History questions?
- What is the client’s overall health?
- Has there been a history of injury or recurrent contusions of this muscle?
- When did the injury occur?
- How did the injury happen?
- What was done at the time of injury?
- Was the client able to continue with the activity after the contusion?
- Did the limb “give way” at the time of injury?
- Is any swelling or any edema present?
- Did the client see any other health care practitioner for this injury?
- Is the client taking any medications?
- Is the client using any supports/crutches?
- What symptoms is the client currently experiencing?
- What aggravates or relieves the pain?
- What are the client’s ADL’s?
Contraindication?
- In the acute stage, testing of a moderate or severe contusion other than pain-free active free ROM is CI’d to prevent further tissue damage
- In the acute stage of a mild contusion, on-site work is CI’d
- In the acute and early subacute stages of a moderate to severe contusion, local and on-site Swedish massage is CI’d as to not disturb the hematoma, but proximal lymphatic drainage is indicated
- Avoid removing protective muscle splinting of acute contusions
- In the 7-10 days with a moderate to severe contusion, take care with stretching and avoid vigorous massage since there is a risk of rebleeding. Any applications of heat or contrast hydrotherapy are CI’d for the same reason
- Distal circulation techniques are CI’d in the acute and early subacute stages to avoid increasing congestion through the injury site
With moderate or severe contusions in the acute or early subacute stages it is CI’d to take ROM or passive stretch beyond the onset of discomfort or pain - Frictions are CI’d if the client is taking anti-inflammatories or blood thinners
Treatment acute stage?
- Muscle is treated with RICE
- Hydrotherapy used is cold
- Initial goal is to decrease edema using lymphatic drainage techniques before any general compensatory work begins
- If the contusion is in the limb, techniques proximal to the contusion are used to reduce pain and hypertonicity and maintain local circulation
- Do not significantly reduce any protective muscle spasm in the synergists and antagonists by overtreating these tissues
- On-site work is CI’d
- Gentle muscle squeezing and light stroking can be done distal to the contusion
- Passive relaxed ROM of the proximal and distal joints to the onset of pain can be done with mild contusions
Treatment early subacute stage?
- Do not interfere with the healing process of a moderate to severe contusion, the tissue is fragile
- Hydrotherapy used is cold
- Reduce edema proximal to the lesion with lymphatic drainage techniques
- Reduce hypertonicity and maintain local circulation proximal to the lesion, being more careful with moderate to severe contusions
- Reduce spasm/protective muscle spasming using GTO release
- Reduce trigger points in proximal muscles that refer to the injured limb and the injury site itself, being careful to only treat trigger points in the injured muscle if they are well proximal to the injury site
- On-site work is now indicated with a mild contusion only using vibrations and stroking
- Gentle muscle squeezing and light stroking can be done distal to the contusion
- Inner to mid-range passive relaxed ROM is used with mild contusions on the joints proximal and distal to the contusion
Treatment late subacute stage?
- The healing tissue is less fragile
- Hydrotherapy applications on-site are cold/warm
- Reduce any remaining edema
- Reduce hypertonicity and increase circulation proximal to the injury
- Reduce trigger points in muscles that refer to the injured limb and the injury site itself are treated, but heat and a full stretch are not used
- On-site work includes vibration, stroking and fingertip kneading working from the periphery to the centre and back to the periphery
- As inflammation subsides, reducing adhesions within the muscles is important using skin rolling, petrissage and short cross-fibre strokes
- Also important to realign the developing CT to form a functional scar
- After frictioning, specific stretching to lengthen and realign the muscle fibres is performed cautiously
- Ice is applied to the frictioned tissue joint play techniques to the proximal and distal joints are introduced
- Increase ROM with mid to full-range passive relaxed ROM is used on the joints proximal and distal to the contusion
- Increase local circulation distally to promote tissue health
Treatment chronic stage?
- Hydrotherapy applications proximal to the contusion and on the lesion site itself include deep moist heat
- Reduce hypertonicity and trigger points proximal to the lesion site
- Reduce adhesions and scar tissue using specific kneading, muscle stripping, fascial techniques and cross-fibre frictions. This is followed by a passive stretch or post-isometric relaxation of the muscle to realign the fibres. This is followed by ice.
- Passive relaxed ROM to full ROM is used on the proximal and distal joints to maintain joint health
- Increase local circulation to the distal limb
Home care?
- Hydrotherapy is chosen that is appropriate for the stage of healing
- Self-massage is useful for the affected muscle in the late subacute and chronic stages
- In the acute stage with a mild contusion, pain-free active free ROM of the distal and proximal joints with gentle stretch to the onset of pain is indicated
- In the early subacute stage with mild or moderate contusions, pain free active free ROM of the proximal and distal joints with isometric contractions from inner to mid-ranges
In the late subacute stage, all stretching and strengthening exercises are gradually increased in duration and repetition - In chronic, the focus continues to be active resisted isotonic concentric and eccentric exercises to gradually strengthen the affected muscle
What is a Contusion?
a crush injury to a muscle?
