Muscle strains, pulls, tears, and ruptures are all different names that describe the same injury conditions. The only difference is in the degree of injury sustained. For example, we tend to think of a strain or pull as less serious than a tear or rupture. To keep it simple, I am going to refer to them all as strains from now on.
In this article we will discuss how these injuries arise, how to identify them, and how to rehabilitate them.
Strain Etiology / To the top
The briefest summary of how a strain occurs is when the amount of force put on a muscle is greater than the ability of the muscle to generate an opposing force then the muscle will strain. This most often occurs during high speed movement; however, it can occur during sustained contractions.
This means that strains have a higher frequency of occurring:
- in people with previous strains because of existing muscle weakness
- after static stretching muscles because of the inhibition of muscles spindles which control the stretch-shorten cycle by regulating muscle length
- in older populations because the muscles become less pliable as age increases
- in muscles with poor flexibility and mobility because the muscle cannot elongate very far without straining especially as a person fatigues
- near the end of workouts because muscles have less ability to maintain adequate force output to prevent straining as fatigue increases
- in weak people because weak muscles are easier to strain
- with impingement where motor nerve output is decreased for whatever reason thus leading to decreased force output of the muscle and increased likelihood to strain
Now you may have heard that muscle damage, especially factors related to the damage such as delayed onset muscle soreness, is caused by eccentric muscle contraction. This is true. The same thing occurs with strains. They always occur during the eccentric contraction of the muscle.
Even in cases where a strain occurs during a ‘concentric’ contraction are actually during an eccentric right at the time when the concentric motion is switching to the eccentric contraction. For instance, if you are one who tends to arch/crane your neck by looking up instead of keeping head neutral during deadlifts, squats, and pullups, the impingement of the nerves that come out from the cervical plexus may inhibit force output during the movement. Thus, as the movements move into the eccentric phase, the body may not have enough muscular force to exert to slow the movement down and the muscles may strain. This is one of the major reasons for correctly executed these techniques as well as the fact that craning the neck often gives people pain and tight muscles as well as headaches.
Therefore, knowing what we know now it is important that if you are getting older, having poor technique, poor flexibility and mobility, tight muscles, or are weak and do intense workouts you may be more susceptible to strains.
Obviously, if you have previous medical issues or strains you will know that you need to be proactive. If you are doing intense workouts at high speeds, save the static stretching for afterwards unless you have flexibility detriments that need to be addressed prior to workouts to ensure safety during the workout. You can find more about the the when and why of static stretching in this previous published article.
Common areas that strain
As we discussed strains always occur during eccentric loading of the muscles.
This means that during sprinting in the hamstrings they will tend to occur during the phase where the foot is starting to receive the ground as that is where the muscle is at its longest. Groin strains (at least adductor magnus) tend to be similar. The other half of groin strains – the hip flexor strains, adductors longus and brevis and pectineus – occur on the opposite side of the stride where the foot is starting to leave the ground to come forward.
In kicking sports strains will tend to occur after kicking the ball extremely hard as the leg travels up and forward in front of you.
Strains during lifting such as the back tend to occur when technique breaks down and the muscles lose their isometric contraction such as during squats and deadlifts when the back starts rounding. Likewise, in the upper body they will occur on the descent of pullups, the descent of the dips, and lowering the weight half heartedly or jerky.
This is why it is important to keep strict form especially when you are getting fatigued because that is when they are most likely to occur.
Strain assessment and grading / To the top
When a strain occurs you can recognize them through the fact that they:
- will occur in the muscle belly – if you feel it in the soft tissue it is most likely a strain
- is a sudden sharp onset pain
- there is pain on lengthening the muscle as well as contracting it
- if the strain is severe enough swelling or bruising may appear
- if the strain is a tear, a divot or gap may appear in the muscle or it may rend apart altogether
Strains are graded on a 1-3 scale.
Grade 1 tears consist of minor tearing of the muscle. There is no bruising and little to no swelling, but the pain is present in the soft tissue. The amount of pain is often variable to how the person perceives it. It is possible that there is no pain on concentric movements and only eccentrics, and there is unlikely to be pain with some light pressure to the area. This is what most often occurs with people who workout.
Grade 2 tears are partial tears of the muscle. There is likely to be some swelling. Bruising is still variable but most likely will occur as the tissues are damaged/ruptured enough that there will be blood leaking out. Both concentric and eccentric movements will hurt, and putting pressure on the area will cause pain. Since the muscle has a large injury it will result in limited range of motion.
Grade 3 tears are complete ruptures of muscle or close to it. There will be swelling and bruising. There is also likely to be a divot/gap left by the muscle where it tore in two. It is important that if this occurs to throw RICE it right away – rest, ice, compression, and elevation – and to get to the emergency room ASAP to get it checked out
I would also advise going to the ER in the case of a grade 2 partial tear as well, but it may not be necessary depending on the circumstances. In any case, this article is mostly directed at grade 1 and low grade 2 strain prehabilitation and rehabilitation.
