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Terminology and classi1047297cation of muscle injuriesin sport a consensus statement

Hans-Wilhelm Mueller-Wohlfahrt1 Lutz Haensel1 Kai Mithoefer2 Jan Ekstrand3

Bryan English4 Steven McNally5 John Orchard67 C Niek van Dijk8 Gino M Kerkhoffs9

Patrick Schamasch10

Dieter Blottner11

Leif Swaerd12

Edwin Goedhart13

Peter Ueblacker1

Supplementary onlineappendices are publishedonline only To view these 1047297 lesplease visit the journal online(httpdxdoiorg101136 bjsports-2012-091448)

For numbered af 1047297liations seeend of article

Correspondence toDr Peter Ueblacker Center of

Orthopedics and SportsMedicine Munich and FootballClub FC Bayern MunichDienerstrasse 12 Munich80331 Germany peterueblackergmxnet

Accepted 5 September 2012

ABSTRACTObjective To provide a clear terminology andclassi 1047297cation of muscle injuries in order to facilitate

effective communication among medical practitioners anddevelopment of systematic treatment strategies

Methods Thirty native English-speaking scientists and

team doctors of national and 1047297rst division professionalsports teams were asked to complete a questionnaire onmuscle injuries to evaluate the currently used

terminology of athletic muscle injury In addition aconsensus meeting of international sports medicineexperts was established to develop practical andscienti 1047297c de 1047297nitions of muscle injuries as well as a new

and comprehensive classi 1047297cation system

Results The response rate of the survey was 63 Theresponses con 1047297rmed the marked variability in the use of

the terminology relating to muscle injury with the mostobvious inconsistencies for the term strain In theconsensus meeting practical and systematic terms were

de 1047297ned and established In addition a newcomprehensive classi 1047297cation system was developedwhich differentiates between four types functional muscle disorders (type 1 overexertion-related and type 2

neuromuscular muscle disorders) describing disorderswithout macroscopic evidence of 1047297bre tear and structural muscle injuries (type 3 partial tears and type 4 (sub)total tearstendinous avulsions) with macroscopic

evidence of 1047297bre tear that is structural damageSubclassi 1047297cations are presented for each type

Conclusions A consistent English terminology as well

as a comprehensive classi 1047297cation system for athleticmuscle injuries which is proven in the daily practice arepresented This will help to improve clarity of

communication for diagnostic and therapeutic purposesand can serve as the basis for future comparative studiesto address the continued lack of systematic information

on muscle injuries in the literatureWhat are the new things Consensus de 1047297nitions of the terminology which is used in the 1047297eld of muscle

injuries as well as a new comprehensive classi 1047297cationsystem which clearly de 1047297nes types of athletic muscleinjuries

Level of evidence Expert opinion Level V

INTRODUCTIONMuscle injuries are very common in sports They constitute 31 of all injuries in elite football(soccer)1 their high prevalence is well documentedin the international literature in both football2ndash7

and other sports Thigh muscle injuries presentthe most common diagnosis in track and 1047297eld

athletes (16)8ndash10 but have also been documentedin team sports like rugby (104)11 basketball(177)12 and American football (4622 prac-ticegames)13

The fact that a male elite-level soccer team witha squad of 25 players can expect about 15 muscleinjuries each season with a mean absence time of 223 days 148 missed training sessions and 37missed matches demonstrate their high relevancefor the athletes as well as for the clubs1 The rele-vance of muscle injuries is even more obvious if the frequency is compared to anterior cruciateligament-ruptures which occur in the same squadstatistically only 04 times per season14 Eachseason 37 of players miss training or competitiondue to muscle injuries1 with an average of 90 daysand 15 matches missed per club per season fromhamstring injuries alone15 Particularly in elite ath-letes where decisions regarding return to play andplayer availability have signi1047297cant 1047297nancial or stra-tegic consequences for the player and the teamthere is an enormous interest in optimising thediagnostic therapeutic and rehabilitation process

after muscle injuries to minimise the absence fromsport and to reduce recurrence rates

However little information is available in theinternational literature about muscle injury de1047297ni-tions and classi1047297cation systems Muscle strain pre-sents one of the most frequently used terms todescribe athletic muscle injury but this term isstill without clear de1047297nition and used with highvariability

Athletic muscle injuries present a heterogeneousgroup of muscle disorders which have traditionally been dif 1047297cult to de1047297ne and categorise Since musclesexist in many different sizes and shapes with acomplex functional and anatomical organisation16

development of a universally applicable terminology and classi1047297cation is challenging Muscles that arefrequently involved in injuries are often bi-articular17

or are those with a more complex architecture(eg adductor longus) undergo eccentric contractionand contain primarily fast-twitch type 2 muscle1047297bres18 19

In footballsoccer 92 affect the four majormuscle groups of the lower limbs hamstrings37 adductors 23 quadriceps 19 and calf muscles 131 As much as 96 of all muscle injur-ies in footballsoccer occur in non-contact situa-tions1 whereas contusions are more frequently

encountered in contact sports like rugby American football and ice hockey1 1 1 3 The fact

OPEN ACCESS

Br J Sports Med 201201ndash9 doi101136bjsports-2012-091448 1

Consensus statement

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Copyright Article author (or their employer) 2012 Produced by BMJ Publishing Group Ltd under licence

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that 16 of muscle injuries in elite footballsoccer arere-injuries and associated with 30 longer absence from compe-tition than the original injury 1 emphasises the critical import-ance of correct evaluation diagnosis and therapy of the indexmuscle disorder This concerted effort presents a challengingtask in light of the existing inconsistent terminology and classi-1047297cation of muscle injuries

Different classi1047297cation systems are published in the literature(table 1) but there is little consistency within studies and indaily practice20

Previous grading systems based upon clinical signs One of the morewidely used muscle injury grading systems was devised by OrsquoDonoghue This system utilises a classi1047297cation that is based oninjury severity related to the amount of tissue damage and asso-ciated functional loss It categorises muscle injuries into threegrades ranging from grade 1 with no appreciable tissue tear grade2 with tissue damage and reduced strength of the musculotendi-nous unit and grade 3 with complete tear of musculotendinous

unit and complete loss of function21

Ryan published a classi1047297ca-tion for quadriceps injuries which has been applied for othermuscles In this classi1047297cation grade 1 is a tear of a few muscle1047297bres with an intact fascia Grade 2 is a tear of a moderatenumber of 1047297bres with the fascia remaining intact A grade 3injury is a tear of many 1047297bres with a partial tear of the fascia anda grade 4 injury is a complete tear of the muscle and the fascia22

Previous grading systems based up imaging Takebayashi et al23 published in 1995 an ultrasound-based three-grade classi-1047297cation system ranging from a grade 1 injury with less than 5of the muscle involved grade 2 presenting a partial tear withmore than 5 of the muscle involved and up to grade 3 with acomplete tear Peetrons24 has recommended a similar gradingThe currently most widely used classi1047297cation is an MRI-basedgraduation de1047297ning four grades grade 0 with no pathological1047297ndings grade 1 with a muscle oedema only but withouttissue damage grade 2 as partial muscle tear and grade 3 with acomplete muscle tear25

The limitations of the previous grading systems are a lack of subclassi1047297cations within the grades or types with the conse-quence that injuries with a different aetiology treatmentpathway and different prognostic relevance are categorised inone group Some of the grading systems like the Takebayashiclassi1047297cation are relative and not consistently measurable Sofar no terminology or grading system (sub)classi1047297ed disorderswithout macroscopic evidence of structural damage eventhough a muscle injury study of the Union of European

Football Associations (UEFA) has emphasised their high clinicalrelevance in professional athletes26

The objective of our work is to present a more precise de1047297n-ition of the English muscle injury terminology to facilitatediagnostic therapeutic and scienti1047297c communication In add-ition a comprehensive and practical classi1047297cation system isdesigned to better re1047298ect the differentiated spectrum of muscleinjuries seen in athletes

