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DOI 10.1007/s00167-012-2118-z
SPORTS MEDICINE
Nicola Maffulli
Received: 29 March 2012 / Accepted: 18 June 2012 / Published online: 7 July 2012
Ó Springer-Verlag 2012
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Knee Surg Sports Traumatol Arthrosc (2012) 20:2356–2362 2357
Table 1 Present classification system and relationship with imaging features of muscle injuries
Imaging Radiological findings
grading MRI US
I (strain) Less than 5 % of fibre disruption; feathery oedema-like pattern, Normal appearance, focal or general increased echogenicity;
intramuscular high signal on the fluid-sensitive sequences No architectural distortion
II (Partial Oedema and haemorrhage of the muscle or MTJ may extend Muscle fibres are discontinuous, the disruption site is
tear) along the fascial planes, between muscle groups hypervascularized and altered in echogenicity in and around,
Fibres, disorganized and thin, are surrounded by haematoma with no perimysial striation of the area adjacent to the MTJ
and perifascial fluid. If haemosiderin or fibrosis is present,
T2-weighted images have low signal intensity. The small
calibre of the fibres at the site of injury may be also
expression of incomplete healing. In high-performance
athletes, MRI findings, particularly the measure of the cross-
sectional area of injury, are relevant to define the
rehabilitation
III Complete discontinuity of muscle fibres, haematoma and Comparable with MRI
(Complete retraction of the muscle ends
tear)
Table 2 Proposed classification system with conservation or minimally impairment of strength and
Site of lesion function. US findings, often normal, may indicate the
presence of focal or general increased echogenicity [35],
1. Proximal MTJ and perifascial fluid is present in almost 50 % of the
2. Muscle A. Proximal a. Intramuscular patients. Some authors consider ultrasonography not as
B. Middle b. Myofascial accurate as MR imaging, given the difficulty to depict the
C. Distal c. Myofascial/perifascial normal hyperechoic intramuscular portion of the tendon
d. Myotendinous after injury [37]. At MR imaging, a classic ‘feathery’
e. Combined oedema-like pattern visible on fluid-sensitive sequences
3. Distal MTJ may be often associated with some fluid in the central
MTJ musculo-tendinous junction portion of the tendon and, at times, along the perifascial
intermuscular region [16], with no discernible muscle fibre
disruption (Fig. 1) or architectural distortion [34].
Materials and methods Grade II Injury (Partial Tear): Macroscopically, some
continuity of fibres is maintained at the injury site
Traumatic muscle injuries, varying on the directions and (Table 1). Based on injury severity, less than one-third of
angle movements of forces applied, may be broadly muscle fibres are torn in low-grade injuries, from one-third
divided into contusions, strains or lacerations [22, 30]. to two-thirds in moderate ones, and more than two-thirds in
Contusions and strains account for more than 90 % of all high-grade injuries [11]. Muscle strength and high-speed/
sports-related skeletal muscle injuries, while lacerations are high-resistance athletic activities are usually impaired, with
relatively uncommon [30]. Contusions are frequent in marked loss of muscle function (ability to contract). At US,
contact or combat sports as a result of large compressive muscle fibres are discontinuous, the disruption site is hy-
forces applied directly on the muscle. Muscle strains, very pervascularized, and echogenicity is altered in and around
common in sprinters and jumpers [13, 22], usually arise the lesion [37], with no perimysial striation of the area
from an indirect insult, from application of excessive ten- adjacent to the MTJ [35]. Intramuscular fluid and a sur-
sile forces. In acute injuries, rectus femoris, hamstrings and rounding hyperechoic halo may also be appreciated
gastrocnemius [13, 22] are the most commonly injured [35, 37]. At MRI, appearance varies with both the acuity
muscles, usually at the MTJ [42]. Passive injuries are and the severity of the partial tear, changes are time-
secondary to tensile overstretch of the muscle in the dependent, and oedema and haemorrhage of the muscle or
absence of contraction, whereas active injuries usually MTJ may extend along the fascial planes, between muscle
result from eccentric muscle actions [21]. Muscle lacera- groups (Fig. 2a, b). Fibres, disorganized and thin are sur-
tions, rare in athletes, arise from direct blunt trauma to the rounded by haematoma and perifascial fluid [20, 43]. In
epimysium and underlying muscles [35]. general, MRI findings, particularly the length and cross-
In Grade I injury (Strain) (Table 1), the tear involves a sectional area of injury, may be used as an estimate of time
few muscle fibres, swelling and discomfort are complained, for rehabilitation [7, 14, 48] and can sometimes be
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Fig. 2 a, b Grade II tear of BF (Sag STIR) oedema and haemorrhage of the muscle or MTJ extending to the fascial planes of biceps femoris. In
the traditional classification system, this would have been a grade II injury. In the newly proposed system, this is a 2.B.b injury
