1. Chapter 12: Muscle Strains

2. Understanding muscle strains
Muscle strain, also called a pulled muscle, occurs when muscle fibers are overstretched
Increased tensile stress is the primary cause of muscle strains
Strains can occur in any muscle but are mostly likely in muscles that cross two joints
Muscles commonly strained muscles: hamstrings, quadriceps, gastrocnemius, muscles of the rotator cuff, pectoralis major, biceps brachialis, muscles of the neck

3. Figure 12-1
Muscle strain. Fibers in the muscle, tendon, or musculotendinous junction or at the attachment site tear due to overstretching.

4. Common signs and symptoms
Signs and symptoms differ depending on grade (severity of injury) and stage (duration of symptoms)
Acute stage: symptoms typically last 3 – 4 days following injury
Subacute stage: symptoms typically remain from 3 days to 3 weeks following acute stage
Chronic stage: symptoms continue beyond subacute stage

5. Figure 12-2
Degrees of strain. Few fibers are torn in first-degree strain (left). Several fibers are torn in second-degree strain (middle). All fibers are torn in third-degree strain (right). The muscles and tendons may shorten and bunch up near the attachment site. Adapted from Clay and Pounds, 2008.

6. Possible causes and contributing factors
Cause of strain is overstretching with too much tensile stress
Strain can also occur in an unhealthy muscle that can’t lengthen in the average normal range
Previous injury increases risk of strain
Athletes are particularly prone to strains
Age

7. Figure 12-3
Injury – re-injury cycle. Scar tissue alters the shape and function of the affected fibers, leaving the muscle at risk for re-injury. From Werner R. A Massage Therapist’s Guide to Pathology, 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2009.

8. Conditions commonly confused with or contributing to muscle strains
Sprain
Tendinitis
Spasm/cramp
Myofascial pain syndrome
DOMS
Avulsion fracture
Bursitis
Hernia

9. Massage therapy research
Hopper et al. (2005). Evaluation of the effect of two massage techniques on hamstring muscle length in competitive female hockey players.
Farr et al. (2002). The effects of therapeutic massage on delayed muscle soreness and muscle function following downhill walking.

10. Working with the client
Client assessment
Health history
Postural assessment
ROM assessment: active, passive, resisted
Special tests: none
Palpation assessment

11. Figure 12-4
Bruise following muscle strain. The darkest area of bruising suggest the precise location of torn fibers.

12. Condition-specific massage
Treatment goals and techniques are the same for first- degree strains in all stages and second- and third-degree strains in the subacute and chronic stages
Treatment should be relaxing
Remember that you are working on tissue that is compromised

13. Figure 12-5
Muscle strains overview diagram. Follow the general principles from left to right or top to bottom when treating muscle strains.

14. Client self-care Avoid re-injury Perform self-care throughout the day
Take regular breaks from stationary postures or repetitive actions
Gentle self-massage
Stretching and strengthening exercises

15. Suggestions for further treatment
There should be some improvement with each session. If not, consider the following:
There is too much time between treatments
The client is not adjusting ADLs or not doing self-care
The condition is advanced or involves complications
The client has an undiagnosed underlying condition

16. Chapter 13: Ligament Sprains

17. Understanding ligament sprains
Sprain is an overstretch injury to a ligament
Ligaments are tough but flexible fibrous bands; they stabilize joints, restrict excessive movement, and prevent joints from moving in a direction that would cause injury
Injury to a ligament often initiates an inflammatory response

18. Common signs and symptoms
Sprains can occur in any joint but occur most often in the ankles, knees, wrists, and fingers
Overstretching may result in injury ranging from minor tears to complete rupture
Signs and symptoms differ depending on the grade (severity of injury) and stage (duration of symptoms)
Sprains produce local pain, stiffness, pain on passive stretch, and impaired ROM
Bruises and inflammation may be present

19. Figure 13-3
Ligaments that cross joints are most commonly injured. It is essential to know the fiber direction of each of the ligaments that cross and injured joint in order to properly assess and treat the sprain. Adapted from Clay and Pounds, 2008.

20. Figure 13-4
Acute ankle sprain. Common signs of an acute ankle sprain include inflammation and bruising.

21. Stages of ligament sprains
Acute: symptoms typically last 2 – 3 days following injury
Subacute: symptoms typically remain from 2 – 4 weeks following acute stage
Chronic: symptoms continue beyond the subacute stage

22. Possible causes and contributing factors
Most common cause is a swift, high-impact movement that stretches the ligament beyond its capacity
May also occur during ADLs if client has systemic disorders, deconditioning, or repetitive actions have weakened the ligament and destabilized the joint
Beginning a new activity following a period of inactivity
Failure to warm-up before vigorous activity
Poor technique; immobility; insufficient rehabilitation
Weight gain, especially from pregnancy

23. Conditions commonly confused with or contributing to ligament sprains
Muscle strain
Tendinopathy
Avulsion fracture
Bursitis

24. Contraindications and special considerations
Hemarthrosis
Bruises
Muscle testing
Protective muscle splinting
Re-injury
Treatment duration and pressure
Friction

25. Massage therapy research
Several studies report significant improvement in sprains treated with combination therapies
Gemmell et al. (2005). A theoretical model for treatment of soft tissue injuries: treatment of an ankle sprain in a college tennis player.

26. Working with the client
Client assessment
Health history
Postural assessment
ROM assessment: active, passive, resisted
Special tests: ligamentous stress test
Palpation assessment

27. Condition-specific massage
Treatment goals and techniques are the same for grade 1 sprains in all stages and grade 2 and 3 sprains in subacute and chronic stages
An acute grade 3 sprain requires medical attention
Wait 24 – 48 hours after a grade 1 or 2 sprain before beginning treatment
Treatment must be relaxing

28. Figure 13-7
Ligament sprains overview diagram. Follow the general principles from left to right or top to bottom when treating ligament sprains.

29. Client self-care Avoid re-injury Perform self-care throughout the day
Take regular breaks from stationary postures or repetitive actions
Gentle self-massage
Stretching and strengthening exercises

30. Suggestions for further treatment
There should be some improvement with each session. If not, consider the following:
There is too much time between treatments
The client is not adjusting ADLs or not doing self-care
The condition is advanced or involves complications
The client has an undiagnosed underlying condition