Keywords
skeletal muscle/injuries - thigh - hematoma - drainage
Introduction
Muscle injuries are the most frequent conditions in athletes from several modalities,
with an incidence rate of up to 39.2%.[1]
This is a very relevant subject due to its high incidence, high treatment costs and
negative impact over an athlete's career. Several therapeutic proposals tried to minimize
the harmful effects of a muscle injury. Among them, therapy with platelet-rich plasma
appears promising. However, some studies failed to show a decrease in the time required
to return to sport.[2] More traditional approaches, such as nonsteroidal anti-inflammatory drugs (NSAIDs)
or steroids injections, did not demonstrate benefits in improving muscle healing or
reducing the time for return to sport.[3] Accordingly, a muscle hematoma puncture could represent an option in the treatment
of extensive muscle injuries.
Muscle hematomas are blood collections resulting from contusions or indirect traumas
and can be intra- or intermuscular. These muscle collections are consistently present
in partial and (sub)total lesions (Munich Consensus Statement) and can be aspirated
by puncture in their chronic phase.[4] However, there is no consensus that hematoma puncture must be performed during the
acute phase. It is hypothesized that this procedure could speed up tissue healing
and, consequently, allow a quicker return to sport. This reasoning is grounded in
the physiopathological foundations of muscle injury, in which the phases of degeneration,
regeneration and cellular remodeling are present.[5]
According to some studies, the degeneration period is marked by the accumulation of
inflammatory cells and proteins (chemokines, cytokines and growth factors) involved
in absorbing the muscle hematoma.[6]
[7] In the presence of an extensive hematoma, there would be a delay in muscle healing
resulting from a prolonged degeneration phase.[8] Moreover, it is believed that the hematoma would also favor cicatricial, fibrous
tissue formation, which would be inadequate for the proper function of the injured
muscle.[9]
Therefore, the present study was based upon the need to evaluate the effects of puncturing
a muscle hematoma resulting from acute lesions on the recovery time of amateur and
professional athletes.
Material and Methods
Study Type
Clinical intervention, pilot, longitudinal, controlled, and non-randomized study approved
by the Ethics and Research Committee of Universidade Federal de São Paulo (Unifesp,
in the Portuguese acronym).
Data Collection
Data were collected between 2014 and 2016, at the Sports Medicine outpatient facility
(Ambulatório de Medicina Esportiva) from Unifesp and at the Medical Department of
Clube Sociedade Esportiva Palmeiras, after obtaining a signed informed consent from
the participants. Data were obtained during medical care, and some information, such
as the number of physical therapy sessions, date of return to sport (normal training
and/or competitions), and lesion recurrence, were obtained by telephone. Lesions were
considered as recurrences if they happened up to 30 days after medical discharge.
Sample
Twenty amateur and professional athletes from several modalities participated in the
study. Their ages ranged from 18 to 68 years-old among men, and from 39 to 48 years-old
among women, with an average of 34.70 ± 12.79 years-old. Five participants (25%) were
professional athletes and 15 (75%) were amateur athletes, with 17 (85%) men and 3
(15%) women.
Nine (45%) individuals were submitted to muscle hematoma puncture (intervention group)
and physical therapy. The remaining participants (control group) did not comply with
the muscle puncture and were submitted only to physical therapy. The physical therapy
followed the conventional muscular rehabilitation protocol. Professional athletes
attended an average of two physical therapy sessions per day, totaling 10 sessions
per week. Amateur athletes attended an average of three physical therapy sessions
per week. Each physical therapy session lasted about 90 minutes in both groups. Strengthening
trainings were also considered as rehabilitation sessions and were performed as prescribed
by the physical therapist at the late recovery phases. During physical therapy sessions,
performed by a sports physical therapist, electrothermal phototherapy and kinesiotherapy
were done according to the individual evolution of each athlete. Initially, the rehabilitation
approach emphasized pain relief, followed by slow and gradual progression to isometric,
isotonic exercises, functional trainings and proprioceptive routines for lower limbs.
Since the athletes must agree with the muscle hematoma puncture, participants allocation
in each group occurred based on consent with the procedure. In the professional athlete
group, 3 (15%) patients were submitted to the puncture, and in the amateur group,
6 (30%). Most (55%) athletes played soccer and were male.
