Muscular Injuries : There are five grades of muscle injury categorised in this grading

system: grade 0 through grade 4, primarily, and exclusively for grades 1–4, based on the
MRI features of the muscle injury (see online supplementary table S1), with Grades 1–4
including an additional suffix ‘a’, ‘b’ or ‘c’ if the injury is ‘myofascial’, ‘musculo-tendinous’
or ‘intratendinous’. For grade 1–4 injuries, the suffix ‘a’ denotes a myofascial injury in the
peripheral aspect of the muscle, ‘b’ an injury within the muscle belly, most commonly at
the muscle tendon junction (MTJ) and ‘c’ an injury which extends into the tendon. The
most common site of muscle injury is at the MTJ.
There is an additional descriptor included in the classification to denote the site of injury
(proximal, central or distal third) relative to the muscle origin
Grade 0 muscle injury has been developed. This usually represents a clinical syndrome of
muscle abnormality but without imaging evidence of pathology.
0a focal neuromuscular injury with normal MRI. Grade 0a classifies a clinical presentation
of focal muscle soreness usually after exercise, although it may also occur during exercise.
The clinician may be able to palpate a focal area of increased muscle tone. This clinical
picture probably reflects a pathological process of microscopic muscle damage or
peripheral nerve irritation.
0b generalised muscle soreness with normal MRI or MRI characteristic of DOMS (parche
de alta señal de intensidad en uno o mas musculos). El grado 0b representa dolor
muscular generalizado, que en la mayoría de los casos comúnmente ocurre después de un
ejercicio no acostumbrado y con frecuencia se denomina DOMS (dolor muscular de
aparición retardada: es el dolor y la rigidez que se siente en los músculos varias horas o
días después de un ejercicio desacostumbrado o extenuante). Se cree que es causado por
ejercicio excéntrico (alargamiento), que causa daño a pequeña escala (microtrauma) a las
fibras musculares. Después de tal ejercicio, el músculo se adapta rápidamente para evitar
el daño muscular y, por lo tanto, el dolor, si el ejercicio se repite
Puede haber cambios característicos en la MRI con una señal alta generalizada e
inhomogenea que afecta varios músculos.

Grade 1 (leves) injuries are small injuries (tears) to the muscle. The athlete will usually
present with pain during or after activity. The athlete’s range of movement at 24 h will
usually be normal and although there may be pain on contraction, strength and initiation
of contraction may be well maintained on clinical examination.
Grade 1a (miofascial) injuries extend from the fascia and demonstrate high signal change
on fat suppressed/STIR images within the periphery of the muscle, no greater than 10%
into the muscle and with a longitudinal length of less than 5 cm within the muscle. Frank
muscle fibre disruption is not usually seen in this grade of injury but evidence of fibre
disruption of less than 1 cm with limited high signal change, as noted above, may still be
classified in this grade. Intermuscular fluid/haematoma on MRI may be evident within the
fascial planes over a greater distance.

Grade 1b (MTJ) injuries are sited within the muscle or, more commonly, at the MTJ. High
signal change is evident at this site and extends over a limited area of less than 5 cm and
less than 10% of the muscle cross-sectional area at its maximal site.

GRADO 2 (MODERADAS)
Grade 2a injuries usually extend from the peripheral fascia into the muscle. Clinical
experience suggests that they may be associated with a clinical history of pain during
change of direction and manual strength testing may be less reduced with grade 2a
injuries relative to other grade 2 injuries. On MRI, high signal change will be evident from
the periphery of the muscle. The high signal change will either measure between 10% and
50% of the cross-sectional area of that individual muscle at the site of injury or extend
between 5 and 15 cm within the muscle. Architectural fibre disruption will be less than 5
cm.
Grade 2b injuries occur within the muscle or, more commonly, at the MTJ. On MRI, the
high signal change will either measure between 10% and 50% of the muscle cross-
sectional area or have a longitudinal length between 5 and 15 cm. There is likely to be
evidence of muscle fibre disruption of less than 5 cm.
Grade 2c injuries extend into the tendon but injury within the tendon is evident over a
longitudinal length of less than 5 cm and less than 50% of the maximal tendon diameter
on axial images. If the injury is near the end of the free tendon there may be some loss of
tension in the free tendon. It may still be classified as a 2c, rather than 3c, if the injury size
is compatible with the measurements above.

