Muscles and tendons

A pulled muscle is an injury caused by overstretching or overburdening the muscle, which leads to muscle fibre injuries; at the anatomical level, smaller veins and nerve endings are slightly damaged.

A pulled muscle most commonly appears with sudden movements, especially with take-offs, sprinting, swinging the arms, throwing, or when landing.

Muscle groups that are typically prone to being pulled are: hamstrings, muscle groups of the calf, hip adductors (hip movers) and iliopsoas (hip flexors).

The cause of a pulled muscle is most commonly poor physical readiness for the activity we perform, tiredness, or poor warm-up routine in combination with quickly putting a strain on the muscle. When resting, muscles are less supplied with blood and therefore more rigid. By warming up, we increase the elasticity of the muscles and tendons and thus reduce the likelihood of injuring muscle fibres.

The symptom of a pulled muscle is sudden pain that can vary in intensity. The patients usually describe the injury as a sudden “burning sensation” in a certain part of the body. The pain is specific, localised, and burning and what is typical is that it intensifies after sports activities when the affected muscle group cools down.

The injury is typically followed by mild stiffness; the pain grows more intense when putting a strain on the affected muscle, however, it does not prevent sports activity, it only limits it. A pulled muscle is not accompanied by swelling.

A pulled muscle group is treated without medical support. In the acute phase, the injured muscle should be relieved of activity for a period of 2 to 4 days. It is unnecessary to completely immobilise the injured area.

When returning to sports activities, it is important to pay attention to progressive overload of the injured muscle.

Pulling a muscle group has high recurrence rates and a higher likelihood of developing muscle tears, which is why it is important to follow the exercise part of rehabilitation with appropriate strength exercises since this prevents the formation of a weak spot.

A partially torn muscle denotes a muscle group injury where individual fibres are locally injured, however, the muscle does not fully rupture. According to the number of torn muscle fibres or according to the extent of muscle injury, we differentiate between various grades of tears.

Grade I muscle tear means that multiple muscle fibres are injured, slight swelling and pain are present. Muscle contraction is possible; however, it is accompanied by pain, which limits the capacity of strength.

Grade II muscle tear means that a moderate proportion of muscle fibres is injured, but the muscle is not fully ruptured. Grade II is characterised by stronger pain, swelling, and subcutaneous bleeding may also be present. It is not possible to fully contract the muscle, even minor muscle strain produces intense pain.

When muscle tears are suspected, ultrasound diagnostics is recommended to determine the exact extent of muscle injury or to confirm the suspected muscle damage. In any case, if sudden sharp and burning pain appears in the muscle, we must stop exercising and apply the R.I.C.E. protocol.

If a partial tear of muscle fibres is confirmed, it is necessary to relieve the injured extremity of stress for the first few days after the injury by using additional instrumental therapies to promote healing. The use of therapeutic laser and TECAR Therapy is recommended. It is important to begin performing customized exercises early in the rehabilitation process. In the event of torn muscles, low-intensity therapeutic exercise treatment should begin on the third day after injury.

The programme should progressively increase the stress up to the 21st day after muscle injury. After three weeks, we include high-intensity exercises in the programme of secondary rehabilitation. In the case of athletes, a return to the regular training process follows, but with progressive overload training. It is important to carry out the “return to sport” protocols and thus prevent the recurrence of muscle injuries at the spot where tears were developed since muscle fibre tears have high recurrence rates. Before we can go back to high-intensity sports activities, it is important to establish appropriate muscle strength and muscle symmetry.

Surgical treatment is not needed in grade I and II muscle tears. The entire course of treatment is based on the conservative physiotherapeutic and kinesiological approaches. The injury healing window lasts between 4 and 8 weeks, depending on the extent of muscle injury and accompanying symptoms.

The entire course of treatment is based on the conservative physiotherapeutic and kinesiological approaches. The injury healing window lasts between 4 and 8 weeks, depending on the extent of muscle injury and accompanying symptoms.

Before we can go back to high-intensity sports activities, it is important to establish appropriate muscle strength and muscle symmetry.

Tendons are fibrous tissue, their primary function is to transmit mechanical forces, generated by muscles on the bones. Tendons can resist high forces, up to five times the body weight. The causes of tendon injuries are most often poor blood supply, micro-injuries, repeated stress, and severe contact trauma.

In the majority of cases, a spontaneous rupture of a tendon is caused by repetitive microtraumas, mechanical overload at the spot, poor vascularisation, or former injuries. This means that before the rupture, certain local conditions must have already existed for the stimuli to cause damage. If the tendons have a healthy and functional blood supply, they will regenerate properly after mechanical stress.

In athletes, an appropriate conditioning and regeneration protocol plays a key role in preventing tendon injuries. The regeneration time window is key; if it is too small then the tendon regeneration after overburdening it will not be complete. Tendon ruptures occur most often in professional athletes who are subjected to burdens and in older generations due to poorer vascularization of the fibrous tissue of the tendons.

The injury is oftentimes caused by direct trauma or sudden strong stretch with an eccentric load and a fixed point of growth – this is common in basketball (Achilles tendon rupture).

Symptoms of a ruptured tendon depend on the extent of rupture and the type of injured tendon.

Tendons that are most often damaged:

• Achilles tendon,
• tendons of the quadriceps muscle,
• tendons of the rotator cuff muscle,
• long head of the biceps tendon.

