Professional Documents
Culture Documents
342 Full PDF
342 Full PDF
Br J Sports Med: first published as 10.1136/bjsports-2012-091448 on 18 October 2012. Downloaded from http://bjsm.bmj.com/ on February 16, 2023 at Centro Universitario de
Terminology and classification of muscle injuries
in sport: The Munich consensus statement
Hans-Wilhelm Mueller-Wohlfahrt,1 Lutz Haensel,1 Kai Mithoefer,2 Jan Ekstrand,3
Bryan English,4 Steven McNally,5 John Orchard,6,7 C Niek van Dijk,8
Gino M Kerkhoffs,9 Patrick Schamasch,10 Dieter Blottner,11 Leif Swaerd,12
Edwin Goedhart,13 Peter Ueblacker1
▸ Supplementary online ABSTRACT (16%),8–10 but have also been documented in team
appendices are published Objective To provide a clear terminology and sports like rugby (10.4%),11 basketball (17.7%)12
online only. To view these files
please visit the journal online classification of muscle injuries in order to facilitate and American football (46%/22% practice/games).13
(http://dx.doi.org/10.1136/ effective communication among medical practitioners The fact that a male elite-level soccer team with
bjsports-2012-091448) and development of systematic treatment strategies. a squad of 25 players can expect about 15 muscle
For numbered affiliations see Methods Thirty native English-speaking scientists and injuries each season with a mean absence time of
end of article team doctors of national and first division professional 223 days, 148 missed training sessions and 37
sports teams were asked to complete a questionnaire missed matches demonstrate their high relevance
Correspondence to on muscle injuries to evaluate the currently used for the athletes as well as for the clubs.1 The rele-
Dr Peter Ueblacker, Center of
Orthopedics and Sports terminology of athletic muscle injury. In addition, a vance of muscle injuries is even more obvious if
Br J Sports Med: first published as 10.1136/bjsports-2012-091448 on 18 October 2012. Downloaded from http://bjsm.bmj.com/ on February 16, 2023 at Centro Universitario de
and associated with 30% longer absence from competition than The objective of our work is to present a more precise defin-
the original injury1 emphasises the critical importance of correct ition of the English muscle injury terminology to facilitate diag-
evaluation, diagnosis and therapy of the index muscle disorder. nostic, therapeutic and scientific communication. In addition, a
This concerted effort presents a challenging task in light of the comprehensive and practical classification system is designed to
existing inconsistent terminology and classification of muscle better reflect the differentiated spectrum of muscle injuries seen
injuries. in athletes.
Different classification systems are published in the literature
(table 1), but there is little consistency within studies and in
daily practice.20 METHODS
Previous grading systems based upon clinical signs: One of the To evaluate the extent of the inconsistency and insufficiency of
more widely used muscle injury grading systems was devised by the existing terminology of muscle injuries in the English litera-
O’Donoghue. This system utilises a classification that is based on ture a questionnaire was sent to 30 native English-speaking
injury severity related to the amount of tissue damage and asso- sports medicine experts. The recipients of the questionnaires
ciated functional loss. It categorises muscle injuries into three were invited based on their international scientific reputation
grades, ranging from grade 1 with no appreciable tissue tear, and extensive expertise as team doctors of the national or first
grade 2 with tissue damage and reduced strength of the musculo- division sports teams from the Great Britain, Australia the USA,
tendinous unit and grade 3 with complete tear of musculotendi- the FIFA, UEFA and International Olympic Committee. The
nous unit and complete loss of function.21 Ryan published a included experts were responsible for covering a variety of dif-
classification for quadriceps injuries which has been applied for ferent sports with high muscle injury rates including football/
other muscles. In this classification, grade 1 is a tear of a few soccer, rugby, Australian football and cricket. Qualification cri-
muscle fibres with an intact fascia. Grade 2 is a tear of a moderate teria also included long-term experience with sports team cover-
number of fibres, with the fascia remaining intact. A grade 3 age which limited the number of available experts since team
Grade I No appreciable tissue tearing, no loss Tear of a few muscle No abnormalities or diffuse bleeding MRI-negative=0% structural damage.