GRADO 3 (EXTENSAS)
Grades 3a (myofascial) and 3b (muscular/musculotendinous) will demonstrate MRI
features of high signal change patterns of greater than 50% of the muscle cross-sectional
area or greater than 15 cm in length. There will be evidence of architectural fibre
disruption which is likely to be greater than 5 cm. Grades 3a and 3b are differentiated by
the location extending to the periphery (3a) or being within the muscle/at the MTJ.
Grade 3c (intratendinous) injuries have evidence of injury in the tendon over a
longitudinal length of greater than 5 cm or greater than 50% of the tendon’s maximal
cross-sectional area. There is no evidence of a complete defect but there may be loss of
the usual straight margins and tendon tension suggesting some loss of the tendon
integrity.

GRADO 4 (COMPLETAS)
Grade 4 injuries Grade 4 injuries are complete tears to either the muscle (grade 4) or
tendon (grade 4c). The athlete will experience sudden onset pain and significant and
immediate limitation to activity. A palpable gap will often be felt. There may be less pain
on contraction than with a grade 3 injury
ARTICULO DR
TIPOS DE FIBRA
The dominant skeletal muscle fiber types are type 1 (slow twitch) and type 2 (fast twitch).
Type 1 fibers exhibit lower power but contain more mitochondria and myoglobin,
affording tremendous capacity for repetitive and extended periods of contraction (11).
Type 2 fibers display higher power for short bursts of activity owing to a greater number
of glycolytic enzymes but cannot function for long durations and have a lower threshold
for injury

Indirect Injury
Muscle Strain is an acute indirect muscle injury that occurs during activity, typically related
to excessive stretching of a contracted muscle during eccentric exercise while engaged in
sports that emphasize speed and power, such as soccer, American football, rugby, and
track and field (18). Some authors prefer the term tear rather than strain for such injuries,
noting that strain is often applied indiscriminately to a range of muscle injuries that vary in
etiology and pathophysiology.
Strains have traditionally been divided into three grades based on clinical severity. Grade
1 is a mild injury resulting in pain without loss of range of motion and function, so that the
athlete is able to continue activity soon after the injury. Grade 2 is a moderate injury with
loss of muscle strength and range of motion. Grade 3 is a severe injury, typically related to
a complete tear, with loss of function.
TIPOS DE FIBRAS

Delayed-Onset Muscle Soreness

Delayed-onset muscle soreness (DOMS) is a stretching injury caused by unaccustomed, prolonged,

or overly vigorous eccentric exercise. The intensity, rather than the duration, of exercise is most
closely related to the risk of developing DOMS (35). While strain injuries develop acutely during
activity, patients with DOMS report gradual onset of muscle pain, stiffness, and swelling several
hours or days after activity, followed by spontaneous resolution within 1–2 weeks (36). The
etiology of DOMS is related to increases in compartment pressure and water content that
disproportionately affect type 2 fast-twitch fibers, with disruption of the Z bands of sarcomeres
throughout the muscle (37). Diffusion tensor imaging is particularly sensitive for noninvasive
identification of these microstructural alterations (38). Inflammation and necrosis are not
consistent or dominant feature.

At routine MR imaging, muscle enlargement and increase in fluid signal intensity onT2-weighted
images with preservation of muscle architecture reflect the increased intramuscular and
interstitial fluid seen throughout the damaged muscle at histologic analysis
Direct Trauma

Contusion is an acute injury caused by a direct nonpenetrating blow to the muscle, typically
affecting the anterior thigh, posterior thigh, or anterolateral upper arm. In professional contact
athletes, the most commonly injured muscles are the rectus femoris and vastus intermedius at the
anterior thigh.