METHODSTo evaluate the extent of the inconsistency and insuf 1047297ciency of the existing terminology of muscle injuries in the English litera-ture a questionnaire was sent to 30 native English-speakingsports medicine experts The recipients of the questionnaireswere invited based on their international scienti1047297c reputationand extensive expertise as team doctors of the national or 1047297rstdivision sports teams from the Great Britain Australia theUSA the FIFA UEFA and International Olympic CommitteeThe included experts were responsible for covering a variety of different sports with high muscle injury rates including foot-

ballsoccer rugby Australian football and cricket Quali1047297cationcriteria also included long-term experience with sports teamcoverage which limited the number of available experts sinceteam physicians often tend to change after short periods

The questionnaire (see online supplementary appendix 1)was divided into three categories 1047297rst the experts were askedto individually and subjectively describe their de1047297nitions of several common terms of muscle injuries and to indicate if theterm is a functional (non-structural) or a structural disorderinjuryIn the second category they were asked to associate synonymterms of muscle injuries such as strain and tear In the 1047297nal cat-egory the experts were asked to list given number of muscleinjury terms in the order their increasing injury severity

Following the completion of the survey the principal authors(H-WM-W LH and PU) organised a consensus meeting of 15international experts on the basic science of muscle injury aswell as sports medicine specialists involved in the daily care of premier professional sports and national teams The meetingwas endorsed by the International Olympic Committee (IOC)and the UEFA

A nominal group consensus model approach in which lsquoastructured meeting attempts to provide an orderly procedurefor obtaining qualitative information from target groups whoare most closely associated with a problem area rsquo27 was adoptedfor creating a consensus statement on terminology and classi1047297-cation of muscle disorders and injuries This model was success-fully applied before in other consensus statements28

During the 1-day meeting the authors performed a detailedreview of the structural and functional anatomy and physiology of

Table 1 Overview of previous muscle injury classification systems

OrsquoDonoghue 1962 Ryan 1969 ( initially for quadriceps)

Takebayashi 1995 Peetrons 2002

(Ultrasound-based ) Stoller 2007 (MRI-based)

Grade I No appreciable tissue tearing no loss

of function or strength only a

low-grade inflammatory response

Tear of a few muscle fibres fascia

remaining intact

No abnormalities or diffuse bleeding

withwithout focal fibre rupture less

than 5 of the muscle involved

MRI-negative=0 structural damage

Hyperintense oedema with or without

hemorrhage

Grade II Tissue damage strength of the

musculotendinous unit reduced

some residual function

Tear of a moderate number of fibres

fascia remaining intact

Partial rupture focal fibre rupture

more than 5 of the muscle involved

withwithout fascial injury

MRI-positive with tearing up to 50 of the

muscle fibres Possible hyperintense focal

defect and partial retraction of muscle fibres

Grade III Complete tear of musculotendinous

unit complete loss of function

Tear of many fibres with partial

tearing of the fascia

Complete muscle rupture with

retraction fascial injury

Muscle rupture=100 structural damage

Complete tearing with or without muscle

retraction

Grade IV X Complete tear of the muscle and

fascia of the musclendashtendon unit

X X

2 Br J Sports Med 201201ndash9 doi101136bjsports-2012-091448

Consensus statement




muscle tissue injury epidemiology and currently existing classi-1047297cation systems of athletic muscle injuries In addition theresults of the muscle terminology survey were presented and dis-cussed Based on the results of the survey muscle injury termin-ology was discussed and de1047297ned until a unanimous consensus of group was reached A new classi1047297cation system empirically based on the current knowledge about muscle injuries was dis-cussed compared with existing classi1047297cations reclassi1047297ed and

approved After the consensus meeting iterative draft consensusstatements on the de1047297nitions and the classi1047297cation system wereprepared and circulated to the members The 1047297nal statementwas approved by all coauthors of the consensus paper

RESULTS

Muscle injury survey Nineteen of the 30 questionnaires were returned for evaluation(63) (Eleven experts did not respond even after repeatedreminders) Even though this is a limited number theresponses demonstrated a marked variability in the de1047297nitionsfor hypertonus muscle hardening muscle strain muscle tear bundle

fascicle tear and laceration with the most obvious inconsisten-

cies for the term muscle strain (see online supplementary appen-dix 2) Relatively consistent responses were obtained for pulledmuscle (Laymanrsquos term) and laceration

Marked heterogeneity was also encountered regarding structuralversus functional (non-structural) muscle injuries Sixteen percentof expert responders considered strain a functional muscle injurywhereas 0 percent considered tear a functional injury (see onlinesupplementary appendix 3) Sixteen percent were undecided toboth terms 68 percent considered strain and 84 percent tear a

structural injury (see online supplementary appendix 3)This con1047297rms that even among sports experts considerable

inconsistency exists in the use of muscle injury terminology and that there is no clear de1047297nition differentiation and use of

functional and structural muscle disorders The results empha-

sised the need for a more uniform terminology and classi1047297ca-tion that re1047298ects both the functional and structural aspects of muscle injury

The following consensus statement on terminology and clas-si1047297cation of athletic muscle injuries is perhaps best referred toas a position statement based upon wide-ranging experienceobservation and opinion made by experts with diverse clinicaland academic backgrounds and expertise on these injuries

De 1047297nitionsmdashrecommended terminology

Functional muscle disorder

Acute indirect muscle disorder lsquo without macroscopicrsquo evidence (in MRI or ultrasound ( for limitations see Discussion)) of muscular tear

Often associated with circumscribed increase of muscle tone (muscle 1047297rmness) in varying dimensions and predisposing to tears Based onthe aetiology several subcategories of functional muscle disorders exist

Structural muscle injury Any acute indirect muscle injury lsquo with macroscopicrsquo evidence (in MRI or ultrasound ( for limitations see Discussion)) of muscle tear

Further de1047297nitions reached in the consensus conference arepresented in table 3 together with the classi1047297cation system

De 1047297nitionsmdashterminology without speci 1047297c recommendationMuscle injury terms with highly inconsistent answers in thesurvey were strain pulled-muscle hardening and hypertonus

Strain is a biomechanical term which is not de1047297ned and usedindiscriminately for anatomically and functionally different

muscle injuries Thus the use of this term cannot be recom-mended anymore

Pulled-muscle is a lay-term for different not de1047297ned types orgrades of muscle injuries and cannot be recommended as a sci-enti1047297c term

Hardening and hypertonus are also not well de1047297ned and shouldnot be used as scienti1047297c terminology

Classi 1047297cation systemThe structure of the comprehensive classi1047297cation system forathletic muscle injuries which was developed during the con-sensus meeting is demonstrated in table 2

A clear de1047297nition of each type of muscle injury a differenti-ation according to symptoms clinical signs location andimaging is presented in table 3

DISCUSSIONThe main goal of this article is to present a standardised ter-minology as well as a comprehensive classi1047297cation for athleticmuscle injuries which presents an important step towardsimproved communication and comparability Moreover thiswill facilitate the development of novel therapies systematicstudy and publication on muscle disorders

As stated by Jarvinen et al17 current treatment principles forskeletal muscle injury lack a 1047297rm scienti1047297c basis The 1047297rst treat-ment step is establishment of a precise diagnosis which is crucialfor a reliable prognosis However since injury de1047297nitions are notstandardised and guidelines are missing proper assessment of muscle injury and communication between practitioners areoften dif 1047297cult to achieve Resultant miscommunication willaffect progression through rehabilitation and return to play andcan be expected to affect recurrence and complication rateStudies in Australian Football League players have shown a highrecurrence rate of muscle injuries of 30629 Other studiesdemonstrated recurrence rates of 23 in rugby 30 and 16 in

footballsoccer1

One plausible cause for recurrent muscleinjures which are signi1047297cantly more severe than the 1047297rstinjury 1 30 is the premature return to full activity due to anunderestimated injury Healing of muscle and other soft tissue isa gradual process The connective (immature) tissue scar pro-duced at the injury site is the weakest point of the injured skel-etal muscle17 with full strength of the injured tissue takingtime to return depending on the size and localisation of theinjury ( Note mature scar is stiff or even stronger than healthy muscle) It appears plausible that athletes may be returning tosport before muscle healing is complete As Malliaropoulos

et al10 stated lsquoit is therefore crucial to establish valid criteria torecognise severity and avoid premature return to full activity andthe risk of reinjury rsquo

