Strains

Question 1

Health History Questions

Answer 1

1. What is your overall health history?
2. Has this muscle been injured before?
3. When did the injury occur?
4. Do you know the mechanism of injury?
5. Did you hear any noise or feel any sensation at the time of the injury?
6. What was done at the time of the injury?
7. Were you able to continue activity after the strain?
8. Have you seen any other health care practitioner for this injury?
9. Are you taking any medication for the strain?
10. Were there any complications?
11. Are you using any crutches or supports for the affected limb
12. What symptoms are you currently experiencing?
13. What aggravates or relieves the pain?
14. Is there any swelling or edema present local or distal to the injury?
15. If the strain was in a weight bearing limb, did the limb “give way” at the time of injury?
16. What activities are difficult or painful to complete?
17. What are your ADL’s?

Question 2

Contraindications

Answer 2

1. In the acute stage, testing of a Grade 2 or 3 strain other than pain-free
2. AF ROM is CI’d to prevent further tissue damage
3. Avoid removing protective muscle splinting of acute strains
4. Distal circulation techniques are CI’d in the acute and early subacute stages to avoid increasing congestion through the injury site
5. With Grade 3 strains that are casted, hot hydrotherapy applications should not be applied to the tissue immediately proximal to the cast to prevent congestion
6. Frictions are CI’d if the client is taking anti-inflammatories or blood thinners

Question 3

Treatment
Acute

Answer 3

1. The muscle is treated with RICE
2. Positioning depends on the location of the strained musculotendinous unit and the client’s comfort
3. Hydrotherapy is cold
   Reduce edema on the injured area
4. Maintain local circulation proximal to the injury
5. Reduce but do not remove protective muscle spasm
6. On site work is CI’d
7. Distal muscle squeezing and stroking is indicated
8. Maintain ROM with mid-range PR ROM on the proximal joints

Question 4

Treatment
Early Subacute

Answer 4

1. Hydrotherapy applications on site are cold/warm contrast
2. Diaphragmatic breathing is encouraged
3. Reduce edema proximal to the injured limb
4. Maintain local circulation proximal to the injury
5. Reduce spasm
6. Reduce TPs without disturbing the injury site
7. Do not disturb a hematoma
8. Maintain ROM with mid-range PR ROM to the onset of pain only on the proximal and distal joints

Question 5

Treatment
Late Subacute

Answer 5

1. Hydrotherapy applications are cold/hot contrast local to the injury
2. Reduce any remaining edema
3. Reduce HT and TPs in the proximal limb
4. Reduce adhesions around and on-site to the injury
5. After adhesions have been frictioned, stretch and ice is applied
   Joint play to the proximal and distal joints are performed
6. Increase ROM with mid to full range PR ROM to the onset of pain
7. Increase local circulation

Question 6

Treatment
Chronic

Answer 6

1. Hydrotherapy proximal to the strain and on the lesion itself includes deep, moist heat
2. Reduce any chronic edema
3. Reduce HT and TPs
4. Reduce adhesions
5. Joint play to proximal and distal joints
6. Restore ROM with PR ROM on proximal, distal and affected joints
7. Increase local circulation proximal and distally to the injury
8. Treat the scar if the muscle was surgically repaired

Question 7

Self-Care

Answer 7

1. Educate client on hydrotherapy appropriate for stage of healing
2. Self-massage to the affected muscles in the late subacute and chronic stages
3. Maintain strength of the muscles with pain-free exercises
4. Stretch shortened muscles
5. Gradually increase strength in the late subacute and chronic stages
6. Encourage activity that caused the injury on a gradual basis to avoid re injury

Question 8

Grade of Strain

Answer 8

1. Grade 1 Strain:

• A minor stretch and tear to the musculotendinous unit
• Minimal loss of strength
  The person can continue with the activity with mild discomfort

2. Grade 2 Strain:

• Tearing of the musculotendinous fibres occurs
• The degree of tear is quite variable from several fibres to the majority of the fibres
• There may be a snapping sensation or sound at the time of injury
• A palpable gap may appear at the injury site
• The person has difficulty continuing the activity due to pain and muscle weakness

3. Grade 3 Strain:

• A complete rupture of the musculotendinous unit or an avulsion fracture as the body attachment of the tendon is torn off while the unit remains intact
• There is a snapping sensation or sound at the time of rupture
• A palpable and often visible gap appears at the injury site
• The muscle often shortens and bunches up
• The person cannot continue the activity due to significant pain and muscle weakness

