Multiple injuries slow healing

This is how torn muscles heal

A muscle injury can, depending on the severity of the injury, exclude the athlete from sport for several months. The treatment must take place in the appropriate phase. It also depends on the degree of injury. Most muscle injuries can be treated conservatively. But also operational procedures come, z. B. for complete muscle rupture, used.

Muscle injuries can be divided into acute and chronic injuries and according to their location (e.g. muscle belly, muscle-tendon junction, tendon and tendon insertion). Most authors classify muscle injuries into three to four grades:

  • Grade 1: Tear of individual muscle fibers with intact fascia (<5% of the muscle fibers).
  • Grade 2: Several muscle fibers tore with intact fascia and localized hematoma (> 5% of muscle fibers).
  • Grade 3: Tear of numerous muscle fibers with partial rupture of the fascia and diffuse hemorrhage (> 5% of the muscle fibers).
  • Grade 4: Complete muscle and fascia tear with loss of function.

Causes of injury

Most muscle injuries can be traced back to sudden, violent muscle stretching beyond tolerance limits as well as direct impact trauma (contusion).

Muscles that have not been stress-adapted (insufficient warming up with insufficient vascular flow, poor training condition, tired or hypothermic muscles) increase the sensitivity to injury. Unhealed injuries, infectious diseases, insufficiently balanced fluid losses with electrolyte imbalances, muscular imbalances and unsuitable sports equipment increase the risk of suffering muscle injuries.

Superficial muscles that run across two joints and often have antagonistic functions (e.g. rectus femoris, semitendinosus and gastrocnemius muscles) are predestined for muscle injuries. Direct muscle injuries occur when they come into contact with an opponent or when they hit a hard obstacle. In the case of past muscle injuries, the scar-muscle boundary is the predilection point for a new injury.

Muscle healing

After a muscle injury, the healing process takes place as a repair process in three phases:

1. Destruction and inflammation phase

After the injury, parts of the muscle fiber initially die off and an inflammatory cell reaction occurs, and a hematoma forms between the ruptured muscle fiber parts. The healing process is slowed down by the hematoma. The aim in this phase is therefore initially to avoid excessive hematoma formation or to remove the hematoma quickly.

2. Reparation phase

After the phagocytosis of the destroyed cell debris by macrophages, the muscle fibers regenerate. Capillaries sprout into the injured area, so an optimal supply of oxygen to the muscle is important for the healing process. The fiber regeneration reaches its peak after about two weeks, the developing connective tissue scar intensifies until about four weeks after the injury.

3. Remodeling / recovery phase

This phase overlaps with the reparation phase. The functional capacity of the muscles is restored, among other things. through reinnervation.


The anamnesis of the injury mechanism already gives us important information. During the physical examination, inspection, palpation and functional analysis usually provide the experienced colleague with clear results.

In the case of injury degree 1, sometimes also with degree 2 and 3, symptoms may initially be absent when the muscle is relaxed. In the case of grade 2 and 3 muscle injuries, interruptions in the continuity of the muscle can sometimes be felt. In the case of grade 4 injuries, the deformation of the injured muscle with the corresponding loss of function can be reliably demonstrated.

Sonography is considered a screening method due to economic aspects as well as the lack of radiation exposure, easy availability and good informative value. Muscle tears and hematomas can be clearly identified on the echo texture (Fig. 1). A dynamic assessment of muscles and tendons is also possible with sonography. A hematoma that has formed can be punctured or, if necessary, an injection can be made into the injury site under ultrasound control. However, the results are highly dependent on the examiner and are not fully reproducible.

With magnetic resonance tomography, muscle injuries that are difficult to access can be shown excellently (Fig. 2).

The x-ray shows bony chippings, calcifications (myositis ossificans) and, with a soft tissue image, contours of the soft tissue shadows.

Initial treatment

The blood flow in the muscles (resting state 0.8 l / min) can be 18 l / min during exercise. In the event of muscle injuries during sport, extensive bleeding must therefore be expected at the injury site. The main purpose of initial treatment is to contain the bleeding. The athlete is immediately removed from the sporting activity and a pressure bandage with an elastic bandage is applied. The extremity is relieved or elevated with forearm canes. In the beginning, it has to be cooled regularly (every hour 20 minutes). Muscle relaxation drugs can be given. Short-term use of NSAIDs within the first five to seven days after the injury shows positive results. If there is a sharp increase in pressure in the soft tissues, surgical intervention (removal of the hematoma and stopping the bleeding) may be necessary in rare cases.

The extent of the hematoma can be reliably assessed after 24 hours. A puncture under ultrasound guidance may be required to reduce the hematoma. If the hematoma has already changed into a solid state, the hematoma can be removed via a small incision or arthroscopically.

Conservative treatment

Grade 1 and some of the Grade 2 and 3 injuries can be treated conservatively. After removal of the hematoma and completion of the acute phase treatment, an elastic pressure bandage is applied for two to three weeks. In the first two days, the patient should take it easy on the affected muscle, and exercise treatment can begin on the sixth day at the earliest. The following procedure has proven itself for the training structure:

  • During the first few days, training should be limited to static, stress-free exercises.
  • The dynamic exercises start after about a week. The extent and intensity are determined by the pain.
  • After about two weeks, stretching exercises and sensorimotor training can begin.
  • Training with sports elements is started no earlier than three weeks after the injury.

Operative treatment

The vast majority of muscle injuries can be treated conservatively according to the guidelines described above.

However, the surgical procedure is indicated for complete muscle ruptures and for grade 2 and 3 injuries to muscles that have no agonistic muscles or where other muscles are unable to compensate for the work of the injured muscle (Fig. 3 and 4). In the event of muscle tears from protruding bones or at the insertion of the bone tendons, the indication for surgical refixation should be given generously, especially in competitive sports. In particular, adequate surgical care should be given to those muscles that help stabilize the pelvis while standing on one leg. This mainly affects the adductors.

After surgery, the limb should be immobilized and relieved for about seven days. The subsequent rehabilitation depends on the extent of the injury and the location of the surgical site.

Return to training

The sport-specific training usually does not begin until the fifth week after a serious muscle injury. When deciding to resume training, the following factors have proven useful:

  • Pain-free stress on the muscle during normal movements
  • Identical elasticity of the injured muscle compared to the contra-lateral side. The training is then built up in stages.

Compartment Syndrome

The acute muscle compartment syndrome is usually the result of direct trauma. The trauma leads to soft tissue damage in the lower extremity, which most often leads to anterior, lateral and posterior compartment syndrome in the area of ​​the lower leg. The clinical symptoms consist of pain, pain intensification with passive stretching, as well as sensory and motor-neurological symptoms.

The increased intracompartmental pressure leads to insufficient oxygenation of the muscles (ischemia) and ultimately to muscle necrosis if neglected and inadequate treatment. Rapid fasciotomy is therefore indicated in acute muscle compartment syndromes.


The most important preventive measures are a correct warm-up before sport and a follow-up to the sporting load as well as a targeted, individually tailored muscle training for the athlete. The athlete should be made aware of the increased risk of muscle injuries due to malnutrition and loss of fluids as well as during training with infectious diseases and focal herder diseases (teeth, tonsils).

PD Dr. med. Martin Engelhardt
Clinic for orthopedics, trauma and hand surgery