Prehabilitation and Rehabilitation / To the top
For those of you who do not know what “prehabilitation” means, it is doing preemptive work to decrease the risk of incurring an injury. Thus, the list of risk factors we went over should be your guide to how to properly assess if you need prehabilitative work.
If you are weak you need to get stronger. If you have very tight muscles it is imperative to increase mobility in those muscles through static stretching and/or proprioceptive neuromuscular facilitative stretching after your workouts. If you’re getting up in age, you definitely need proper warmups before workouts. Save your static stretching for after workouts except for where you need it to maintain proper technique.
And, most importantly, ALWAYS maintain proper technique. If you are doing timed workouts it is important to always emphasize technique over getting a faster time. Constantly drilling technique is the key to success in every sport and athletic endeavor. You are not doing yourself any favors by short cutting yourself to look or feel better, and you increase your injury risk. It is a lose-lose situation.
Rehabilitation – Acute/inflammatory phase
The acute phase in all injuries is characterized by tissue damage that elicits an inflammatory response in the muscle. Swelling and bruising may or may not be present. If they are it is all the more necessary to take the proper steps to encourage healing of the tissues.
- 1. RICE
In general, RICE – rest, ice, compression, and elevation – is prescribed. The latter three will be critical to reduction of swelling and inflammation within the first 0-48 hours. Afterwards, compression will be the biggest factor in reduction of inflammation so it would be wise to invest in some compressive material to limit swelling if necessary.
Also, within this first period reduction in inflammation is critical to speed the body’s recovery processes. Inflammation is a natural process which helps stimulate healing through increase of blood flow to the area but blocking the blood flow out of the area as well as increasing the amount of immune response to the area. This is great when we are sick to promote recovery; however, in injuries to our bodies the inflammation is overkill and actually prolongs it. Thus, we want to reduce it a fair amount.
- 2. Keep moving without pain and self massage
It is important to keep the body part moving as much as possible without causing pain. This is because of the inflammation and the scar tissue that is about to be formed. In addition, in any traumatic injury the muscles tend to tighten up and lock down to prevent further damage. These factor will impede the healing processes.
If there is excessive swelling use your hands to push the swelling up towards the heart. This will help clear it out and speed up healing.
Massage in this phase should focus on light/superficial massage to the surface of the skin moving swelling and inflammation out towards the heart. Do not push into the tissue hard or do anything that causes significant pain as you will be interrupting the healing process, but light work is good to stimulate the blood flow and help organize regrowth.
- 3. Anti-inflammatories
Most docs nowadays for grade I or II strains will slap you with a prescription of NSAIDs and possibly a couple other drugs (to counteract the affects of strong NSAIDs) and tell you to RICE or rest.
This is not bad because it works, but my preference is with the strong anti-inflammatory effects of fish oil. Fish oil not only had GREAT side effects such as better overall health through improvement of cardiovascular risk factors and improvement of depression, schizophrenia, etc. Since most of us have problems with inflammation in the modern age (from eating too many carbs, and grain fed meat), reduction in inflammation is extremely positive on healing rates.
Here’s a list compiled by Jae on one of the sites I visit for cost comparison. Unfortunately, Kirkland brand recently changed their products some so I don’t know if they can be trusted or not.
This is the one that I have been using; however the price recently went up $3. (“LOW052” coupon at checkout will get you $5 off plus save me some money on my purchases if you want to go that route). Comes out to be around ~9.5 cents per 1g EPA+DHA if you want to try it.
For an injury where there is visible swelling high dose fish oil is recommend just as you would if you had gut inflammation in various autoimmune disorders. Robb Wolf recommends .5g of EPA+DHA per 10 lbs of body mass. This is good. However, you must get enough vitamin K in your diet or supplement it because EPA I believe is the omega-3 fatty acid that has some anti-coagulant effects. If you are wary of this recommendation then you should see some benefits with 3-5g EPA+DHA and thus that would be a good starting point. If you get 1g soft gels, for example, you need to look on the package to see how much EPA+DHA is in both. It is usually not 1g but 300mg. It is only the EPA+DHA that matters.
- 4. Other vitamins and supplements
The water soluble vitamins such as the B-complex vitamins help promote healing as they are needed for tissue regeneration and repair.
In acute phase damage inflammatory processes tend to cause a lot of oxidative damage. Thus, taking increasing dosage of vitamin C which is an anti-oxidant is good. Increasing A and E which are also anti-oxidants are good too, but not too much because they are fat soluble. The same is true of other supplements such as Coenzyme CoQ10 (ubiquinol) or acetyl-L carnitine or whatever else have you.
Fish oil is vastly more important than these though so if you are going to spend money on anything let it be the fish oil.
Rehabilitation – Repair and Remodeling Phases
Usually these phases are separated. However, repair and remodeling do occur simultaneously if the muscle is taken care of properly. Thus, I am grouping everything together.
The body in this stage is basically repairing what damage it can, breaking down what it cannot repair, forming scar tissue and laying down new tissues.