Intracompartmental Hemorrhage.—Intramuscular hematoma is easily recognized owing to local

architectural distortion, appearing as an intramuscular mass of variable signal intensity depending
on the stage of blood degradation. Acute hematoma exhibits low T1 and T2 signal intensity related
to intracellular deoxyhemoglobin (Fig 20). In the early subacute phase, deoxyhemoglobin converts
to intracellular methemoglobin, increasing T1 signal intensity (Fig 21). In the late subacute phase,
as red cells lyse and methemoglobin becomes extracellular, T2 signal intensity also increases. The
final degradation products are hemosiderin and ferritin, closely related substances responsible for
the low signal intensity of chronic hemorrhage.

Interstitial Hemorrhage.—Unlike brain hemorrhage, muscle hemorrhage often includes a large

poorly marginated interstitial component that may degrade at an even more variable rate than
focal muscle hematoma (45,46). Interstitial bleeding can be substantial enough to lead to
circulatory compromise, particularly in large muscles or if associated with fascial injury that can
decompress the compartment, allowing unrestricted bleeding.

Laceration - Muscle laceration results from acute direct penetrating trauma by a sharp object,
typically a pointed item such as a knife. Such injuries disrupt the skin, subcutaneous tissues, and
fascia before piercing the muscle. MR imaging demonstrates a clearly demarcated linear defect in
the muscle filled with blood and fluid, associated with skin disruption, subcutaneous edema, and
soft-tissue gas.

Acute Compartment Syndrome

Acute compartment syndrome is most commonly seen in the lower leg after a fracture; over 70%
of cases of acute lower extremity compartment syndrome are the result of a tibial or fibular shaft
fracture, often affecting multiple compartments simultaneously. The anterior and lateral
compartments of the calf are the most common sites of acute compartment syndrome, other
locations such as the thigh, upper arm, forearm, and paraspinal musculature can also be affected.
Patients classically present with the six classic signs of arterial insufficiency: pain disproportionate
to the injury, paresthesia, pallor, paralysis, poikilothermia, and pulselessness.

MR imaging shows diffuse compartment bulging related to muscle enlargement and

intracompartmental hemorrhage and/or fluid. T1-weighted signal intensity is normal or mildly
increased due to interstitial hemorrhage, while T2-weighted images typically show slightly
increased muscle signal intensity. Administration of intravenous contrast material emphasizes the
altered muscle perfusion, demonstrating peripheral enhancement with central regions of
hypoperfusion or frank liquefaction reflecting muscle necrosis.
Chronic Exertional Compartment Syndrome (syndrome compartimental de esfuerzo cronico)

Chronic exertional compartment syndrome (CECS) causes aching pain, cramping, and muscle
tightness during exercise, typically of the anterior or lateral calf, and is often bilateral. Symptoms
typically resolve rapidly after cessation of activity without structural damage, although rarely
extreme cases can progress to acute compartment syndrome. Management consists of activity
modification, with fasciotomy reserved for recalcitrant cases.

Muscle Hernia

Muscle hernias are the result of a fascial defect most commonly caused by a fracture, penetrating
injury, or surgery, allowing muscle to protrude through the connective tissue (64). Less commonly,
muscle hernia occurs at an intact but incompetent fascia thinned by injury, chronic compartment
syndrome, or a congenital defect (typically located where the fascia is already attenuated by
traversing vessels and/or nerves).

Myositis Ossificans

Disordered satellite cell differentiation can cause intramuscular bone proliferation, a

nonneoplastic aberration of repair termed myositis ossificans (40). Myositis ossificans is most
common after direct muscle trauma, although burns, immobilization, and neurologic dysfunction
can also incite its formation. Posttraumatic ossification most commonly affects the quadriceps,
adductor, or brachialis musculature of children and young adults