The presented muscle injury classi1047297cation is based on anextensive long-term experience and has been used successfully in the daily management of athletic muscle injuries The classi1047297-cation is empirically based and includes some new aspects of athletic muscle injuries that have not yet been described in theliterature speci1047297cally the highly relevant functional muscle injur-ies An advanced muscle injury classi1047297cation that distinguishesthese injuries as separate clinical entities has great relevance forthe successful management of the athlete with muscle injury and represents the basis for future comparative studies since sci-enti1047297c data are limited for muscle injury in general

Diagnosis of muscle injuries

In accordance with Askling et al31 32

and Jarvinen et al17

we rec-ommend to start with a precise history of the occurrence the


Consensus statement




Table 3 Comprehensive muscle injury classification type-specific definitions and clinical presentations

Type Classification Definition Symptoms Clinical signs Location UltrasoundMRI

1A Fatigue-induced

muscle disorder

Circumscribed longitudinal

increase of muscle tone

(muscle firmness) due to

overexertion change of

playing surface or change in

training patterns

Aching muscle firmness

Increasing with continued

activity Can provoke pain

at rest During or after

activity

Dull diffuse tolerable pain in

involved muscles

circumscribed increase of

tone Athlete reports of

lsquomuscle tightnessrsquo

Focal

involvement up

to entire length

of muscle

Negative

1B Delayed-onset

muscle soreness

(DOMS)

More generalised muscle pain

following unaccustomed

eccentric decelerationmovements

Acute inflammative pain

Pain at rest Hours after

activity

Oedematous swelling stiff

muscles Limited range of

motion of adjacent joints Painon isometric contraction

Therapeutic stretching leads to

relief

Mostly entire

muscle or

muscle group

Negative or oedema only

2A Spine-related

neuromuscular

muscle disorder




functional or structural spinal

lumbopelvical disorder



activity No pain at rest



Discrete oedema between

muscle and fascia Occasional

skin sensitivity defensive

reaction on muscle stretching

Pressure pain

Muscle bundle or

larger muscle

group along

entire length of

muscle


2B Muscle-related

neuromuscular

muscle disorder

Circumscribed

(spindle-shaped) area of

increased muscle tone

(muscle firmness) May result

from dysfunctional

neuromuscular control suchas reciprocal inhibition

Aching gradually

increasing muscle

firmness and tension

Cramp-like pain

Circumscribed



oedematous swelling


relief Pressure pain

Mostly along the

entire length of

the muscle belly


3A Minor partial

muscle tear

Tear with a maximum

diameter of less than muscle

fasciclebundle

Sharp needle-like or

stabbing pain at time of

injury Athlete often

experiences a lsquosnaprsquo

followed by a sudden

onset of localised pain

Well-defined localised pain

Probably palpable defect in

fibre structure within a firm

muscle band Stretch-induced

pain aggravation

Primarily

musclendashtendon

junction

Positive for fibre

disruption on high

resolution MRI

Intramuscular haematoma

3B Moderate partial

muscle tear

Tear with a diameter of

greater than a fasciclebundle

Stabbing sharp pain

often noticeable tearing at

time of injury Athlete

often experiences a lsquosnaprsquo



Possible fall of athlete


Palpable defect in muscle

structure often haematoma

fascial injury Stretch-induced

pain aggravation

Primarily

musclendashtendon

junction

Positive for significant

fibre disruption probably

including some retraction

With fascial injury and

intermuscular haematoma

4 (Sub)total muscleteartendinous

avulsion

Tear involving the subtotal complete muscle diameter

tendinous injury involving the

bonendashtendon junction

Dull pain at time of injuryNoticeable tearing Athlete




Often fall

Large defect in musclehaematoma palpable gap

haematoma muscle retraction

pain with movement loss of

function haematoma

Primarilymusclendashtendon

junction or

Bonendashtendon

junction

Subtotalcompletediscontinuity of muscle

tendon Possible wavy

tendon morphology and

retraction With fascial

injury and intermuscular

haematoma

Contusion Direct injury Direct muscle trauma caused

by blunt external force

Leading to diffuse or

circumscribed haematoma

within the muscle causing

pain and loss of motion

Dull pain at time of injury

possibly increasing due to

increasing haematoma

Athlete often reports

definite external

mechanism

Dull diffuse pain haematoma

pain on movement swelling

decreased range of motion

tenderness to palpation

depending on the severity of

impact Athlete may be able to

continue sport activity rather

than in indirect structural

injury

Any muscle

mostly vastus

intermedius and

rectus femoris

Diffuse or circumscribed

haematoma in varying

dimensions

Recommendations for (high-resolution) MRI high field strength (minimum 15 or 3 T) high spatial resolution (use of surface coils) limited field of view (according to clinicalexaminationultrasound) use of skin marker at centre of injury location and multiplanar slice orientation

Table 2 Classification of acute muscle disorders and injuries

A Indirect muscle disorderinjury Functional muscle disorder Type 1 Overexertion-related muscle disorder Type 1A Fatigue-induced muscle disorder

Type 1B Delayed-onset muscle soreness (DOMS)

Type 2 Neuromuscular muscle disorder Type 2A Spine-related neuromuscular Muscle disorder

Type 2B Muscle-related neuromuscular Muscle disorder

Structural m uscl e injury Typ e 3 Pa rt ia l musc le tear Ty pe 3 A Minor pa rt ial muscl e tear

Type 3B Moderate partial muscle tear

Type 4 (Sub)total tear Subtotal or complete muscle tear

Tendinous avulsion

B Direct muscle injury ContusionLaceration


Consensus statement




circumstances the symptoms previous problems followed by acareful clinical examination with inspection palpation of theinjured area comparison to the other side and testing of thefunction of the muscles Palpation serves to detect (more super1047297-cial and larger) tears perimuscular oedema and increased muscletone An early postinjury ultrasound between 2 and 48 h afterthe muscle trauma24 provides helpful information about any existing disturbance of the muscle structure particularly if there

is any haematoma or if clinical examination points towards a functional disorder without evidence of structural damage We rec-ommend an MRI for every injury which is suspicious for struc-tural muscle injury MRI is helpful in determining whetheroedema is present in what pattern and if there is a structurallesion including its approximate size Furthermore MRI ishelpful in con1047297rming the site of injury and any tendon involve-ment31 However it must be pointed out that MRI alone is notsensitive enough to measure the extent of muscle tissue damageaccurately For example it is not possible to judge from the scanswhere oedemahaemorrhage (seen as high signal) is obscuringmuscle tissue that has not been structurally damaged

Our approach is to include the combination of the currently best available diagnostic tools to address the current de1047297cit of clinical and scienti1047297c information and lack of sensitivity andspeci1047297city of the existing diagnostic modalities Careful com-bination of diagnostic modalities including medical historyinspection clinical examination and imaging will most likely lead to an accurate diagnosis which should be de1047297nitely mainly based on clinical 1047297ndings and medical history not onimaging alone since the technology and sensitivity to detect

structural muscle injury continues to evolve For example thehistory of a sharp acute onset of pain experience of a snap anda well-de1047297ned localised pain with a positive MRI for oedemabut indecisive for 1047297bre tear strongly suggest a minor partialmuscle tear below the detection sensitivity of the MRIOedema or better the increased 1047298uid signal on MRI would be

observed with a localised haematoma and would be consistentwith the working diagnosis in this case The diagnosis of asmall tear (structural defect) that is below the MRI detectionlimit is important in our eyes since even a small tear is relevantbecause it can further disrupt longitudinally for example whenthe athlete sprints

Ekstrand et al26 described a signi1047297cantly and clinically rele-vant shorter return to sports in MRI negative cases (withoutoedema) compared to MRI grade 1 injuries (with oedema butwithout 1047297bre tearing) Similar 1047297ndings are published also by others33 However muscle oedema is a very complex issue andin our opinion too little is known so far Therefore we decidedto mention in the classi1047297cation system that several functional

disorders present lsquowith or withoutrsquo oedema (table 3) This is inour eyes the best way to handle the currently insuf 1047297cient data

We think that discussion of the phenomenon of oedema at thispoint is premature but will be a focus of high level studies inthe future with more precise imaging and with studies whichare based on a common terminology and classi1047297cation