of function or strength, only a fibres, fascia remaining with/without focal fibre rupture less than Hyperintense oedema with or without
low-grade inflammatory response intact 5% of the muscle involved hemorrhage
Grade II Tissue damage, strength of the Tear of a moderate Partial rupture: focal fibre rupture more MRI-positive with tearing up to 50% of the
musculotendinous unit reduced, some number of fibres, fascia than 5% of the muscle involved with/ muscle fibres. Possible hyperintense focal
residual function remaining intact without fascial injury defect and partial retraction of muscle fibres
Grade III Complete tear of musculotendinous Tear of many fibres with Complete muscle rupture with retraction, Muscle rupture=100% structural damage.
unit, complete loss of function partial tearing of the fascial injury Complete tearing with or without muscle
fascia retraction
Grade IV X Complete tear of the X X
muscle and fascia of the
muscle–tendon unit
Br J Sports Med: first published as 10.1136/bjsports-2012-091448 on 18 October 2012. Downloaded from http://bjsm.bmj.com/ on February 16, 2023 at Centro Universitario de
During the 1-day meeting, the authors performed a detailed Often associated with circumscribed increase of muscle tone
review of the structural and functional anatomy and physiology (muscle firmness) in varying dimensions and predisposing to
of muscle tissue, injury epidemiology and currently existing clas- tears. Based on the aetiology several subcategories of functional
sification systems of athletic muscle injuries. In addition, the muscle disorders exist.
results of the muscle terminology survey were presented and dis-
cussed. Based on the results of the survey muscle injury termin- Structural muscle injury
ology was discussed and defined until a unanimous consensus of Any acute indirect muscle injury ‘with macroscopic’ evidence
group was reached. A new classification system empirically (in MRI or ultrasound (for limitations see Discussion)) of
based on the current knowledge about muscle injuries was dis- muscle tear.
cussed, compared with existing classifications, reclassified and Further definitions reached in the consensus conference are
approved. After the consensus meeting, iterative draft consensus presented in table 3 together with the classification system.
statements on the definitions and the classification system were
prepared and circulated to the members. The final statement Definitions—terminology without specific recommendation
was approved by all coauthors of the consensus paper. Muscle injury terms with highly inconsistent answers in the
survey were strain, pulled-muscle, hardening and hypertonus.
RESULTS Strain is a biomechanical term which is not defined and used
Muscle injury survey indiscriminately for anatomically and functionally different
Nineteen of the 30 questionnaires were returned for evaluation muscle injuries. Thus, the use of this term cannot be recom-
(63%). (Eleven experts did not respond even after repeated mended anymore.
reminders.) Even though, this is a limited number, the responses Pulled-muscle is a lay-term for different, not defined types or
demonstrated a marked variability in the definitions for hyperto- grades of muscle injuries and cannot be recommended as a sci-
nus, muscle hardening, muscle strain, muscle tear, bundle/fascicle entific term.
Br J Sports Med: first published as 10.1136/bjsports-2012-091448 on 18 October 2012. Downloaded from http://bjsm.bmj.com/ on February 16, 2023 at Centro Universitario de
Table 3 Comprehensive muscle injury classification: type-specific definitions and clinical presentations
Type Classification Definition Symptoms Clinical signs Location Ultrasound/MRI
1A Fatigue-induced Circumscribed longitudinal Aching muscle firmness. Dull, diffuse, tolerable pain in Focal Negative
muscle disorder increase of muscle tone Increasing with continued involved muscles, involvement up
(muscle firmness) due to activity. Can provoke pain circumscribed increase of to entire length
overexertion, change of at rest. During or after tone. Athlete reports of of muscle
playing surface or change in activity ‘muscle tightness’
training patterns
1B Delayed-onset More generalised muscle Acute inflammative pain. Oedematous swelling, stiff Mostly entire Negative or oedema only
muscle soreness pain following Pain at rest. Hours after muscles. Limited range of muscle or
(DOMS) unaccustomed, eccentric activity motion of adjacent joints. muscle group
deceleration movements. Pain on isometric contraction.