This phase begins within about 48-96 hours after injury; however, we are going to take a bit more conservative measures. Basically, once the tissue starts to feel better with your movement that you are doing everyday from the acute phase, and the swelling is reduced we can consider ourselves in this phase.
- 1. Keep up the fish oil supplementation.
This is important again to help keep excessive inflammatory processes down. Vitamin C and B complexes in large amounts as well as enough of vitamins A, E, and other anti-oxidants are great.
- 2. Start using heat instead of ice.
Since the swelling is reduced and the anti-inflammatory fish oil should keep it in check, we can move towards heating up the muscles.
The benefits of heating is that it helps increase blood flow to the muscles. Heat will also loosen up the tightened muscles to allow improved movement capabilities. Keep up the painless movement.
- 3. Maintain the massage, but add light stretching afterwards
The massage is to be maintained, but the main focus of it now is to loosen up the tight muscles. Add in very light stretching work after to help increase the range of motion. This is in addition to the already frequent painless movement.
The massage + stretching here can be deeper, but still not harder to cause pain. You can start to hit those deeper tissues and stimulate blood flow to them as well as help reorganize the tissues more correctly.
Programming in this phase may follow these steps:
1. Heat to the affected muscle (10-15 minutes)
2. Massage to the muscle (10-15 minutes)
3. Light stretching focusing on improving range of motion without pain (5-10 minutes)
- Restarting exercise
Like in tendonitis we first want to start with very light weights to give us a good degree of control over the movement to make sure we do not restrain. Remember, we are only a couple days or weeks out from major damage to the muscles, so it will be very easy to reaggravate it.
If it is possible to do some isolation work with the muscle go for it. Keep the weight very low and only do a few sets of 15-25 reps. Now is not the time to be aggressive with the weight increases. If there is any type of twinge back off immediately.
Likewise, with an injury that cannot be isolation such as a lower back strain, isometrics can be supplemented instead. For example, non-weighted squats or hyperextensions or very light deadlifts/good mornings can work. Be very careful.
At this phase we are looking to exercise, and then allow the body total healing over the next 24-48 hours. So only reintegrate exercise 3-4x a week, and keep the progressions small. Being extra cautious will save you more time than having to come back from a restrain which can often be worse than the first one since the tissues are already more vulnerable to take more damage.
From here, it is just a slow progression working your way back to full workouts.
- For more experienced lifters Bill Starr’s method of rehabilitation may be effective.
Novice or even intermediate lifters should not use this technique, in my opinion, because you do not know how to differentiate between pain very well. Experienced lifters will often have had to go through periods of injuries or tendonitis, so they can differentiate between rehabilitation pain and reinjury pain much better. If you have any doubts as whether you should use this protocol, I would avoid it completely.
Prehabilitation after rehabilitation / To the top
Like we discussed earlier strains are more likely to reappear in those with previous strains. Thus, it is important to do a few things to prevent another strain.
Improving mobility and flexibility is a major factor. This work should be integrated into your warmup and your cooldown. Add in some soft tissue work such as foam rolling, and self massage. Do dynamic and static stretches when appropriate. Add in mobility work.
The second is to make the muscle more resistant to damage. As you know, eccentric movement is when the majority of damage occurs during exercise. However, the muscles themselves gain a resistance to the damage with repetitive eccentric work. The model by which this occurs is the “popping sarcomere theory” (which you may google if you want more information).
To sum it up, during eccentric exercise individual sarcomeres distend during the lengthening of the muscle which accrues as damage (excess sarcomeric distension in a localized area is a strain). The body responds to this micro damage by adding additional sarcomeres to the muscle during inflammatory phase healing process (as well as changing some other factors). Subsequently, the muscle becomes more resistant to damage because of its ability to take damage.
This means that the major aspect of prehabilitative work should focus on eccentric exercise which we already described in the previous section. This is especially true with explosive movements. Thus, for a sprinter with a hamstring or groin strain we want to focus on eccentric hamstring curls, and then progress in our prehabilitative work to a 5-10 second count eccentric on the eccentric portion of lifts such as deadlifts, good mornings, hyperextensions, etc. As we stated earlier, do not be too aggressive with the weight and be careful to maintain strict technique.
Conclusion / To the top
All in all strains are not that complicated to deal with if they are grade I or low grade II. Higher grade II should be treated exactly like these except the acute, repair and remodeling phases will take much longer. Grade III tears you should discuss with a qualified medical professional.
The hard part is making yourself take care of your body through the protocols mentioned above. Be disciplined. Do not take your body for granted. Think of it as a learning experience that you care not repeat. Do proper mobility, prehabilitative, rehabilitative work, and focus on your technique.
All of the things I have stated in this article area critical for speeding the healing processes. However, there are natural limits to your healing – it is going to take some time if you strained yourself bad enough. Of course, healing can be improved by sleeping more, eating quality foods, etc. as well as the RICE, massage, fish oil, etc. Be sure to take care of your body, and it will respond in kind.
I hope that this article was informative.
Good luck with your prehabilitative and rehabilitative efforts.
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