The inclusion criteria for the clinical study were: healthy people from both genders
aged from 18 to 70 years-old, with acute thigh lesions (up to 3 weeks) associated
with a hematoma (essentially Type 3 B and 4 lesions according to the Munich Consensus
Statement).
The exclusion criteria were: smoker athletes, those with systemic diseases, those
in regular use of medications such as corticosteroids, antiinflammatory and antifibrotic
agents and patients who abandoned the study.[3]
[8]
[10]
Participants were divided in an intervention group (hematoma puncture associated with
physical therapy) and a control group (physical therapy) and subdivided according
to their sport activity level as professional or amateur athletes. Professional athletes
were those in high-performance sports (official competitions) or receiving some type
of financial compensation to play.
Athletes' lesions were classified according to a superimposition of clinical and ultrasonographic
criteria. Initially, athletes were submitted to a clinical evaluation (history taking
and physical exam) by a physician specialized in sports medicine who observed one
or more of the following clinical parameters: severe pain at the moment of the lesion
(with an analog visual scale for pain); functional inability (muscle contraction inability);
pain when stretching the involved muscles (passive and active stretching); and muscle
alteration at palpation during physical exam.[8]
[11]
[12] Immediately after history taking and physical exam, if the clinical suspicion was
consistent with the diagnostic hypothesis of acute muscle injury, the patient was
submitted to an ultrasound. Ultrasound examinations identifying complete or subtotal
muscle injuries, tendinous avulsions or muscle stump retractions were classified as
structural, type 4 lesions (Munich Classification). Lesions without the sonographic
findings mentioned above, but presenting with measurable hematomas and muscle injuries,
were classified as moderate partial (type 3 B lesions according to the Munich's Classification).
Exams were performed immediately after the medical visit by radiologists with expertise
in the musculoskeletal apparatus; an ultrasound-guided muscle hematoma puncture was
performed by the sports physician who first cared for the athlete. The ultrasound
equipment used for the diagnosis and to orient puncture procedures was the GE Logiq
P6 (GE Healthcare, Chicago, IL, USA). Athletes submitted to the puncture fulfilled
the inclusion and exclusion criteria and signed the informed consent form for the
procedure.
After puncture, the athletes were asked to rest for 2 days and to follow the Price
protocol (protection, rest, limb elevation and ice) 3 times a day, for 7 days.
Discharge occurred after a cooperative evaluation by the sports medicine and physical
therapy teams. To be discharged, the patients had to perform functional exercises
(analogous to the sports they used to play) with no pain or limitations of the knee
and hip range of motion. The ultrasound performed at this moment should demonstrate
the healed muscle lesion. To safely corroborate the medical discharge, the physical
therapist proceeded to a functional test (Hop Test), in which a contralateral difference
of less than 10% should be present.[13]
[14] The successful return to sport was defined as the unrestricted participation in
trainings (like those performed prior to the lesion) or competitions, with no lesions
at the first 30 days postdischarge.
Data Analysis
Data was presented as mean ± standard deviation. Possible differences in the variables
collected from both groups (intervention and control) were analyzed at the GraphPad
Prism 6 software (GraphPad Software, San Diego, CA, USA) through a non-parametric
Mann-Whitney test for unpaired samples. Significance level was 95% (p < 0.05).
Results
Muscle injuries in the posterior region occurred in 13 cases (65%); in the anterior
region, there were 5 cases (25%) and in the adductor region, 2 cases (10%) ([Fig. 1]).
Fig. 1 Thigh muscles evaluated at the study.
The average size of the hematomas was 9.17 ± 7.89 mL, ranging from 2.00 to 28.00 mL.
In the intervention group, the average size of muscle hematomas was 12.06 ± 7.35 mL,
ranging from 4.70 to 27.00 mL. The average aspirated volume from hematomas was 5.33 ± 3.35
mL, ranging from 1.00 to 12.00 mL ([Table 1]).
