There’s an old saying, “If a tree falls in a forest and no one is around, does it make a sound?” Similarly, if a muscle hurts but there’s no tearing, is it a muscle strain?
How many times has your evaluation included a statement similar to this: “no deformity, strength loss, swelling, or discoloration, but with a palpable tight band”? I’ve been telling anyone who will listen (mainly my wife Dr. Alison Gardiner-Shires, a fellow athletic trainer and HawkGrips instructor, because she has no choice but to listen to me) that at least half of the “strains” we see are not actually muscle strains, but rather neuromuscular strains.
A four-year observational study, involving 23 European professional football teams, evaluated magnetic resonance imaging (MRI) scans obtained 24-48 hours after hamstring injuries occurred. The results demonstrated that almost three-quarters of the injuries were without muscle tear, and these accounted for more than 50 percent of player absences.1 So if there’s no tear, is it still considered a muscle strain? Two articles from the British Journal of Sports Medicine tackle this issue, as the Munich Consensus Statement and British Athletics Muscle Injury Classification both attempt to quantify “strains” into new scales.
Quantifying Muscle Strain
The Munich Consensus first divides its nomenclature into the following categories based on presentation: direct injury (such as contusion, laceration or puncture), indirect functional disorder, or indirect structural injury. Functional disorders, those without visible “tears” on an MRI, are split into four types: 1(a) fatigue, 1(b) delayed-onset muscle soreness (DOMS), 2(a) spine-related, and 2(b) muscle-related neuromuscular disorders. Structural injury, meanwhile, is based on the more traditional grading scale: 3(a) minor tear, 3(b) moderate, and 4) sub- to total tear of muscle, tendon and/or avulsion.2
British Athletics expands the traditional grading by starting at 0, extending to 4 and adding suffixes. The new “0 level” refers to the presence of edema without any outward sign of tearing, where “0(a)” represents a neurological pathology and “0(b)” is a typical DOMS evaluation. Grades 1-4 delineate sizes while adding the following suffixes to describe the structures involved: a) myofascial injury, b) musculo-tendinous, and c) intratendinous.3
Don’t get me wrong, as an athletic trainer for a professional baseball team, I understand the need for grading (especially via MRI) and thus the corresponding proposed disability modeling. But as a clinician, I personally like Munich better because it lends more credence to the neurological factor.
So let’s go back to the Ekstrand article where 70 percent of post-injury MRIs demonstrated no tear. Given the setting that I work in, I probably see these injuries more frequently than an office-based clinician would. This is because such injuries don’t tend to reduce functionality to a high degree, and the average person won’t typically seek treatment from a clinician until their condition has become disabling.
But why is any of this important? First, it impacts our training. We need to be more movement-based and core-integrated, rather than muscularly selective. Second, this non-strain’s non-injurious nature will respond quickly to treatment. Stay tuned for Part 2 on this topic, where I’ll discuss how to appropriately treat different types of muscle strain.
- Ekstrand J, Healy JC, Walden M, Lee JC, et al. Hamstring muscle injuries in professional football: The correlation of MRI findings with return to play. Br J Sports Med. 2012; 46(2):112-7.
- Mueller-Wohlfahrt HW, Haensel L, Mithoefer K, Ekstrand J, et al. Terminology and classification of muscle injuries in sport: The Munich consensus statement. Br J Sports Med. 2013; 47:342-350.
- Pollock N, James SL, Lee JC, Chakraverty R. British athletics muscle injury classification: A new grading system. Br J Sports Med. 2014; 48:1347-1351.
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Mark Shires just completed his ninth season as athletic trainer for the Norfolk Tides, the Triple-A affiliate of Major League Baseball’s Baltimore Orioles. This represented his 19th season overall with the Orioles organization, and he has twice been named International League Athletic Trainer of the Year. Shires also serves as an athletic trainer for Harcum College in Bryn Mawr, PA, during the offseason and has utilized HawkGrips since 2012.
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