
 Sciatic nerve tensioning

54.  Eccentric protocol
 Once non-weight bearing exercises are
tolerated start low-velocity eccentric
activities such as stiff leg deadlifts, eccentric
hamstring lowers/Nordic hamstring Ex, and
split squats.
 Nordic Hamstring

55.  Criteria for progression
 Full strength 5/5 without pain during prone
knee flexion at 90
 Pain-free forward and backward, jog,
moderate-intensity
 Strength deficit less than 20% compared to
the normal limb
 Pain-free max eccentric in a non-lengthened
state

56.  Phase 3 (week 12+)
 Goals
 Symptom-free during all activities
 Normal concentric and eccentric strength
through full ROM and speed
 Improve neuromuscular control of trunk and
pelvis
 Integrate postural control into sport-specific
movements

57.  Precautions
 Train within symptoms free intensity

58.  Rehab
 Ice – Post-exercise – as needed
 Treadmill moderate to high intensity as tolerated
 Isokinetic eccentric training at end ROM (in
hyperflexion)
 STM/IASTM
 Plyometric jump training
 5-10 yard accelerations/decelerations
 Single-limb balance windmill touches with weight on
an unstable surface
 Sport-specific drills that incorporate postural control
and progressive spe

59.  Eccentric protocol
 Include higher velocity eccentric exercises that include
plyometric and sports specific activities
 Examples: include squat jumps,
 split jumps,
 bounding and depth jumps, single leg bounding,
backward skips, lateral hops,
 lateral bounding, zigzag hops, bounding, plyometric
box jumps,
 eccentric backward steps, eccentric lunge drops,
eccentric forward pulls, single and double leg
deadlifts, and split stance deadlift (good morning E

60.  Return to sport criteria:-
 Full strength without pain in the lengthened state
testing position
 Bilateral symmetry in knee flexion angle of peak
torque
 Full ROM without pain
 Replication of sport-specific movements at
competition speed without symptoms.
 Isokinetic strength testing should be performed under
both concentric and eccentric action conditions. Less
than a 5% bilateral deficit should exist in the ratio of
eccentric hamstring strength (30d/s) to concentric
quadriceps strength (240d/s).

61.  Calf strain

63.  Calf muscle strain injuries (CMSI) occur
commonly in sports involving high-speed
running which has acceleration and
deceleration as well as during fatiguing
conditions of play or performance

64.  Calf strain is a common muscle injury and if
not managed properly there is a risk of re-
injury
 Muscle strains commonly occur in the medial
head of the gastronemius or close to the
musculotendinous junction.

65.  During sporting activities such as sprinting,
these long, bi-articular muscles have to cope
with high internal forces and rapid changes in
muscle length and mode of contraction
leading to a higher risk of strain.
 despite this, calf muscle strains have also
been reported to occur during slow-
lengthening muscle actions such as those
performed by ballet dancers, but also during
common daily activities.[9]

66.  Various sports such as rugby, football, tennis,
athletics and dancing are impacted by calf
muscle strain injuries.
 In football, 92% of injuries are muscular
injuries, 13% of these are calf injuries

67.  Calf strains are most commonly found in the
medial head of the gastrocnemius
 A sudden pain is felt in the calf, and the
patient often reports an audible "pop" in the
medial aspect of the posterior calf, or they
have a feeling as though someone has kicked
them in the back of the leg.

68.  Strains in the gastrocnemius are also referred
to as a “tennis leg” as the classic presentation
is a middle-aged tennis player who suddenly
extended the knee.

69.  Gastrocnemius is considered at high risk for
strains because it crosses two joints (the knee
and ankle) and has a high density of type two
fast-twitch muscle fibers.
 A tear of the medial head of the
gastrocnemius muscle is due to an eccentric
force being applied to the muscle when the
knee is extended and the ankle is dorsiflexed

70.  Symptoms of gastrocnemius strain can
include
 sudden sharp pain or tearing sensation at the
back of the lower leg,
 tenderness to touch at the point of injury
 Swelling
 Bruising may appear within hours or days
 Stretching of the muscle will reproduce pain
 Pain on resisted plantarflexion

71.  The soleus muscle is injured while the knee is
in flexion. Strains of the proximal medial
musculotendinous junction are the most
common type of soleus muscle injuries
 Soleus strains also tend to be less dramatic in
clinical presentation and more subacute
when compared to injuries of gastrocnemius
 It’s a low risk injury

72.  Plantaris strains
 Plantaris is considered largely vestigial and
rarely involved in calf strains, although it
crosses both the knee and the ankle joint as
well.

73.  ISharp pain at the time of activity or after.
 May have a feeling of tightness
 May be able to continue activity, without pain
or with
 mild discomfort
 Post activity tightness and/or aching

74.  Symtpoms
 Pain on unilateral calf raise
 Average time to return to sports:-
 10 - 12 day

75.  Sharp pain at the time of activity in calf
 Unable to continue activity
 Significant pain with walking afterwards
 May have swelling in muscle
 Mild to moderate bruising may be present

76.  Signs
 Pain with active plantarflexion
 Pain and weakness with resisted
plantarflexion
 Loss of dorsiflexion
 Bilateral calf raise pain

77.  Average time to return to sport:-
 16 - 21 day

78.  severe and immediate pain in the calf, often
at musculotendinous junction
 Unable to continue with activity
 May present with considerable bruising and
swelling
 within hours of injury

79.  Signs:-
 Inability to contract calf muscle
 May have palpable defect
 Thomson's test positive
 Average time to return to sport:-
 6 months after surgery

80.  (shin splints)
 Achilles tendinopathy
 Plantar fasciopathy
 muscles strains and/or joint sprains due to
reduced ROM of the ankle.
 Other lower leg injuries related to sports with
the same symptoms and treatment as a calf
strain are discussed below.
 Chronic exertional syndrome (CECS). CECS
begins with mild pain during periods of training
and can disappear after training.