Hematoma?
A large area of local hemorrhage following a trauma
acute symptom picture?
Acute
Mild:
Minimal local edema, heat and bruising
Tenderness at the lesion site
Minor discomfort local to the injury site with activity that contracts or stretches the muscle
5-20% loss of ROM and minimal or no loss of strength
Client can usually continue activity
Moderate:
Moderate local swelling due to hematoma, heat and bruising
Moderate tenderness at the lesion site
20-50% loss of ROM and moderate loss of strength
Pain is moderate with activities that contract or stretch the muscle
Client has difficulty in continuing activity due to pain and experiences disability the next day
Severe:
Marked, rapid local swelling is present due to hematoma, edema, heat and bruising
Severe pain at the lesion site
More than 50% loss of ROM and functional loss of strength
Client cannot continue the activity
Early Subacute symptom picture?
A mild contusion has little or no pain or reduced strength
A moderate contusion has pain and moderately reduced strength
A severe contusion has pain and markedly reduced strength with active resisted strength testing
Bruising is black and blue
With moderate or severe contusion, the hematoma is still present but reduced from the acute stage
Pain, edema and inflammation are still present but reduced from acute
Adhesions are developing around the injury
Protective muscle spasm diminishes, trigger points occur in affected muscle, its synergists and antagonists
With moderate and severe contusions, the injury may still be bandaged to prevent further swelling
Client is still using crutches with a contusion to a lower limb or a sling with an upper limb contusion
ROM is reduced
Late Subacute symptom picture?
Bruising is yellow, green and brown
Pain, edema and heat are diminishing
Adhesions are maturing around the injury
Protective muscle spasm is replaced by increased tone in the affected muscle, its synergists and antagonists
With moderate or severe contusion, the hematoma diminishes
ROM and strength are reduced
Peripheral nerves may be compressed by edema and swelling that result from a contusion
Chronic symptom picture?
Bruising is gone
Adhesions have matured around the injury
Hypertonicity and trigger points are present in the affected muscle and in any compensating structures
Tissue may be cool due to ischemia
With a moderate or severe contusion, there is discomfort local to the lesion site only if the muscle is stretched. Full ROM and strength of the affected muscle may be reduced
Some hematomas calcify into myositis ossificans with 3-6 weeks after the injury. With myositis ossificans formation, there is reduced strength and loca inflammation. If bone formation is within the muscle belly, it may be surgically removed
Testing-Acute?
Active free ROM of the joints crossed by the affected muscle is reduced
Mild contusion-mild pain when muscle is contracted or stretched and range is reduced by up to 20%
Moderate contusion-pain is moderate and range is reduced by 20-50%
Severe contusion-pain is severe and range is reduced by more than 50%
If moderate or severe contusion is suspected, other testing is CI’d in the acute stage. Indicated by:
Marked swelling
Client having difficulty continuing the activity or being unable to continue activity
By the active free ROM results
Passive relaxed ROM for a mild contusion is performed on the cardinal planes of motion, with the range that stretches the affected muscle to be tested last. A painful muscle spasm end feel is present before the affected muscle reaches its full length. Pain may also be encountered with tissue approximation
Active resisted isometric testing of the affected muscle with a mild contusion reveals minor to no loss of strength and some discomfort
With a moderate or severe contusion, a girth measurement test is positive with a hematoma and the client should be referred for emergency medical attention
Testing-Early and Late Subacute?
Active free ROM of the joints crossed by the affected muscle is reduced. Range is limited due to pain but less than in the acute stage
Passive relaxed ROM is performed on the cardinal planes of motion, with the range that stretches the affected muscle tested last
Active resisted isometric testing of the affected muscle will reveal pain at the injury site. The contraction of the muscle is held to the onset of pain only. Severity of contusion is graded in the following manner:
Mild contusion-minor to insignificant loss of strength and some discomfort
Moderate contusion-moderate loss of strength and pain
Severe contusion-significant loss of strength and pain
Testing-Chronic?
Active free ROM of the joints crossed by the affected muscle is limited by any remaining pain at the end ranges of motion
Passive relaxed ROM may reveal a mildly painful, tissue stretch end feel on fully stretching the affected muscle
Active resisted testing of the affected muscle may reveal decreased muscle strength, especially with severe contusions
Myositis Ossificans?
An occasional complication following a hematoma, where the blood within the muscle calcifies
Fibroblasts are replaced by osteoblasts, which begin to lay down new bone over a period of approx. 6 weeks
They may form within a muscle or may have an attachment to an existing bone
The strength of the muscle decreases
The more severe or more frequent the contusion, the higher the risk of myositis ossificans formation