Terminology An aspect that may contribute to a high rate of inaccurate diag-nosis and recurrent injury is that terminology of muscle injuriesis not yet been clearly de1047297ned and a high degree of variability continues to exist between terms frequently used to describemuscle injury Since it has been documented that variations inde1047297nitions create signi1047297cant differences in study results and

conclusions34ndash38

it is critically important to develop astandardisation

Strain and tearHagglund et al34 de1047297ned lsquomuscle strainrsquo as lsquoacute distractioninjury of muscles and tendonsrsquo However this de1047297nition israrely used in the literature and in the day-to-day managementof athletic muscle injuries Our survey demonstrates that theterm strain is used with a high degree of variability betweenpractitioners Strain is a biomechanical term thus we do notrecommend the use of this term Instead we propose to use

the term tear for structural injuries of muscle 1047297bresbundlesleading to loss of continuity and contractile properties Tearbetter re1047298ects structural characteristics as opposed to a mechan-ism of injury

Functional muscle disorders According to Fuller et al28 a sports injury is de1047297ned as lsquoany physical complaint sustained by an athlete that results from amatchcompetition or training irrespective of the need formedical attention or time loss from sportive activitiesrsquo Thatmeans also irrespective of a structural damage By this de1047297n-ition functional muscle disorders irrespective of any structuralmuscle damage present injuries as well However the term dis-

order may better differentiate functional disorders from structuralinjuries Thus the term functional muscle disorder was speci1047297cally chosen by the consensus conference

Functional muscle disorders present a distinct clinical entity since they result in a functional limitation for the athlete forexample painful increase of the muscle tone which can repre-sent a risk factor for structural injury However they are notreadily diagnosed with standard diagnostic methods such asMRI since they are without macroscopic evidence of structuraldamage de1047297ned as absence of 1047297bre tear on MRI They are indir-

ect injuries that is not caused by external force A recent UEFA muscle injury study has demonstrated their relevance in foot-ballsoccer26 This study included data from a 4-year observa-tion period of MRI obtained within 24ndash48 h after injury anddemonstrated that the majority of injuries (70) were withoutsigns of 1047297bre tear However these injuries caused more than50 of the absence of players in the clubs26 These 1047297ndings areconsistent with the clinical and practical observations of theexperienced members of the consensus panel

Functional muscle disorders are multifactorial and can begrouped into subgroups re1047298ecting their clinical origin includinglsquooverexertionalrsquo or lsquoneuromuscularrsquo muscle disorders This isimportant since the origin of muscle disorder in1047298uences theirtreatment pathway A spine-related muscle disorder associatedwith a spine problem (eg spondylolysis) will better respond totreatment by addressing not only the muscle disorder but alsothe back disorder (ie including core-performance injections)

One could argue that this presents mainly a back problemwith a secondary muscle disorder But this secondary musculardisorder prevents the athlete from sports participation and willrequire comprehensive treatment that includes the primary problem as well in order to facilitate return to sport Thereforea broader de1047297nition and classi1047297cation system is suggested by the consensus panel at this point which is important not only because of the different pathogenesis but more importantly because of different therapeutic implications

Comprehensive classi 1047297cation system

Fatigue-induced muscle disorder and delayed onset musclesoreness

Muscle fatigue has been shown to predispose to injury39

Onestudy has demonstrated that in the hind leg of the rabbit


Consensus statement




fatigued muscles absorb less energy in the early stages of stretch when compared with non-fatigued muscle40 Fatiguedmuscle also demonstrates increased stiffness which has beenshown to predispose to subsequent injury (Wilson AJ andMyers PT unpublished data 2005) The importance of warmup prior to activity and of maintaining 1047298exibility was empha-sised since a decrease in muscle stiffness is seen with warmingup40 A study by Witvrouw et al41 found that athletes with an

increased tightness of the hamstring or quadriceps muscleshave a statistically higher risk for a subsequent musculoskeletallesion

Delayed onset muscle soreness (DOMS) has to be differentiatedfrom fatigue-induced muscle injury42 DOMS occurs severalhours after unaccustomed deceleration movements while themuscle is stretched by external forces (eccentric contractions)whereas fatigue-induced muscle disorder can also occur duringathletic activity DOMS causes its characteristic acute in1047298am-matory pain (due to local release of in1047298ammatory mediatorsand secondary biochemical cascade activation) with stiff andweak muscles and pain at rest and resolves spontaneously usually within a week In contrast fatigue-induced muscle dis-order leads to aching circumscribed 1047297rmness dull ache to stab-bing pain and increases with continued activity It canmdashif unrecognised and untreatedmdashpersist over a longer time andmay cause structural injuries such as partial tears However inaccordance with Opar et al39 it has to be stated that it remainsan area for future research to de1047297nitely describe this muscle dis-order and other risk factors for muscle injuries

Spine-related and muscle-related neuromuscular muscle disordersTwo different types of neuromuscular disorders can be differen-tiated a spinal or spinal nerve-related (central) and a neuromus-cular endplate-related (peripheral) type Since muscles act as atarget organ their state of tension is modulated by electricalinformation from the motor component of the corresponding

spinal nerve Thus an irritation of a spinal nerve root can causean increase of the muscle tone It is known that back injuriesare very common in elite athletes particularly at the L45 andthe L5S1 level43 and lumbar pathology such as disc prolapse atthe L5S1 level may present with hamstring andor calf painand limitations in 1047298exibility which may result in or mimic amuscle injury44 Orchard states that theoretically any pathology relating to the lumbar spine the lumbosacral nerve roots orplexus or the sciatic nerve could result in hamstring or calf pain44 This could be transient and range from fully reversible

functional disturbances to permanent structural changes whichmay be congenital or acquired Several other studies have sup-ported this concept of a lsquoback relatedrsquo (or more speci1047297cally lumbar spine related) hamstring injury 1 5 3 3 4 5 although this isa controversial paradigm to researchers44 However this multi-factorial type of injury would logically require variable forms of treatment beyond simply treatment of the musclendashtendoninjuries46 Thus it is important that assessment of hamstringinjury should include a thorough biomechanical evaluationespecially that of the lumbar spine pelvis and sacrum15

Lumbar manifestations are not present in all cases howevernegative structural 1047297ndings on the lumbar spine do not excludenerve root irritation Functional lumbar disturbances likelumbar or iliosacral blocking can also cause spine-related muscledisorders47 The diagnosis is then established through preciseclinical-functional examination The spine-related muscle dis-order is usually MRI-negative or shows muscle oedema only44

Many clinicians also believe that athletes with lumbar spinepathology have a greater predisposition to hamstring tears33 44

although this has not been prospectively proven Verrall et al33

showed that footballers with a history of lumbar spine injury had a higher rate of MRI-negative posterior thigh injury butnot of actual structural hamstring injury

We differentiate muscle-related neuromuscular disorders fromthe spine-related ones because of different treatment pathwaysMuscle tone is mainly under the control of the gamma loopand activation of the α-motor neurons remains mainly under

the control of motor descending pathways Sensory informa-tion from the muscle is carried by ascending pathways to thebrain Ia afferent signals enter the spinal cord on the α-motorneurons of the associated muscle but branches also stimulateinterneurons in the spinal cord which act via inhibitory synap-ses on the alpha motor neurons of antagonistic musclesThereby simultaneous inhibition of the alpha motor neurons toantagonistic muscles (reciprocal inhibition) occurs to supportmuscle contraction of agonistic muscle48 Dysfunction of theseneuromuscular control mechanisms can result in signi1047297cantimpairment of normal muscle tone and can cause neuromuscu-lar muscle disorders when inhibition of antagonistic muscles isdisturbed and agonistic muscles overcontract to compensatethis48 Increasing fatigue with a decline in muscle force willincrease the activity of the alpha motor neurons of the agoniststhrough Ib disinhibition The rising activity of the alpha motorneurons can lead to an overcontraction of the individual motorunits in the target muscle resulting in a painful muscle 1047297rmnesswhich can prevent an athlete from sportive activities48

For anatomic illustration of the location and extent of func-tional muscle disorders see 1047297gure 1