Table 1
|
Athlete
|
Gender/Age (years-old)
|
Sport/Performance level
|
Affected muscle
|
Lesion degree /puncture
|
Days for return
|
|
1
|
M/30
|
Soccer/Professional
|
Adductor Longus
|
3/yes
|
15
|
|
2
|
M/52
|
Soccer/Amateur
|
Semimembranosus
|
3/yes
|
75
|
|
3
|
M/22
|
Soccer/Professional
|
Rectus Femoris
|
3/yes
|
35
|
|
4
|
M/18
|
Soccer/Amateur
|
Adductor Longus
|
3/yes
|
15
|
|
5
|
M/18
|
Soccer/Amateur
|
Biceps Femoris
|
3/yes
|
30
|
|
6
|
M/26
|
Rugby/Professional
|
Biceps Femoris
|
3/yes
|
62
|
|
7
|
F/39
|
Soccer/Amateur
|
Semitendinosus
|
4/yes
|
40
|
|
8
|
M/50
|
Soccer/Amateur
|
Rectus Femoris
|
4/yes
|
80
|
|
9
|
M/28
|
Handball/Amateur
|
Semimembranosus
|
4/yes
|
85
|
|
10
|
M/68
|
Table tennis/Amateur
|
Semitendinosus
|
3/no
|
30
|
|
11
|
F/41
|
Classical ballet/Professional
|
Semimembranosus
|
4/no
|
120
|
|
12
|
M/45
|
Street race/Amateur
|
Biceps Femoris
|
4/no
|
180
|
|
13
|
M/27
|
Soccer/Amateur
|
Biceps Femoris
|
3/no
|
90
|
|
14
|
M/25
|
Soccer/Amateur
|
Rectus Femoris
|
3/no
|
70
|
|
15
|
M/36
|
Street race/Amateur
|
Biceps Femoris
|
3/no
|
78
|
|
16
|
M/33
|
Soccer/Amateur
|
Rectus Femoris
|
4/no
|
120
|
|
17
|
M/32
|
Soccer/Amateur
|
Semitendinosus
|
3/no
|
45
|
|
18
|
M/29
|
Taekwondo/Amateur
|
Biceps Femoris
|
3/no
|
180
|
|
19
|
M/25
|
Indoor soccer/Professional
|
Rectus Femoris
|
3/no
|
60
|
|
20
|
F/48
|
Pole Dance/Amateur
|
Semimembranosus
|
3/no
|
150
|
The mean time to return to sport in the intervention group was 48.50 ± 27.50 days,
ranging from 15 to 85 days; in the control group, the mean time was 102.09 ± 52.02
days, ranging from 30 to 180 (p = 0.022) ([Fig. 2]).
Fig. 2 Mean time in days to return to sport in the intervention group (Yes) and in the control
group (No). The Mann-Whitney test was performed, and a significant difference was
noted in the intervention group with p = 0.022(*).
The 6 amateur athletes submitted to hematoma puncture (40% of the amateur athletes)
performed, on average, 12.50 ± 4.76 physical therapy sessions and returned to sport
in an average time of 54.16 ± 29.56 days. Patients who were not submitted to puncture
performed, on average, 28.66 ± 16.02 physical therapy sessions and returned to sport
in an average time of 104.77 ± 55.79 days.
On the other hand, professional athletes submitted to puncture performed, on average,
38.33 ± 18.77 physical therapy sessions and returned to sport in an average time of
37.83 ± 23.58 days. However, those who were not submitted to hematoma puncture performed,
on average, 40.00 ± 11.31 physical therapy sessions and returned to sport in an average
time of 90.00 ± 42.42 days ([Fig. 3]). The only complication observed was the de novo formation of a hematoma in one
of the athletes submitted to puncture. In this case, recovery took 80 days (above
the average time observed in the intervention group), but the athlete had no other
complications or lesion recurrence after medical discharge. Moreover, one weightlifting
athlete was excluded from the study after deciding to abandon the sport and discontinue
the treatment.
Fig. 3 Amateur (left) and professional athletes (right) groups. The intervention is evaluated
among amateur and professional athletes and confronted with the control group through
the following variables: average number of physical therapy sessions and mean time,
in days, for the return to sport.