Therapeutic stretching leads
to relief
2A Spine-related Circumscribed longitudinal Aching muscle firmness. Circumscribed longitudinal Muscle bundle Negative or oedema only
neuromuscular increase of muscle tone Increasing with continued increase of muscle tone. or larger muscle
muscle disorder (muscle firmness) due to activity. No pain at rest Discrete oedema between group along
functional or structural muscle and fascia. entire length of
spinal/lumbopelvical Occasional skin sensitivity, muscle
disorder. defensive reaction on muscle
stretching. Pressure pain
2B Muscle-related Circumscribed Aching, gradually Circumscribed Mostly along the Negative or oedema only
neuromuscular (spindle-shaped) area of increasing muscle (spindle-shaped) area of entire length of
muscle disorder increased muscle tone firmness and tension. increased muscle tone, the muscle belly
recurrence rate of muscle injuries of 30.6%.29 Other studies skeletal muscle,17 with full strength of the injured tissue taking
demonstrated recurrence rates of 23% in rugby30 and 16% in time to return depending on the size and localisation of the
football/soccer.1 One plausible cause for recurrent muscle injury. (Note: mature scar is stiff or even stronger than healthy
injures, which are significantly more severe than the first muscle.) It appears plausible, that athletes may be returning to
injury1 30 is the premature return to full activity due to an sport before muscle healing is complete. As Malliaropoulos
underestimated injury. Healing of muscle and other soft tissue is et al10 stated ‘it is therefore crucial to establish valid criteria to
a gradual process. The connective (immature) tissue scar pro- recognise severity and avoid premature return to full activity
duced at the injury site is the weakest point of the injured and the risk of reinjury’.
Br J Sports Med: first published as 10.1136/bjsports-2012-091448 on 18 October 2012. Downloaded from http://bjsm.bmj.com/ on February 16, 2023 at Centro Universitario de
The presented muscle injury classification is based on an our eyes the best way to handle the currently insufficient data.
extensive, long-term experience and has been used successfully We think that discussion of the phenomenon of oedema at this
in the daily management of athletic muscle injuries. The classifi- point is premature but will be a focus of high level studies in the
cation is empirically based and includes some new aspects of future, with more precise imaging and with studies which are
athletic muscle injuries that have not yet been described in the based on a common terminology and classification.
literature, specifically the highly relevant functional muscle
injuries. An advanced muscle injury classification that distin- Terminology
guishes these injuries as separate clinical entities has great rele- An aspect that may contribute to a high rate of inaccurate diag-
vance for the successful management of the athlete with muscle nosis and recurrent injury is that terminology of muscle injuries
injury and represents the basis for future comparative studies is not yet been clearly defined and a high degree of variability
since scientific data are limited for muscle injury in general. continues to exist between terms frequently used to describe
muscle injury. Since it has been documented that variations
Diagnosis of muscle injuries in definitions create significant differences in study results and
In accordance with Askling et al31 32 and Jarvinen et al,17 we conclusions,34–38 it is critically important to develop a
recommend to start with a precise history of the occurrence, the standardisation.
circumstances, the symptoms, previous problems, followed by a
careful clinical examination with inspection, palpation of the Strain and tear
injured area, comparison to the other side and testing of the Hagglund et al34 defined ‘muscle strain’ as ‘acute distraction
function of the muscles. Palpation serves to detect (more super- injury of muscles and tendons’. However, this definition is
ficial and larger) tears, perimuscular oedema and increased rarely used in the literature and in the day-to-day management
muscle tone. An early postinjury ultrasound between 2 and 48 h of athletic muscle injuries. Our survey demonstrates that the
after the muscle trauma24 provides helpful information about term strain is used with a high degree of variability between
Br J Sports Med: first published as 10.1136/bjsports-2012-091448 on 18 October 2012. Downloaded from http://bjsm.bmj.com/ on February 16, 2023 at Centro Universitario de
One could argue, that this presents mainly a back problem, with injury would logically require variable forms of treatment
a secondary muscle disorder. But, this secondary muscular dis- beyond simply treatment of the muscle–tendon injuries.46 Thus,
order prevents the athlete from sports participation and will it is important that assessment of hamstring injury should
require comprehensive treatment that includes the primary include a thorough biomechanical evaluation, especially that of
problem as well in order to facilitate return to sport. Therefore, the lumbar spine, pelvis and sacrum.15 Lumbar manifestations
a broader definition and classification system is suggested by the are not present in all cases; however, negative structural findings
consensus panel at this point which is important not only on the lumbar spine do not exclude nerve root irritation.