Structural injuriesThe most relevant structural athletic muscle injuries that isinjuries lsquowith macroscopicrsquo evidence of muscle damage areindirect injuries that is stretch-induced injuries caused by asudden forced lengthening over the viscoelastic limits of

muscles occurring during a powerful contraction (internalforce) These injuries are usually located at the musclendashtendonjunction1 7 4 0 4 9 since these areas present biomechanical weakpoints The quadriceps muscle and the hamstrings are fre-quently affected since they have large intramuscular or centraltendons and can get injured along this interface50 51

Theoretically a tear can occur anywhere along the musclendashtendonndashbonendashchain either acutely or chronically

Exact knowledge of the muscular macro- and microanatomy is important to understand and correctly de1047297ne and classify indirect structural injuries The individual muscle 1047297bre presents amicroscopic structure with an average diameter of 60 μm52

Thus an isolated tear of a single muscle 1047297bre remains usually without clinical relevance Muscle 1047297bres are anatomically orga-nised into primary and secondary muscle fasciclesbundlesSecondary muscle bundles (1047298eshndash1047297bres) with a diameter of 2ndash5 mm (this diameter can vary according to the trainingstatus according to hypertrophy) are visible to the humaneye52 Secondary muscle bundles present structures that can bepalpated by the experienced examiner when they are tornMultiple secondary bundles constitute the muscle (1047297gure 2)

Partial muscle tearsMost indirect structural injuries are partial muscle tears Clinicalexperience clearly shows that most partial injuries can beassigned to one of two types either a minor or a moderatepartial muscle tear which ultimately has consequences for

therapy respectively for absence time from sports Thus indirect structural injuries should be subclassi1047297ed Since previous


Consensus statement




Figure 1 Anatomic illustration of the location and extent of functional and structural muscle injuries (eg hamstrings) (A) Overexertion-relatedmuscle disorders (B) Neuromuscular muscle disorders (C) Partial and (sub)total muscle tears (from Thieme Publishers Stuttgart planned to be

published Reproduced with permission) This 1047297gure is only reproduced in colour in the online version

Figure 2 Anatomic illustration of theextent of a minor and moderate partialmuscle tear in relation to theanatomical structures Please notethat this is a graphical illustrationthere are variations in extent (FromThieme Publishers Stuttgart plannedto be published Reproduced withpermission) This 1047297gure is only

reproduced in colour in the onlineversion


Consensus statement




graduation systems23 24 refer to the complete muscle size they are relative and not consistently measurable In addition tothis there is no differentiation of grade 3 injuries with the con-sequence that many structural injuries with different prognosticconsequences are subsumed as grade 3

We recommend a classi1047297cation of structural injuries based onanatomical 1047297ndings Taking into account the aforementionedanatomical factors and as a re1047298ection of our daily clinical work

with muscle injuries we differentiate between minor partialtears with a maximum diameter of less and moderate partialtears with a diameter of greater than a muscle fasciclebundle(see 1047297gure 2)

In addition to the size it is the participation of the adjacentconnective tissue the endomysium the perimysium the epi-mysium and the fascia that distinguish a minor from a moder-ate partial muscle tear Concomitant injury of the externalperimysium seems to play a special role This connective tissuestructure has a somehow intramuscular barrier function in caseof bleeding It may be the injury to this structure (withoptional involvement of the muscle fascia) that differentiates amoderate from a minor partial muscle tear

Drawing a clear differentiation between partial muscle tearsseems dif 1047297cult because of the heterogeneity of the muscles thatcan be structured very differently Technical capabilities today (MRI and ultrasound) are not precise enough to ultimately determine and prove the effective muscular defect within theinjury zone of haematoma andor liquid seen in MRI which issomewhat oversensitive at times17 and usually leads to overesti-mation of the actual damage It will remain the challenge of future studies to exactly rule out the size which describes thecut-off between a minor and a moderate partial muscle tear

The great majority of muscle injuries heal without formationof scar tissue However greater muscle tears can result in adefective healing with scar formation17 which has to be consid-ered in the diagnosis and prognosis of a muscle injury Our

experience is that partial tears of less than a muscle fascicleusually heal completely while moderate partial tears can resultin a 1047297brous scar

(Sub)total muscle tears and tendinous avulsionsComplete muscle tears with a discontinuity of the wholemuscle are very rare Subtotal muscle tears and tendinous avul-sions are more frequent Clinical experience shows that injuriesinvolving more than 50 of the muscle diameter (subtotaltears) usually have a similar healing time compared with com-plete tears

Tendinous avulsions are included in the classi1047297cation systemsince they mean biomechanically a total tear of the origin orinsertion of the muscle The most frequently involved locationsare the proximal rectus femoris the proximal hamstrings theproximal adductor longus and the distal semitendinosus

Intratendinous lesions of the free or intramuscular tendonalso occur Pure intratendinous lesions are rare The most fre-quent type is a tear near the musclendashtendon junction (eg of the intramuscular tendon of the rectus femoris muscle)Tendinous injuries are either consistent with the partial(type 3) or (sub)total (type 4) tear in our classi1047297cation systemand can be included in that aspect of the classi1047297cation

For anatomic illustration of the location and extent of struc-tural muscle injuries see 1047297gure 1

Muscle contusions

In contrast to indirect injuries (caused by internal forces) lacera-tions or contusions are caused by external forces5 3 5 4 like a

direct blow from an opponentrsquos knee Thus muscle contusionsare classi1047297ed as acute direct muscle injuries (tables 2 and 3)Contusion injuries are common in athletes and present acomplex injury that includes de1047297ned blunt trauma of the mus-cular tissue and associated haematoma53 54 The severity of theinjury depends on the contact force the contraction state of the affected muscle at the moment of injury and other factorsContusions can be graded into mild moderate and severe55

The most frequently injured muscles are the exposed rectusfemoris and the intermediate vastus lying next to the bonewith limited space for movement when exposed to a directblunt blow Contusion injury can lead to either diffuse or cir-cumscribed bleeding that displaces or compresses muscle 1047297brescausing pain and loss of motion It happens that muscle 1047297bresare torn off by the impact but typically muscle 1047297bres are nottorn by longitudinal distraction Therefore contusions are notnecessarily accompanied by a structural damage of muscletissue For this reason athletes even with more severe contu-sions can often continue playing for a long time whereas evena smaller indirect structural injury forces the player often to stopat once However contusions can also lead to severe complica-tions like acute compartment syndrome active bleeding orlarge haematomas

CONCLUSIONThis consensus statement aims to standardise the de1047297nitionsand terms of muscle disorders and injuries and proposes a prac-tical and comprehensive classi1047297cation Functional muscle disordersare differentiated from structural injuries The use of the term

strain mdashif used undifferentiatedmdashis no longer recommendedsince it is a biomechanical term not well de1047297ned and usedindiscriminately for anatomically and functionally differentmuscle injuries Instead of this we propose to use the term tearfor structural injuries graded into (minor and moderate) partialand (sub)total tears used only for muscle injuries with macro-

scopic evidence of muscle damage ( structural injuries) While thisclassi1047297cation is most applicable to lower limb muscle injuries itcan be translated also to the upper limb

Scienti1047297c data supporting the presented classi1047297cation systemwhich is based on clinical experience are still missing We hopethat our work will stimulate researchmdashbased on the suggestedterminology and classi1047297cationmdashto prospectively evaluate theprognostic and therapeutic implications of the new classi1047297ca-tion and to specify each subclassi1047297cation It also remains de1047297n-itely the challenge of future studies to exactly rule out the sizewhich describes the cut-off between a minor and a moderatepartial muscle tear

Author af 1047297

liations1MW Center of Orthopedics and Sports Medicine Munich and Football Club FCBayern Munich Munich Germany2Harvard Vanguard Medical Associates Harvard Medical School US SoccerFederation Boston Massachusetts USA3UEFA Injury Study Group Medical Committee UEFA University of LinkoumlpingLinkoumlping Sweden4Football Club Chelsea London UK5Football Club Manchester United Manchester UK6School of Public Health University of Sydney Sydney Australia7Australian Cricket team and Sydney Roosters Rugby League team School of PublicHealth University of Sydney Australia8Orthopedic Department Academic Medical Centre Amsterdam The Netherlands9Department of Orthopedic Surgery and Orthopedic Research Center AcademicMedical Center Amsterdam The Netherlands10International Olympic Committee Lausanne Switzerland11Department of Vegetative Anatomy Chariteacute University of Berlin Berlin Germany12University of Gothenborg and National Football Team Sweden Gothenburg Sweden13Football Club Ajax Amsterdam Amsterdam The Netherlands