Discussion
In sports such as soccer, thigh lesions represent up to 30% of the musculoskeletal
complaints.[15]
[16] Most athletes from the present study were male and played soccer ([Table 1]). Moreover, the incidence of lesions in the posterior aspect of the thigh was higher,
a finding consistent with the international literature.[11]
[17]
A recently published meta-analysis showed that the risk of thigh lesion development
was high in athletes with a history de previous ischiotibial injuries, increased age
and higher quadriceps peak torque.[18] Other associated risk factors, such as inadequate flexibility and muscular balance,
could also contribute to these lesions.[19]
[20] Regarding biomechanical aspects, the higher incidence of lesions in the posterior
thigh could also be influenced by the biarticular muscles from these region. Therefore,
rapid contraction movements could predispose them to lesion.[21]
[22]
[23]
Some supplementary imaging methods are used to help diagnosing muscle injuries and
identifying hematomas. Musculoskeletal ultrasound has an important role, since it
estimates the prognosis through the complete evaluation of the lesion (extension,
hematoma formation, dynamic stability of the muscle stumps and fibrosis resulting
from muscle healing).[24]
In addition, ultrasound use to guide muscle hematoma puncture procedures is also described.
It is believed that extensive hematomas on lesion site would make proper healing of
the affected tissue difficult.[25]
[26] There is even the recommendation to perform an ultrasound 1 week after the lesion,
since the hematoma could not be easily aspirated before such period.[4]
[12]
[27]
Regarding complications resulting from hematoma puncture, similarly to what was found
in this work, the rate of severe complications of ultrasound-guided punctures is low.[26]
The amateur athletes group treated only with physical therapy presented a longer average
period, of 104.7 days, to return to sport. This can be partially justified by the
lower commitment of amateur athletes with the proposed treatment. Moreover, the three
amateur athletes, even after cleared for physical activities, were afraid to return
to sport and chose to perform more physical therapy sessions. These factors certainly
influenced to increase the time to return to sport observed in the amateur group compared
with the professional group.
On the other hand, amateur athletes submitted to muscle hematoma puncture performed
a lower number of physical therapy sessions (on average, 12.50 versus 28.60 days)
and their returned to sports was quicker. The average time to return to sport was
of 54.16 days and it represented about half the time from the control group. These
results favored hematomas puncture on this group.
A few papers in the literature state the time to return to sport in amateur athletes
with more severe muscle injuries. The complexity of research in this group probably
results from the longer period required for rehabilitation, the need of serial medical
follow-up and the difficulty controlling several variables, such as physical therapy.
A group of amateur athletes with more severe muscle injuries was studied, and, at
the end of the research, 4 athletes presented an average time to return to sport of
67 weeks, ranging from 40 to 104.[28] This period is considerably higher than the average observed in the present study,
and it reflects the heterogenous evolution of the different injury types according
to the athlete's age, the size of the lesion, its location (more proximal), the affected
thigh region, the lesion mechanism (stretching or running) and also the criteria used
to define the return to sport.[28]
[29]
Regarding professional athletes, there is enough information in the medical literature
about muscle injuries, especially in the posterior thigh of soccer players. However,
there is a similar difficulty in controlling the several variables involved in the
study of the muscle injury, and there are few publications with a high scientific
evidence level about the time to return to sport. The quicker return to sport in this
group is probably influenced by the higher commitment of the athletes and the higher
number of physical therapy sessions. However, despite such factors, muscle hematoma
puncture also reduced the time to return to sport in the professional athletes' group
of this work.
A recently published study revealed the mean time to return to sport of 37.90 ± 24.00
days in moderate lesions at the anterior thigh.[30] This published data is analogous to the results observed in our study, with the
case of a professional soccer player with a similar injury at the anterior thigh that
returned to sport in 35 days after hematoma puncture. The similar time probably results
from the fact that muscle puncture is already used in high-performance soccer players
although its efficacy lacks scientific proof.
In addition to the possible limitations already mentioned, this work presented some
other valuable questions. The studied population had few women. The age of the participants
was inhomogeneous, and it is possible that the evolution time of the muscle injuries
differs among sports. Moreover, there was a variation in the moment when the hematoma
punctures were performed, and we do not know for sure if there is a difference in
the muscle healing evolution at the early (3 days) or late (21 days) phase of hematoma
formation. Other limitations were the lack of randomization, and the small number
of participants in the sample. Therefore, further studies are required to corroborate
these findings and elucidate the questions raised.
Conclusions
This study demonstrated that a muscle hematoma puncture is effective in reducing the
time to return to sport in athletes with moderate, partial and (sub)total muscle injuries
associated to hematomas.