because of the different pathogenesis, but more importantly Functional lumbar disturbances, like lumbar or iliosacral block-
because of different therapeutic implications. ing can also cause spine-related muscle disorders.47 The diagno-
sis is then established through precise clinical-functional
Comprehensive classification system examination. The spine-related muscle disorder is usually
Fatigue-induced muscle disorder and delayed onset muscle MRI-negative or shows muscle oedema only.44 Many clinicians
soreness also believe that athletes with lumbar spine pathology have a
Muscle fatigue has been shown to predispose to injury.39 One greater predisposition to hamstring tears,33 44 although this has
study has demonstrated that in the hind leg of the rabbit fati- not been prospectively proven. Verrall et al33 showed that foot-
gued muscles absorb less energy in the early stages of stretch ballers with a history of lumbar spine injury had a higher rate of
when compared with non-fatigued muscle.40 Fatigued muscle MRI-negative posterior thigh injury, but not of actual structural
also demonstrates increased stiffness, which has been shown to hamstring injury.
predispose to subsequent injury (Wilson AJ and Myers PT, We differentiate muscle-related neuromuscular disorders from
unpublished data, 2005). The importance of warm up prior to the spine-related ones because of different treatment pathways.
activity and of maintaining flexibility was emphasised since a Muscle tone is mainly under the control of the gamma loop and
decrease in muscle stiffness is seen with warming up.40 A study activation of the α-motor neurons remains mainly under the
Br J Sports Med: first published as 10.1136/bjsports-2012-091448 on 18 October 2012. Downloaded from http://bjsm.bmj.com/ on February 16, 2023 at Centro Universitario de
Investigaciones Biomedicas. Protected by copyright.
Figure 1 Anatomic illustration of the location and extent of functional and structural muscle injuries (eg, hamstrings). (A) Overexertion-related
muscle disorders, (B) Neuromuscular muscle disorders, (C) Partial and (sub)total muscle tears (from Thieme Publishers, Stuttgart; planned to be
published. Reproduced with permission.). This figure is only reproduced in colour in the online version.
Secondary muscle bundles (flesh–fibres) with a diameter of 2– In addition to the size, it is the participation of the adjacent
5 mm (this diameter can vary according to the training status connective tissue, the endomysium, the perimysium, the epimy-
according to hypertrophy) are visible to the human eye.52 sium and the fascia that distinguish a minor from a moderate
Secondary muscle bundles present structures that can be pal- partial muscle tear. Concomitant injury of the external peri-
pated by the experienced examiner, when they are torn. mysium seems to play a special role: This connective tissue
Multiple secondary bundles constitute the muscle (figure 2). structure has a somehow intramuscular barrier function in case
of bleeding. It may be the injury to this structure (with optional
involvement of the muscle fascia) that differentiates a moderate
Partial muscle tears from a minor partial muscle tear.
Most indirect structural injuries are partial muscle tears. Clinical Drawing a clear differentiation between partial muscle tears
experience clearly shows that most partial injuries can be seems difficult because of the heterogeneity of the muscles that
assigned to one of two types, either a minor or a moderate can be structured very differently. Technical capabilities today
partial muscle tear, which ultimately has consequences for (MRI and ultrasound) are not precise enough to ultimately
therapy, respectively for absence time from sports. Thus, indirect determine and prove the effective muscular defect within the
structural injuries should be subclassified. Since previous gradu- injury zone of haematoma and/or liquid seen in MRI which is
ation systems23 24 refer to the complete muscle size, they are somewhat oversensitive at times17 and usually leads to overesti-
relative and not consistently measurable. In addition to this, mation of the actual damage. It will remain the challenge of
there is no differentiation of grade 3 injuries with the conse- future studies to exactly rule out the size which describes the
quence that many structural injuries with different prognostic cut-off between a minor and a moderate partial muscle tear.
consequences are subsumed as grade 3. The great majority of muscle injuries heal without formation
We recommend a classification of structural injuries based on of scar tissue. However, greater muscle tears can result in a
anatomical findings. Taking into account the aforementioned defective healing with scar formation17 which has to be consid-
anatomical factors and as a reflection of our daily clinical work ered in the diagnosis and prognosis of a muscle injury. Our
with muscle injuries, we differentiate between minor partial tears experience is that partial tears of less than a muscle fascicle
with a maximum diameter of less and moderate partial tears with usually heal completely while moderate partial tears can result
a diameter of greater than a muscle fascicle/bundle (see figure 2). in a fibrous scar.
