Contusions

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Muscle contusion indicates a direct, blunt, compressive force to a muscle. Contusions are one of the most common sports-related injuries. [1, 2, 3] 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 the Medscape Reference articles Concussion, Sacroiliac Joint Injury, Femur Injuries and Fractures, and Hip Pointer).

For excellent patient education resources, visit eMedicineHealth’s Skin Conditions and Beauty Center and Eye and Vision Center. Also, see eMedicineHealth’s patient education articles Bruises and Black Eye.

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 are most often involved (see the images below). [4, 5, 6, 7]

A study that compared incidence, duration of absence and characteristics of indirect (strain) and direct (contusion) quadriceps and hamstring muscle injuries reported that these thigh injuries are more frequent than have been previously described. Direct injuries (contusion) are less frequent than indirect ones (strain), and players can usually return to full activity in under half the average time for an indirect injury. [8]

Rotator cuff contusions of the shoulder have also been seen in professional football players. Cohen et al evaluated the incidence, treatment, and magnetic resonance imaging (MRI) appearance of players sustaining such injuries in a North American professional football team. [9] . The team’s injury records from 1999 to 2005 were retrospectively reviewed for athletes who had sustained a rotator cuff contusion of the shoulder during in-season participation.

The investigators reported 26 players had a rotator cuff contusion, with an average of 5.5 rotator cuff contusions per season (47% of all shoulder injuries), 70.3% of which the predominant mechanism of injury was a direct blow. MRI findings included peritendon edema at the myotendinous junction, critical zone tendon edema, and subentheseal bone bruises. [9]

All patients were treated with a protocol involving modalities and cuff rehabilitation; 6 patients had persistent pain and weakness for at least 3 days and were given a subacromial corticosteroid injection. Overall, 3 patients (11.4%) required later surgical treatment on the shoulder. [9]

Cohen et al determined that rotator cuff contusions composed nearly half of all shoulder injuries in the football players in their study, [9] but the majority of affected athletes are able to return to sports with conservative treatment. A minority of shoulders might progress to more severe injuries such as rotator cuff tears. See the images below.

International

The international frequency of contusions is similar to that in the United States.

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. [1] The resultant tissue necrosis and hematoma lead to inflammation. [10] 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. Because 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 is often considered excessive and detrimental to muscle regeneration. However, controversy exists regarding 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, whereas others question its utility. [11, 12, 13]

Best TM. Soft-tissue injuries and muscle tears. Clin Sports Med. 1997 Jul. 16(3):419-34. [Medline].

Kasemkijwattana C, Menetrey J, Somogyl G, et al. Development of approaches to improve the healing following muscle contusion. Cell Transplant. 1998 Nov-Dec. 7(6):585-98. [Medline].

Nozaki M, Li Y, Zhu J, et al. Improved muscle healing after contusion injury by the inhibitory effect of suramin on myostatin, a negative regulator of muscle growth. Am J Sports Med. 2008 Dec. 36(12):2354-62. [Medline].

Jackson DW, Feagin JA. Quadriceps contusions in young athletes. Relation of severity of injury to treatment and prognosis. J Bone Joint Surg Am. 1973 Jan. 55(1):95-105. [Medline]. [Full Text].

Rothwell AG. Quadriceps hematoma. A prospective clinical study. Clin Orthop Relat Res. 1982 Nov-Dec. 171:97-103. [Medline].

Ryan JB, Wheeler JH, Hopkinson WJ, Arciero RA, Kolakowski KR. Quadriceps contusions. West Point update. Am J Sports Med. 1991 May-Jun. 19(3):299-304. [Medline].

Kary JM. Diagnosis and management of quadriceps strains and contusions. Curr Rev Musculoskelet Med. 2010 Jul 30. 3(1-4):26-31. [Medline]. [Full Text].

Ueblacker P, Mueller-Wohlfahrt HW, Ekstrand J. Epidemiological and clinical outcome comparison of indirect (‘strain’) versus direct (‘contusion’) anterior and posterior thigh muscle injuries in male elite football players: UEFA Elite League study of 2287 thigh injuries (2001-2013). Br J Sports Med. 2015 Mar 9. [Medline].

Cohen SB, Towers JD, Bradley JP. Rotator cuff contusions of the shoulder in professional football players: epidemiology and magnetic resonance imaging findings. Am J Sports Med. 2007 Mar. 35(3):442-7. [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. 2002 Feb. 282(2):E326-35. [Medline]. [Full Text].

MacAuley D. Do textbooks agree on their advice on ice?. Clin J Sport Med. 2001 Apr. 11(2):67-72. [Medline].

Deal DN, Tipton J, Rosencrance E, Curl WW, Smith TL. Ice reduces edema. A study of microvascular permeability in rats. J Bone Joint Surg Am. 2002 Sep. 84-A(9):1573-8. [Medline].