Consensus statement




Contributors H-WM-W member of Conference senior author of 1047297nal statementresponsible for the overall content LH member of Conference senior co-author of 1047297nal statement KM member of Conference co-author of 1047297nal statement JEmember of Conference co-author of 1047297nal statement BE member of Conferenceco-author of 1047297nal statement SM member of Conference co-author of 1047297nalstatement JO member of Conference co-author of 1047297nal statement NvD member of Conference co-author of 1047297nal statement GMK member of Conference co-author of 1047297nal statement PS member of Conference co-author of 1047297nal statement DBmember of Conference co-author of 1047297nal statement LS member of Conferenceco-author of 1047297nal statement EG member of Conference co-author of 1047297nal

statement PU member of Conference executive and corresponding authorresponsible for the overall content

Funding The Consensus Conference was supported by grants from FC BayernMunich Adidas and Audi

Competing interests None

Provenance and peer review Not commissioned externally peer reviewed

REFERENCES1 Ekstrand J Hagglund M Walden M Epidemiology of muscle injuries in

professional football (soccer) Am J Sports Med 2011391226ndash32

2 Andersen TE Engebretsen L Bahr R Rule violations as a cause of injuries in male

Norwegian professional football are the referees doing their job Am J Sports Med

20043262Sndash8S

3 Arnason A Sigurdsson SB Gudmundsson A et al Risk factors for injuries in

football Am J Sports Med

200432

5Sndash16S

4 Brophy RH Wright RW Powell JW et al Injuries to kickers in American football

the National Football League experience Am J Sports Med 2010381166ndash73

5 Hagglund M Walden M Ekstrand J Injuries among male and female elite football

players Scand J Med Sci Sports 200919819ndash27

6 Hawkins RD Hulse MA Wilkinson C et al The association football medical

research programme an audit of injuries in professional football Br J Sports Med

20013543ndash7

7 Walden M Hagglund M Ekstrand J UEFA Champions League study a prospective

study of injuries in professional football during the 2001ndash2002 season Br J Sports

Med 200539542ndash6

8 Alonso JM Junge A Renstrom P et al Sports injuries surveillance during the

2007 IAAF World Athletics Championships Clin J Sport Med 20091926ndash32

9 Malliaropoulos N Isinkaye T Tsitas K et al Reinjury after acute posterior thigh

muscle injuries in elite track and 1047297eld athletes Am J Sports Med 201139304ndash10

10 Malliaropoulos N Papacostas E Kiritsi O et al Posterior thigh muscle injuries in

elite track and 1047297eld athletes Am J Sports Med 2010381813ndash19

11 Lopez V Jr Galano GJ Black CM et al Pro 1047297le of an American amateur rugby unionsevens series Am J Sports Med 201240179ndash84

12 Borowski LA Yard EE Fields SK et al The epidemiology of US high school

basketball injuries 2005ndash2007 Am J Sports Med 2008362328ndash35

13 Feeley BT Kennelly S Barnes RP et al Epidemiology of National Football League

training camp injuries from 1998 to 2007 Am J Sports Med 2008361597ndash603

14 Walden M Hagglund M Magnusson H et al Anterior cruciate ligament injury in

elite football a prospective three-cohort study Knee Surg Sports Traumatol Arthrosc

20111911ndash19

15 Woods C Hawkins RD Maltby S et al The Football Association Medical Research

Programme an audit of injuries in professional footballmdashanalysis of hamstring

injuries Br J Sports Med 20043836ndash41

16 Arm 1047297eld DR Kim DH Towers JD et al Sports-related muscle injury in the lower

extremity Clin Sports Med 200625803ndash42

17 Jarvinen TA Jarvinen TL Kaariainen M et al Muscle injuries biology and

treatment Am J Sports Med 200533745ndash64

18 Anderson K Strickland SM Warren R Hip and groin injuries in athletes Am J

Sports Med 200129521ndash33

19 Noonan TJ Garrett WE Jr Muscle strain injury diagnosis and treatment J Am

Acad Orthop Surg 19997262ndash9

20 Bryan Dixon J Gastrocnemius vs soleus strain how to differentiate and deal with

calf muscle injuries Curr Rev Musculoskelet Med 2009274ndash7

21 OrsquoDonoghue DO Treatment of injuries to athletes Philadelphia WB Saunders 1962

22 Ryan AJ Quadriceps strain rupture and charlie horse Med Sci Sports

19691106ndash11

23 Takebayashi S Takasawa H Banzai Y et al Sonographic 1047297ndings in muscle strain

injury clinical and MR imaging correlation J Ultrasound Med 199514899ndash905

24 Peetrons P Ultrasound of muscles Eur Radiol 20021235ndash43

25 Stoller DW MRI in orthopaedics and sports medicine 3rd edn Philadelphia

Wolters KluwerLippincott 2007

26 Ekstrand J Healy JC Walden M et al Hamstring muscle injuries in professional

football the correlation of MRI 1047297ndings with return to play Br J Sports Med

201246112ndash17

27 Fink A Kosecoff J Chassin M et al Consensus methods characteristics and

guidelines for use Am J Public Health 198474979ndash83

28 Fuller CW Ekstrand J Junge A et al Consensus statement on injury de 1047297nitions

and data collection procedures in studies of football (soccer) injuries Clin J Sport

Med 20061697ndash106

29 Orchard J Marsden J Lord S et al Preseason hamstring muscle weakness

associated with hamstring muscle injury in Australian footballers Am J Sports Med

19972581ndash

530 Brooks JH Fuller CW Kemp SP et al Incidence risk and prevention of

hamstring muscle injuries in professional rugby union Am J Sports Med

2006341297ndash306

31 Askling CM Tengvar M Saartok T et al Acute 1047297rst-time hamstring strains during

high-speed running a longitudinal study including clinical and magnetic resonance

imaging 1047297ndings Am J Sports Med 200735197ndash206

32 Askling CM Tengvar M Saartok T et al Proximal hamstring strains of stretching

type in different sports injury situations clinical and magnetic resonance imaging

characteristics and return to sport Am J Sports Med 2008361799ndash804

33 Verrall GM Slavotinek JP Barnes PG et al Clinical risk factors for hamstring

muscle strain injury a prospective study with correlation of injury by magnetic

resonance imaging Br J Sports Med 200135435ndash9

34 Hagglund M Walden M Bahr R et al Methods for epidemiological study of

injuries to professional football players developing the UEFA model Br J Sports

Med 200539340ndash6

35 Brooks JH

Fuller CW The in 1047298uence of methodological issues on the results and

conclusions from epidemiological studies of sports injuries illustrative examples


36 Finch CF An overview of some de 1047297nitional issues for sports injury surveillance


37 Junge A Dvorak J In 1047298uence of de 1047297nition and data collection on the incidence of

injuries in football Am J Sports Med 200028S40ndash6

38 Junge A Dvorak J Graf-Baumann T et al Football injuries during FIFA tournaments

and the Olympic Games 1998ndash2001 development and implementation of an

injury-reporting system Am J Sports Med 20043280Sndash9S

39 Opar DA Williams MD Shield AJ Hamstring strain injuries factors that lead to

injury and re-injury Sports Med 201242209ndash26

40 Garrett WE Jr Muscle strain injuries Am J Sports Med 199624S2ndash8

41 Witvrouw E Danneels L Asselman P et al Muscle 1047298exibility as a risk factor for

developing muscle injuries in male professional soccer players A prospective study