Question 9

Commonly Strained Muscles

Answer 9

1.Hamstrings-middle of the muscle belly or at the musculotendinous junction close to the ischial tuberosity

2. Quadriceps-especially rectus femoris
3. Gastrocnemius-usually at the musculotendinous junction or at the attachment of the Achilles tendon to the calcaneus
4. Adductors of the hip
5. Gracilis
6. Erector spinae
7. Rotator cuff-most frequently supraspinatus
8. Pectoralis major-at the insertion of the humerus
9. Long head of biceps brachii
10. Muscles of the neck-during whiplash

Question 10

Symptom Picture-Acute

Answer 10

• Grade 1:

1. There is minor discomfort local to the injury site on activity that contracts or stretches the muscle
2. Local edema, heat, bruising are minimal or not present
3. Tenderness at the lesion site
4. Little or no loss of strength or ROM
5. Client can continue activity

*Grade 2:

1. Tearing of several or many fibres of the musculotendinous unit
2. Snapping noise or sensation at the time of injury
3. Moderate local edema, heat, hematoma and bruising
4. A gap may be palpated in the tissue
5. Moderate tenderness at the lesion site
6. Moderate pain with activities that contract or stretch the musculotendinous unit
7. Moderate loss of strength and ROM
8. Difficulty continuing activity due to pain

• Grade 3:

1. Complete rupture of the muscle or avulsion fracture of the tendinous attachment
2. Snapping noise or sensation at the time of injury
3. Marked local edema, heat, hematoma and bruising
4. Severe pain at the lesion site
5. Immediate loss of strength and ROM
6. Client cannot continue activity

*** Grade 2 & 3:

1. Bruising is red, black and blue
2. Hematoma present at the lesion site
3. Decreased ROM of the joints crossed by the affected muscle as protective muscle spasm limits movement
4. There is little, moderate or severe loss of function of the affected limb
5. The muscle may be bandaged to prevent further injury
6. With a Grade 3 strain of the lower limb, the ruptured muscle is usually surgically repaired

Question 11

Symptom Picture-Early Subacute

Answer 11

• Grade 1:

Little or no pain and reduced strength

• Grade 2:

1. Pain and moderately reduced strength
2. Bruising is black and blue with a hematoma
3. Alteration in the contour of the muscle

• Grade 3:

1. Pain and markedly reduced strength with AR strength testing
2. Bruising is black and blue with a hematoma
3. There is agap in the tissue and the muscle may bunch up
4. Pain, edema and inflammation are still present
5. Adhesions are developing around the injury site
6. Slow healing of tendons due to hypovascularity
7. Protective muscle spasm diminishes
8. TPs occur in the affected muscle, its synergists and its antagonists
9. ROM is reduced

Question 12

Symptom Picture-Late Subacute

Answer 12

1. With a Grade 2 or 3 strain, bruising is yellow, green and brown.
2. Hematoma diminishes and a gap is still palpable in the tissue
3. Pain, edema and inflammation are diminishing
4. Protective muscle spasm is replaced by increased tone in the affected muscle, its synergists and its antagonists
5. TPs occur in the affected muscle and in compensatory muscles
6. Adhesions are maturing around the injury
7. ROM is reduced

Question 13

Symptom Picture-Chronic

Answer 13

1. Bruising is gone
2. HT and TPs are present in the affected muscle and in any compensating structures
3. Adhesions have matured around the injury
4. Tissue may be cool due to ischemia
5. Discomfort local to the lesion site only if the muscle is stretched
6. With Grade 2 and 3 strains, the full ROM of the joint crossed by the affected muscle may be reduced
7. If the ruptured muscle was not surgically repaired, there is reduced strength
8. Reduced strength of the affected musculotendinous unit and possible disuse atrophy

Question 14

Observations
Acute

Answer 14

1. Antalgic gait if the strain is in the lower limb
2. The affected muscle may be supported by taping, elastic bandages or splints
3. Antalgic posture
4. The client may have a pained facial expression
5. Edema is present at the lesion site
6. With a Grade 2 or 3 strain a hematoma is present at the lesion site
7. Some redness may be present local to the injury
8. Red, black or purple bruising may be visible over the injury site
9. With Grade 2 strains, a gap in the tissue or an alteration in the contour of the muscle may be noted
10. With a Grade 3 strain, there is a visible gap at the lesion site and the muscle may bunch up