Hubbard TJ, Denegar CR. Does Cryotherapy Improve Outcomes With Soft Tissue Injury?. J Athl Train. 2004 Sep. 39(3):278-279. [Medline]. [Full Text].

Schwartz AJ, Ricci LR. How accurately can bruises be aged in abused children? Literature review and synthesis. Pediatrics. 1996 Feb. 97(2):254-7. [Medline].

Kneeland JP. MR imaging of muscle and tendon injury. Eur J Radiol. 1997 Nov. 25(3):198-208. [Medline].

Kneeland JB. MR imaging of sports injuries of the hip. Magn Reson Imaging Clin N Am. 1999 Feb. 7(1):105-15, viii. [Medline].

Bencardino JT, Rosenberg ZS, Brown RR, et al. Traumatic musculotendinous injuries of the knee: diagnosis with MR imaging. Radiographics. 2000 Oct. 20 Spec No:S103-20. [Medline]. [Full Text].

Wilkin LD, Merrick MA, Kirby TE, Devor ST. Influence of therapeutic ultrasound on skeletal muscle regeneration following blunt contusion. Int J Sports Med. 2004 Jan. 25(1):73-7. [Medline].

Rantanen J, Thorsson O, Wollmer P, Hurme T, Kalimo H. Effects of therapeutic ultrasound on the regeneration of skeletal myofibers after experimental muscle injury. Am J Sports Med. 1999 Jan-Feb. 27(1):54-9. [Medline].

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. 1999 Jan-Feb. 27(1):2-9. [Medline].

Rahusen FT, Weinhold PS, Almekinders LC. Nonsteroidal anti-inflammatory drugs and acetaminophen in the treatment of an acute muscle injury. Am J Sports Med. 2004 Dec. 32(8):1856-9. [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. 1998 Mar-Apr. 26(2):172-6. [Medline].

Torres RJL, Hattori S, Kato Y, Yamada S, Ohuchi H. Ultrasonography and return to play of the different clinical grading of quadriceps contusions: a case series. J Med Ultrason (2001). 2018 Apr. 45 (2):375-380. [Medline].

Mishra DK, Fridén 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. 1995 Oct. 77(10):1510-9. [Medline]. [Full Text].

Powell JW, Barber-Foss KD. Injury patterns in selected high school sports: a review of the 1995-1997 seasons. J Athl Train. 1999 Jul. 34(3):277-84. [Medline]. [Full Text].

Punwar S, Hall-Craggs M, Haddad FS. Bone bruises: definition, classification and significance. Br J Hosp Med (Lond). 2007 Mar. 68(3):148-51. [Medline].

Sun JH, Wang YY, Zhang L, et al. Time-dependent expression of skeletal muscle troponin I mRNA in the contused skeletal muscle of rats: a possible marker for wound age estimation. Int J Legal Med. 2009 Jan 28. epub ahead of print. [Medline].

Wankhede AG. The bruise which depicted the pattern of subjacent bone. Forensic Sci Int. 2009 Apr 15. 186(1-3):e5-7. [Medline].

Michael A Herbenick, MD Assistant Professor of Orthopedic Surgery and Sports Medicine, Wright State University, Boonshoft School of Medicine; Residency Director, Department of Orthopedic Surgery, Miami Valley Hospital

Michael A Herbenick, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine

Disclosure: Nothing to disclose.

Michael S Omori, MD Attending Staff, Emergency Medicine Residency, St Vincent Mercy Medical Center; Acting Director, Pediatric Emergency Center, Mercy Children’s Hospital; Clinical Assistant Professor, Department of Surgery, University of Toledo Medical Center, The University of Toledo College of Medicine

Michael S Omori, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Paul Fenton, MD Assistant Professor, Department of Orthopaedic Surgery, Division of Sports Medicine, Medical College of Ohio at Toledo

Paul Fenton, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Sherwin SW Ho, MD Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Arthroscopy Association of North America, Herodicus Society, American Orthopaedic Society for Sports Medicine

Disclosure: Received consulting fee from Biomet, Inc. for speaking and teaching; Received grant/research funds from Smith and Nephew for fellowship funding; Received grant/research funds from DJ Ortho for course funding; Received grant/research funds from Athletico Physical Therapy for course, research funding; Received royalty from Biomet, Inc. for consulting.

Joseph P Garry, MD, FACSM, FAAFP Associate Professor, Department of Family Medicine and Community Health, University of Minnesota Medical School

Joseph P Garry, MD, FACSM, FAAFP is a member of the following medical societies: American Academy of Family Physicians, American Medical Society for Sports Medicine, Minnesota Medical Association, American College of Sports Medicine

Disclosure: Nothing to disclose.

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Brett J Earl, MD, to the development and writing of this article.

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