Am J Sports Med 20033141ndash6

42 Boening D Delayed-onset muscle soreness (DOMS) Dtsch Arztebl

200299372ndash

7743 Ong A Anderson J Roche J A pilot study of the prevalence of lumbar disc

degeneration in elite athletes with lower back pain at the Sydney 2000 Olympic

Games Br J Sports Med 200337263ndash6

44 Orchard JW Farhart P Leopold C Lumbar spine region pathology and hamstring

and calf injuries in athletes is there a connection Br J Sports Med 2004

38502ndash4

45 Orchard JW Intrinsic and extrinsic risk factors for muscle strains in Australian

football Am J Sports Med 200129300ndash3

46 Hoskins WT Pollard HP Successful management of hamstring injuries in Australian

Rules footballers two case reports Chiropr Osteopat 2005134

47 Mueller-Wohlfahrt HW Diagnostik und Therapie von Muskelzerrungen und

Muskelfaserrissen Sportorthop Sporttraumatol 20011717ndash20

48 Brenner B Maassen N Physiologische Grundlagen und sportphysiologische

Aspekte In Mueller-Wohlfahrt HW Ueblacker P Haensel L eds Muskelverletzungen

im Sport Stuttgart Germany New York Thieme 201073ndash4

49 Clanton TO Coupe KJ Hamstring strains in athletes diagnosis and treatment

J Am Acad Orthop Surg 19986237ndash48

50 Garrett WE Jr Rich FR Nikolaou PK et al Computed tomography of hamstring

muscle strains Med Sci Sports Exerc 198921506ndash14

51 Hughes Ct Hasselman CT Best TM et al Incomplete intrasubstance strain injuries

of the rectus femoris muscle Am J Sports Med 199523500ndash6

52 Schuenke M Schulte E Schumacher U Atlas of Anatomy Stuttgart Germany

New York Thieme 2005

53 Beiner JM Jokl P Muscle contusion injuries current treatment options J Am Acad

Orthop Surg 20019227ndash37

54 Kary JM Diagnosis and management of quadriceps strains and contusions Curr

Rev Musculoskelet Med 2010326ndash31

55 Ryan JB Wheeler JH Hopkinson WJ et al Quadriceps contusion West Point

update Am J Sports Med 199119299ndash304


Consensus statement




injuries in sport a consensus statementTerminology and classification of muscle

Edwin Goedhart and Peter UeblackerGino M Kerkhoffs Patrick Schamasch Dieter Blottner Leif Swaerd

DijkEkstrand Bryan English Steven McNally John Orchard C Niek vanHans-Wilhelm Mueller-Wohlfahrt Lutz Haensel Kai Mithoefer Jan

published online October 18 2012Br J Sports Med

httpbjsmbmjcomcontentearly20121017bjsports-2012-091448Updated information and services can be found at

These include

MaterialSupplementary

DC1htmlhttpbjsmbmjcomcontentsuppl20121017bjsports-2012-091448Supplementary material can be found at

References BIBL

httpbjsmbmjcomcontentearly20121017bjsports-2012-091448This article cites 51 articles 32 of which you can access for free at

Open Access

httpcreativecommonsorglicensesby-nc30legalcode andhttpcreativecommonsorglicensesby-nc30 with the license See

properly cited the use is non commercial and is otherwise in compliancedistribution and reproduction in any medium provided the original work isCommons Attribution Non-commercial License which permits useThis is an open-access article distributed under the terms of the Creative

serviceEmail alerting

box at the top right corner of the online articleReceive free email alerts when new articles cite this article Sign up in the

CollectionsTopic Articles on similar topics can be found in the following collections

(399)Musculoskeletal syndromes (191)Open access

Notes

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that 16 of muscle injuries in elite footballsoccer arere-injuries and associated with 30 longer absence from compe-tition than the original injury 1 emphasises the critical import-ance of correct evaluation diagnosis and therapy of the indexmuscle disorder This concerted effort presents a challengingtask in light of the existing inconsistent terminology and classi-1047297cation of muscle injuries

Different classi1047297cation systems are published in the literature(table 1) but there is little consistency within studies and indaily practice20

Previous grading systems based upon clinical signs One of the morewidely used muscle injury grading systems was devised by OrsquoDonoghue This system utilises a classi1047297cation that is based oninjury severity related to the amount of tissue damage and asso-ciated functional loss It categorises muscle injuries into threegrades ranging from grade 1 with no appreciable tissue tear grade2 with tissue damage and reduced strength of the musculotendi-nous unit and grade 3 with complete tear of musculotendinous

unit and complete loss of function21

Ryan published a classi1047297ca-tion for quadriceps injuries which has been applied for othermuscles In this classi1047297cation grade 1 is a tear of a few muscle1047297bres with an intact fascia Grade 2 is a tear of a moderatenumber of 1047297bres with the fascia remaining intact A grade 3injury is a tear of many 1047297bres with a partial tear of the fascia anda grade 4 injury is a complete tear of the muscle and the fascia22

Previous grading systems based up imaging Takebayashi et al23 published in 1995 an ultrasound-based three-grade classi-1047297cation system ranging from a grade 1 injury with less than 5of the muscle involved grade 2 presenting a partial tear withmore than 5 of the muscle involved and up to grade 3 with acomplete tear Peetrons24 has recommended a similar gradingThe currently most widely used classi1047297cation is an MRI-basedgraduation de1047297ning four grades grade 0 with no pathological1047297ndings grade 1 with a muscle oedema only but withouttissue damage grade 2 as partial muscle tear and grade 3 with acomplete muscle tear25

The limitations of the previous grading systems are a lack of subclassi1047297cations within the grades or types with the conse-quence that injuries with a different aetiology treatmentpathway and different prognostic relevance are categorised inone group Some of the grading systems like the Takebayashiclassi1047297cation are relative and not consistently measurable Sofar no terminology or grading system (sub)classi1047297ed disorderswithout macroscopic evidence of structural damage eventhough a muscle injury study of the Union of European

Football Associations (UEFA) has emphasised their high clinicalrelevance in professional athletes26

The objective of our work is to present a more precise de1047297n-ition of the English muscle injury terminology to facilitatediagnostic therapeutic and scienti1047297c communication In add-ition a comprehensive and practical classi1047297cation system isdesigned to better re1047298ect the differentiated spectrum of muscleinjuries seen in athletes

METHODSTo evaluate the extent of the inconsistency and insuf 1047297ciency of the existing terminology of muscle injuries in the English litera-ture a questionnaire was sent to 30 native English-speakingsports medicine experts The recipients of the questionnaireswere invited based on their international scienti1047297c reputationand extensive expertise as team doctors of the national or 1047297rstdivision sports teams from the Great Britain Australia theUSA the FIFA UEFA and International Olympic CommitteeThe included experts were responsible for covering a variety of different sports with high muscle injury rates including foot-

ballsoccer rugby Australian football and cricket Quali1047297cationcriteria also included long-term experience with sports teamcoverage which limited the number of available experts sinceteam physicians often tend to change after short periods

The questionnaire (see online supplementary appendix 1)was divided into three categories 1047297rst the experts were askedto individually and subjectively describe their de1047297nitions of several common terms of muscle injuries and to indicate if theterm is a functional (non-structural) or a structural disorderinjuryIn the second category they were asked to associate synonymterms of muscle injuries such as strain and tear In the 1047297nal cat-egory the experts were asked to list given number of muscleinjury terms in the order their increasing injury severity

Following the completion of the survey the principal authors(H-WM-W LH and PU) organised a consensus meeting of 15international experts on the basic science of muscle injury aswell as sports medicine specialists involved in the daily care of premier professional sports and national teams The meetingwas endorsed by the International Olympic Committee (IOC)and the UEFA

A nominal group consensus model approach in which lsquoastructured meeting attempts to provide an orderly procedurefor obtaining qualitative information from target groups whoare most closely associated with a problem area rsquo27 was adoptedfor creating a consensus statement on terminology and classi1047297-cation of muscle disorders and injuries This model was success-fully applied before in other consensus statements28

During the 1-day meeting the authors performed a detailedreview of the structural and functional anatomy and physiology of

Table 1 Overview of previous muscle injury classification systems

OrsquoDonoghue 1962 Ryan 1969 ( initially for quadriceps)

Takebayashi 1995 Peetrons 2002

(Ultrasound-based ) Stoller 2007 (MRI-based)