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Fig. 3 a–d Grade III tear (Cor T1 and STIR and axial STIR showing oedema with complete interruption of muscle fibres and associated
BF muscle and avulsed MTJ from fibula head) of BF with complete haematoma
avulsion of musculotendinous junction and associated large amount of
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New concepts
the disruption sites (\24 h after disruption), whereas an In early or low-grade injuries, the focal muscle swelling on
inflammatory reaction is evident later, usually after 2 days US is secondary to oedema and haematoma. A muscle
[46]. Laying down of fibrous tissue and scar tissue starts haematoma appears as a hypoechoic fluid collection and
after 7 days [22, 41] and becomes visible as early as may contain debris [37] (Fig. 5). At times, an intramus-
14 days following the initial insult [25]. After 2 weeks, the cular haematoma is assessed at MRI between 2 days and
muscle has regained over 90 % of its function. However, 5 months from injury [17, 18]. T1- and T2-weighted ima-
the presence of retracted fibrous tissue alters the muscle’s ges are hyperintense if methemoglobin levels are increased
optimal length, may impair maximal contraction and pre- [15], while the serous-appearing fluid may produce an
dispose to further injuries [32]. In muscle–tendon complex intramuscular pseudocyst [26]. In patients with an equiv-
of the long head of biceps femoris, a clinical assessment of ocal or remote history of trauma, imaging is advised, as it
the point of highest pain on palpation, within 3 weeks from may help to better define a soft tissue mass if a neoplastic
the injury, is predictive of recovery time [4]. Since palpa- mass is clinically suspected [29, 43, 45, 50, 51]. Pseu-
tion alone cannot distinguish between tissues involved, dotumors within the rectus femoris, semimembranosus or
MRI findings showing the involvement of the free proximal semitendinosus may occur after a muscle strain. In patients
tendon have been associated with longer time to return to with uncertain clinical and imaging features, the
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administration of contrast material may help to differenti- differentiated: in the first instance, given the action of the
ate a simple haematoma from a haemorrhagic neoplasm. If intact muscle fascia which compresses the intramuscular
the lesion shows no enhancement, the diagnosis of neo- vessels, the increased compartment pressure reduces
plasm is improbable; conversely, an enhancing nodule bleeding and limits the size of the haematoma; in the
induces greater suspicion of neoplasm than haematoma second instance, when the fascia surrounding the muscle is
[38]. torn, blood spreads into the interstitial and interfascial
spaces, with no significant increase in pressure within the
muscle [31]. An inevitable weakness of this article is that it
Imaging assessment nomenclature (Table 2) reports an evidence-based but nevertheless subjective
opinion. Prior to its general acceptance, this system must
The advent of new technological advances in imaging has be assessed in several different muscles, and well planned
improved both diagnosis and prognosis of musculoskeletal and powered clinical investigations should be performed to
disorders. However, the diagnosis of muscle strain injury is determine whether the classification proposed in this article
most often a clinical one. US is increasingly used because can be applied in clinical practice and be of greater value
of its lower costs and portability, particularly in experi- than the present system.
enced hands [8]. MRI, very sensitive for contrast resolu-
tion, anatomic detail, and reproducibility [47] may be
helpful when patient’s symptoms, physician’s findings and/ Conclusion
or US are discrepant [16, 30].
Anatomically, muscles have an origin, proximal and Clinical assessment, site of injury and pattern of the lesion
distal tendons, proximal and distal MTJs, one or more can all provide prognostic information regarding conva-
muscle bellies and an insertion. Since injuries may involve lescence and recovery time following both an acute and
each of the above observed sites, we propose to distinguish recurrent muscle strain injury [31]. We describe a com-
muscular, MTJ (proximal and distal) and tendon injuries prehensive system to classify all muscle injuries, on the
(proximal and distal). Considering the anatomy, muscular basis of exact anatomical site involved, and severity at
lesions can be further classified as intramuscular, myofas- imaging assessment (Tables 1, 2). We define muscular
cial (Fig. 5b), myofascial/perifascial, musculotendinous or injuries by site as proximal, middle and distal, as intra-
a combination. With regard to the site of injury, we classify muscular, myofascial, myofascial/perifascial, and muscu-
muscular injuries as proximal, middle and distal. The lotendinous. We propose a new terminology for muscle
severity of the muscular and musculotendinous injuries is injuries, a proposal of which will undergo appropriate
classified according to a 3-grade classification system from validation and reliability studies and will also be used for
MRI and US [35]. prognostic studies.
Some studies suggest that the extent of the muscle injury
is a prognostic factor for recovery time [12, 48], and
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