Question 15

Observations
Early & Late Subacute

Answer 15

1. Antalgic gait if the strain is in the lower limb
2. The affected muscle may be supported by taping, elastic bandages or splints
3. Antalgic posture

4 .Edema diminishes both on site and distally

5. With a Grade 2 or 3 strain, a hematoma is resolving at the lesion site
6. Bruising over the injury site changes from purple and black in early subacute to brown, yellow and green in late subacute and then disappears
7. With Grade 2 strains, an alteration in the contour of the muscle is still apparent
8. With a Grade 3 strain, there is still a visible gap at the lesion site and the muscle may remain bunched up if it was not surgically repaired

Question 16

Observations
Chronic

Answer 16

1. Habituated antalgic gait and posture may be observed with a strain in a weight bearing limb
2. With a Grade 2 or 3 strain, the affected muscle may be supported during activities that stress the tissue
3. There may be some residual chronic edema present local to the injury site with repeated strains of the same muscle
4. With a Grade 2 strain, an alteration in the contour of the muscle is still present
5. With a Grade 3 strain, the visible gap at the lesion site remains and the muscle may be bunched up if it was not surgically repaired

Question 17

Palpation

Answer 17

*Acute:
1. Heat present over the injured muscle and possibly surrounding tissue

2. Tenderness local to the lesion site and refers into the nearby tissue
3. Texture of the edema is firm. With a Grade 2 or 3 strain a hematoma may be palpable
4. A palpable gap or alteration in the muscle’s contour is present with a
   Grade 2 or 3 strain
5. Protective muscle spasm is present in the affected muscle, the synergists and the antagonists

• Early & Late Subacute:

1. Temperature over the injury site diminishes from the early to late subacute stage
2. Tenderness present local to the injury
3. Texture of the edema is less firm
4. Adhesions are present as healing progresses from the early to late subacute stages, hematoma diminishes
5. A palpable gap or alteration in the muscle’s contour or fascial distortions may be present with a Grade 2 or 3 strain
6. Tone of the affected muscle and the synergists and antagonists changes from spasm to tightness and HT
7. TPs are present in these muscles

• Chronic:

1. Injury site may be cool due to ischemia
2. Point tenderness occurs local to the lesion site
3. Adhesions are present local to the injury site
4. A palpable gap may be present with a Grade 2 or 3 strain
5. HT and TPs may be present local to the injured musculotendinous unit and in the compensating muscles

Question 18

Testing
Acute

Answer 18

1. AF ROM of the joints crossed by the affected muscle is reduced. The degree of limitation increases with the severity of the injury
2. Grade 1 strain-mild local pain when the muscle is contracted or stretched and ROM is normal or near normal
3. Grade 2 strain-pain is moderate and only mid ranges of movement are possible
4. Grade 3-pain is severe and there is loss of function
5. Other testing is CI’d in the acute stage if a Grade 2 or 3 strain is suspected
   PR ROM for a Grade 1 strain is performed on the cardinal planes of motion with the range that stretches the affected muscle tested last
6. AR isometric testing of the affected muscle with a Grade 1 reveals minor to insignificant loss of strength and some discomfort

Question 19

Testing
Early & Late Subacute

Answer 19

1. AF ROM of the joints crossed by the affected muscle is reduced. The degree of limitation increases with the severity of the injury
2. PR ROM is performed on the cardinal planes of motion with the range that stretches the affected muscle tested last
3. AR isometric testing of the affected muscle is the differential assessment for a strain. To avoid further injury, it is important that the strength of the client’s contraction is gradually increased to the maximum strength. The contraction is increased to the onset of pain only
4. The severity of the strain is graded in the following manner:

a. Grade 1 reveals minor to insignificant loss of strength and some discomfort

b. Grade 2 reveals moderate loss of strength and pain
c. Grade 3 reveals significant loss of strength and pain

Question 20

Testing
Chronic

Answer 20

1. AF ROM of joints crossed by the affected muscle may be limited by any remaining pain at the end ranges of motion
2. PR ROM is performed on the cardinal planes of motion, with the range that stretches the affected muscle tested last
3. AR strength testing of the affected muscle may reveal decreased muscle strength, especially with disuse atrophy or Grade 3 strains