Grade I No appreciable tissue tearing no loss

of function or strength only a

low-grade inflammatory response

Tear of a few muscle fibres fascia

remaining intact

No abnormalities or diffuse bleeding

withwithout focal fibre rupture less

than 5 of the muscle involved

MRI-negative=0 structural damage

Hyperintense oedema with or without

hemorrhage

Grade II Tissue damage strength of the

musculotendinous unit reduced

some residual function

Tear of a moderate number of fibres

fascia remaining intact

Partial rupture focal fibre rupture

more than 5 of the muscle involved

withwithout fascial injury

MRI-positive with tearing up to 50 of the

muscle fibres Possible hyperintense focal

defect and partial retraction of muscle fibres

Grade III Complete tear of musculotendinous

unit complete loss of function

Tear of many fibres with partial

tearing of the fascia

Complete muscle rupture with

retraction fascial injury

Muscle rupture=100 structural damage

Complete tearing with or without muscle

retraction

Grade IV X Complete tear of the muscle and

fascia of the musclendashtendon unit

X X


Consensus statement






RESULTS

























footballsoccer1









Consensus statement






1A Fatigue-induced

muscle disorder






training patterns





activity


involved muscles




Focal

involvement up

to entire length

of muscle

Negative

1B Delayed-onset

muscle soreness

(DOMS)






activity





relief

Mostly entire

muscle or

muscle group


2A Spine-related

neuromuscular

muscle disorder















Pressure pain

Muscle bundle or

larger muscle

group along

entire length of

muscle


2B Muscle-related

neuromuscular

muscle disorder

Circumscribed




from dysfunctional


Aching gradually

increasing muscle


Cramp-like pain

Circumscribed



oedematous swelling



Mostly along the

entire length of

the muscle belly


3A Minor partial

muscle tear

Tear with a maximum


fasciclebundle











pain aggravation

Primarily

musclendashtendon

junction

Positive for fibre

disruption on high

resolution MRI


3B Moderate partial

muscle tear



Stabbing sharp pain











pain aggravation

Primarily

musclendashtendon

junction







avulsion








Often fall




function haematoma


junction or

Bonendashtendon

junction






haematoma











definite external

mechanism









injury

Any muscle

mostly vastus

intermedius and

rectus femoris



dimensions










Tendinous avulsion



Consensus statement




























Consensus statement

























Consensus statement









Consensus statement















Muscle contusions








Author af 1047297



Consensus statement













20043262Sndash8S



200432

5Sndash16S







20013543ndash7



Med 200539542ndash6














20111911ndash19
















19691106ndash11








201246112ndash17








19972581ndash



2006341297ndash306












Med 200539340ndash6

35 Brooks JH


















200299372ndash






38502ndash4

























Consensus statement









These include



References BIBL


Open Access







Notes









RESULTS

























footballsoccer1









Consensus statement






1A Fatigue-induced

muscle disorder






training patterns





activity


involved muscles




Focal

involvement up

to entire length

of muscle

Negative

1B Delayed-onset

muscle soreness

(DOMS)






activity





relief

Mostly entire

muscle or

muscle group


2A Spine-related

neuromuscular

muscle disorder















Pressure pain

Muscle bundle or

larger muscle

group along

entire length of

muscle


2B Muscle-related

neuromuscular

muscle disorder

Circumscribed




from dysfunctional


Aching gradually

increasing muscle


Cramp-like pain

Circumscribed



oedematous swelling



Mostly along the

entire length of

the muscle belly


3A Minor partial

muscle tear

Tear with a maximum


fasciclebundle











pain aggravation

Primarily

musclendashtendon

junction

Positive for fibre

disruption on high

resolution MRI


3B Moderate partial

muscle tear



Stabbing sharp pain











pain aggravation

Primarily

musclendashtendon

junction







avulsion








Often fall




function haematoma


junction or

Bonendashtendon

junction






haematoma











definite external

mechanism









injury

Any muscle

mostly vastus

intermedius and

rectus femoris



dimensions










Tendinous avulsion



Consensus statement




























Consensus statement

























Consensus statement









Consensus statement















Muscle contusions








Author af 1047297



Consensus statement













20043262Sndash8S



200432

5Sndash16S







20013543ndash7



Med 200539542ndash6














20111911ndash19
















19691106ndash11








201246112ndash17








19972581ndash



2006341297ndash306












Med 200539340ndash6

35 Brooks JH


















200299372ndash






38502ndash4

























Consensus statement









These include



References BIBL


Open Access







Notes









1A Fatigue-induced

muscle disorder






training patterns





activity


involved muscles




Focal

involvement up

to entire length

of muscle

Negative

1B Delayed-onset

muscle soreness

(DOMS)






activity





relief

Mostly entire

muscle or

muscle group


2A Spine-related

neuromuscular

muscle disorder















Pressure pain

Muscle bundle or

larger muscle

group along

entire length of

muscle


2B Muscle-related

neuromuscular

muscle disorder

Circumscribed




from dysfunctional


Aching gradually

increasing muscle


Cramp-like pain

Circumscribed



oedematous swelling



Mostly along the

entire length of

the muscle belly


3A Minor partial

muscle tear

Tear with a maximum


fasciclebundle











pain aggravation

Primarily

musclendashtendon

junction

Positive for fibre

disruption on high

resolution MRI


3B Moderate partial

muscle tear



Stabbing sharp pain











pain aggravation

Primarily

musclendashtendon

junction







avulsion








Often fall




function haematoma


junction or

Bonendashtendon

junction






haematoma











definite external

mechanism









injury

Any muscle

mostly vastus

intermedius and

rectus femoris



dimensions










Tendinous avulsion



Consensus statement




























Consensus statement

























Consensus statement









Consensus statement















Muscle contusions








Author af 1047297



Consensus statement













20043262Sndash8S



200432

5Sndash16S







20013543ndash7



Med 200539542ndash6














20111911ndash19
















19691106ndash11








201246112ndash17








19972581ndash



2006341297ndash306












Med 200539340ndash6

35 Brooks JH


















200299372ndash






38502ndash4

























Consensus statement









These include



References BIBL


Open Access







Notes































Consensus statement

























Consensus statement









Consensus statement















Muscle contusions








Author af 1047297



Consensus statement













20043262Sndash8S



200432

5Sndash16S







20013543ndash7



Med 200539542ndash6














20111911ndash19
















19691106ndash11








201246112ndash17








19972581ndash



2006341297ndash306












Med 200539340ndash6

35 Brooks JH


















200299372ndash






38502ndash4

























Consensus statement









These include



References BIBL


Open Access







Notes




























Consensus statement









Consensus statement















Muscle contusions








Author af 1047297



Consensus statement













20043262Sndash8S



200432

5Sndash16S







20013543ndash7



Med 200539542ndash6














20111911ndash19
















19691106ndash11








201246112ndash17








19972581ndash



2006341297ndash306












Med 200539340ndash6

35 Brooks JH


















200299372ndash






38502ndash4

























Consensus statement









These include



References BIBL


Open Access







Notes












Consensus statement















Muscle contusions








Author af 1047297



Consensus statement













20043262Sndash8S



200432

5Sndash16S







20013543ndash7



Med 200539542ndash6














20111911ndash19
















19691106ndash11








201246112ndash17








19972581ndash



2006341297ndash306












Med 200539340ndash6

35 Brooks JH


















200299372ndash






38502ndash4

























Consensus statement









These include



References BIBL


Open Access







Notes


















Muscle contusions








Author af 1047297



Consensus statement













20043262Sndash8S



200432

5Sndash16S







20013543ndash7



Med 200539542ndash6














20111911ndash19
















19691106ndash11








201246112ndash17








19972581ndash



2006341297ndash306












Med 200539340ndash6

35 Brooks JH


















200299372ndash






38502ndash4

























Consensus statement









These include



References BIBL


Open Access







Notes
















20043262Sndash8S



200432

5Sndash16S







20013543ndash7



Med 200539542ndash6














20111911ndash19
















19691106ndash11








201246112ndash17








19972581ndash



2006341297ndash306












Med 200539340ndash6

35 Brooks JH


















200299372ndash






38502ndash4

























Consensus statement









These include



References BIBL


Open Access







Notes












These include



References BIBL


Open Access







Notes





0.2 2012_BrJSM_Classificação Lesões Desportivas

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Transcript of 0.2 2012_BrJSM_Classificação Lesões Desportivas