General symptoms of a ruptured tendon include an audible bang that can be felt, accompanied by sudden severe pain.

Significant swelling and externally visible muscle deformation appear at the spot of injury, making it non-functional. Achilles tendon rupture makes it impossible to walk and downward plantar flexion is dysfunctional. Rupture of the rotator cuff tendons often makes it impossible to raise the arms to the side and above shoulder height. Rupture of the long head of the biceps prevents raising the arm with the palm facing upwards.

A muscle tendon rupture is diagnosed after physical examination. MRI imaging is used to determine the exact location of the injury and the extent of deformation. MRI diagnosis is key to determining the damage in partial tendon ruptures, which are most common.

The acute care of tendon rupture should include complete immobilisation of the affected area by isolating two joints. Immediately after the injury, it is advised to cool it to reduce the intense pain; a combination of mild compression and elevation of the injured area is also recommended until surgical treatment can be performed or until physical therapy can begin in the case of conservative treatment.

Partial ruptures are treated over a period of 6 to 12 weeks to fully restore the tendon’s functional capacity. In the case of surgical treatment and/or full tendon rupture, complete rehabilitation can last from 8 to 12 months. The treatment of the complete rupture of the Achilles tendon takes the longest and it is a common reason for professional sportspeople to prematurely terminate their career. Ruptures of the rotator cuff tendons occur due to degenerative causes in 90% of cases and therefore do not require surgical treatment.

If the rotator cuff tendon is ruptured traumatically, surgical treatment is used; if the extent of the injury is less than 50% of the thickness of the tendon, then the damaged (dead) tissue is removed arthroscopically. If the tendon is fully ruptured, the tendon is sutured. Rupture of the long head of the biceps is very specific in nature; unless dealing with a professional sportsperson, surgical treatment is not performed since the long head of the biceps contributes only 10-15% of the function of elbow flexion. In athletes, surgical repositioning of the growth of the biceps longus is often performed using tenodesis surgery.

The rehabilitation programme should include outpatient physiotherapy during the first phase and a progressive regimen of individually oriented kinesiological exercises to improve muscle capacity, adapt the tendon to stress, and establish muscle symmetries in the second phase. Tendon ruptures carry a high risk of recurrence and development of chronic tendinopathies. This is why it is important that rehabilitation includes the final “return to sport” phase where we apply high stress and specific training to the tendons to adapt them to the patient’s sports and recreational goals.

Tendinopathies represent the most common overuse injuries of the soft tissues, they oftentimes appear on specific, known spots – points of growth. Tendinopathies are classified as overuse degenerative pathologies; they may last from a few months to several years.

The cause for the development of tendinopathies are chronic micro-traumas on the collagen structure of the tendon, which cause poor tissue vascularisation, inflammation, and localised thickening. The main causes of overloaded tendons include acute excess of mechanical effort, poor strength and endurance in terms of strength of the muscle group, former injury, incorrect sports or exercise technique, though most commonly it is a combination of the above.

Tendinopathies appear most often on the inner or outer side of the elbow (golfer’s elbow and tennis elbow), Achilles tendon, quadriceps tendon, patellar ligament (jumper’s knee), tendons of the rotator cuff muscle, tendon of the long head of the biceps, and iliopsoas muscle group.

In the progressive phases, tendinopathies may be a highly restricting factor in performing daily tasks. Statistic information that patellar tendinopathy (jumper’s knee) causes career regression and gradual abandonment of sports in 50% of sportspeople who suffer from it tells a lot. In the early phases, tendinopathies are innocent and only occasional; it is important to address the issue early on during its development.

The symptoms are oftentimes nonspecific. The patients report stiffness at the site of injury, discomfort, and occasional pain that appears when stressing the body part. In tendinopathies, the pain oftentimes disappears during exertion and comes back more intense a few hours after finishing the activity. In the reactive stages of tendinopathy, it is possible to experience strong sharp pain when placing stress on the affected area, however, this is more typical in later stages.

In the early phases of tendinopathy, the pain appears only occasionally after overstraining the body and it subsides after a few days.

Progressive phases of tendinopathy include pain that also appears during movement; in extreme cases, it can also limit daily activities and last continuously. Physiological changes of the tissue are typical – during the later stages, the tendon may visibly thicken.

Reduced mobility of the affected part and loss of muscle strength in the final position of the range of motion also appear with increased frequency.

Treatment of tendinopathies is complex. It is advisable to carry out a preliminary ultrasound diagnostic and clinically test the patient. The treatment is conservative, and yet highly individually adapted to the patient’s symptoms and tendinopathy progression.

By using therapeutic laser, TECAR and cooling, we alleviate acute pain and inflammation with the goal to begin implementing a progressive programme of special exercises on the affected body part. The application of eccentric-isometric regimes that stimulate the formation of new collagen fibres is a vital part of the rehabilitation exercise programme.

It is important that the exercises are performed in isolation unilaterally and that we gradually progress to complex strength exercises and sport-specific exercises where it is important not to perform compensatory movements.

Surgical treatment by removing the degenerated part of the tendon is implemented only in rare cases when the tendinopathy does not respond to conservative treatment.

In the case of chronic advanced tendinopathy, it is possible to inject platelet-rich plasma (PRP). The longer the tendinopathy is present, the less likely we are to successfully resolve the symptoms.

It is important that we begin treating the tendinopathy early and that we simultaneously stop the activities that are symptomatic.