81.  PoplitealArtery Entrapment Syndrome
(PAES). An abnormal relationship between
the popliteal artery and the surrounding
myofascial structures.
 Baker cyst

82.  Calf strains rarely require surgery however
may be necessary in a complete rupture.
 Otherwise it can be treated conservatively
 Soft tissue injury management
 Steroid injection
 If hematoma is present it should be removed
quickly so to prevent myositis ossificans

83.  limit bleeding
 pain
 prevent complication

84.  Tape or a compressive wrap can be applied
and the leg elevated where possible. [23]
 If major bleeding has occurred, the use of
NSAIDs has to be carefully controlled as they
have an anti-platelet effect
 Gentle passive stretching exercises without
pain to maintain range of motion in the
plantar flexors.

85.  Isotonic exercises for the antagonists tibialis anterior,
and the peronei are recommended as well as light
exercises for the injured muscle
 Shoes with a low heel are recommended to encourage
improved heel-toe gait.
 When the calf muscles can be fully extended pain free,
a shift can be made from gentle passive stretching to
active stretches, in both a flexed knee position
(soleus) and a straightened knee position
(gastrocnemius).
 Gradual loading/strengthening exercises of the calf
muscles should be given in order to have a full
recovery.

86.  Lower extremity functional scale
 Visual analog scale
 NPRS

87.  Quadriceps strain

89.  This injury is usually due to an
acute stretch of the muscle, often at the
same time of a forceful contraction or
repetitive functional overloading.

90.  1. Sudden deceleration of the leg (e.g.
kicking),
2. violent contraction of the quadriceps
(sprinting) and
3. rapid deceleration of an overstretched
muscle (by quickly change of direction)

91.  Divided into 3 or more categories
 Grade 1 symptom
 Grade 2 symptom
 Grade 3 symptoms

92.  Grade 1 symptoms
 Symptoms of a grade 1 quadriceps strain are
not always serious enough to stop training at
the time of injury. A twinge may be felt in the
thigh and a general feeling of tightness
 The athlete may feel mild discomfort on
walking and running might be difficult.

93.  The athlete may feel a sharp pain when
running, jumping or kicking and be unable to
play on.
 Pain will make walking difficult and swelling
or mild bruising may be noticed.

94.  Symptoms consist of a severe pain in the
front of the thigh.
 The patient will be unable to walk without the
aid of crutch

95.  It includes devices such as
 X rays
 Ct scans
 MRI

96.  large intramuscular hematoma(s),
 a complete (III degree) strain or
 tear of a muscle with few or no agonist muscles,
or
 a partial (II degree) strain if more than half of the
muscle belly is torn.
 surgical intervention should be considered if a
patient complains of persisting extension pain
(duration, >4-6 months) in a previously injured
muscle, particularly if the pain is accompanied
by a clear extension deficit

97.  The operated muscle is immobilized in a
neutral position
 the duration of immobilization naturally
depends on the severity of the trauma, but
patients with a complete rupture of the m.
quadriceps femoris or gastrocnemius are
instructed not to bear any weight for 4
weeks,

98.  Although one is allowed to cautiously stretch
the operated muscle within the limits of pain
at 2 weeks postoperatively.
 Four weeks after operation, bearing weight
and mobilization of the extremity are
gradually initiated until approximately 6
weeks after the surgery,

99.  It is divided in three phases
 Phase 1
 Phase 2
 Phase 3

100.  Diminish pain and inflammation
 Gradually improve flexibility and ROM
 Retard muscular atrophy and strength loss
 Enhance healing of muscular strain
 The above metioned is goals in phase 1

101.  RICE–Rest,Cryotherapy, compression wrap, and
elevation
 Use of crutches initially to facilitate rest and
immobilization of the quadriceps
 NSAIDS
 Soft tissue mobs/IASTM
 Pulsed ultrasound (Duty cycle 50%, 1 MHz, 1.2
W/cm2)
 ConventionalTENS
 Ankle pumps, isometric quadriceps sets,
hamstring sets, glut sets

102.  Regain pain-free quadriceps strength,
progressing through full ROM Develop
neuromuscular control of trunk and pelvis
with progressive increase in movement and
speed preparing for functional movements

103.  Cryotherapy
 NSAIDS
 Electrical stimulation
 Initial isometrics with quadriceps contractions done with the knee
fully extended and in different positions at 20 degree increments
as knee flexion improves
 May discontinue isometrics when can sit comfortably, perform
straight leg raises at 0 degrees, 20 degrees, and 40 degrees
 Isotonics–begin with the lightest free weight that athlete can lift;
three sets of 10 repetitions up to three times per day
 Terminal knee extensions instituted at 20 degree increments as
comfort and knee flexion allow
 Once terminal knee extensions are done properly without
extensor lag, free weights are added to the SLRs and terminal
knee extensions

104.  Symptom free during all activitiesNormal
concentric and eccentric strength through full
ROM and speed
 Improve neuromuscular control of trunk and
pelvis
 Integrate postural control into sport-specific
movements

105.  Ice – Post exercise – as needed
 Treadmill moderate to high intensity as
tolerated
 Isokinetic eccentric training at end ROM (in
hyperflexion)
 STM/IASTM
 Plyometric jump training
 5-10 yard accelerations/decelarations
 Single-limb balance windmill touches with
weight on unstable surface
 Sport-specific drills that incorporate postural
control and progressive speed

106.  Thank you