Br J Sports Med: first published as 10.1136/bjsports-2012-091448 on 18 October 2012. Downloaded from http://bjsm.bmj.com/ on February 16, 2023 at Centro Universitario de
Figure 2 Anatomic illustration of the
extent of a minor and moderate partial
muscle tear in relation to the
anatomical structures. Please note,
that this is a graphical illustration,
there are variations in extent. (From
Thieme Publishers, Stuttgart; planned
to be published. Reproduced with
permission.). This figure is only
reproduced in colour in the online
version.
Br J Sports Med: first published as 10.1136/bjsports-2012-091448 on 18 October 2012. Downloaded from http://bjsm.bmj.com/ on February 16, 2023 at Centro Universitario de
3
UEFA Injury Study Group, Medical Committee UEFA, University of Linköping, 16 Armfield DR, Kim DH, Towers JD, et al. Sports-related muscle injury in the lower
Linköping, Sweden extremity. Clin Sports Med 2006;25:803–42.
4
Football Club Chelsea, London, UK 17 Jarvinen TA, Jarvinen TL, Kaariainen M, et al. Muscle injuries: biology and
5
Football Club Manchester United, Manchester, UK treatment. Am J Sports Med 2005;33:745–64.
6
School of Public Health, University of Sydney, Sydney, Australia 18 Anderson K, Strickland SM, Warren R. Hip and groin injuries in athletes. Am J
7
Australian Cricket team and Sydney Roosters Rugby League team, School of Public Sports Med 2001;29:521–33.
Health, University of Sydney, Australia 19 Noonan TJ, Garrett WE Jr. Muscle strain injury: diagnosis and treatment. J Am Acad
8
Orthopedic Department Academic Medical Centre, Amsterdam, The Netherlands Orthop Surg 1999;7:262–9.
9
Department of Orthopedic Surgery and Orthopedic Research Center, Academic 20 Bryan Dixon J. Gastrocnemius vs. soleus strain: how to differentiate and deal with
Medical Center, Amsterdam, The Netherlands calf muscle injuries. Curr Rev Musculoskelet Med 2009;2:74–7.
10
International Olympic Committee, Lausanne, Switzerland 21 O’Donoghue DO. Treatment of injuries to athletes. Philadelphia: WB Saunders, 1962.
11
Department of Vegetative Anatomy, Charité University of Berlin, Berlin, Germany 22 Ryan AJ. Quadriceps strain, rupture and charlie horse. Med Sci Sports
12
University of Gothenborg and National Football Team Sweden, Gothenburg, 1969;1:106–11.
Sweden 23 Takebayashi S, Takasawa H, Banzai Y, et al. Sonographic findings in muscle strain
13
Football Club Ajax Amsterdam, Amsterdam, The Netherlands injury: clinical and MR imaging correlation. J Ultrasound Med 1995;14:899–905.
24 Peetrons P. Ultrasound of muscles. Eur Radiol 2002;12:35–43.
Contributors H-WM-W: member of Conference, senior author of final statement, 25 Stoller DW. MRI in orthopaedics and sports medicine. 3rd edn. Philadelphia:
responsible for the overall content; LH: member of Conference, senior co-author of Wolters Kluwer/Lippincott, 2007.
final statement; KM: member of Conference, co-author of final statement; JE: 26 Ekstrand J, Healy JC, Walden M, et al. Hamstring muscle injuries in professional
member of Conference, co-author of final statement; BE: member of Conference, football: the correlation of MRI findings with return to play. Br J Sports Med
co-author of final statement; SM: member of Conference, co-author of final 2012;46:112–17.
statement; JO: member of Conference, co-author of final statement; NvD: member of 27 Fink A, Kosecoff J, Chassin M, et al. Consensus methods: characteristics and
Conference, co-author of final statement; GMK: member of Conference, co-author of guidelines for use. Am J Public Health 1984;74:979–83.
final statement; PS: member of Conference, co-author of final statement; DB: 28 Fuller CW, Ekstrand J, Junge A, et al. Consensus statement on injury definitions and
member of Conference, co-author of final statement; LS: member of Conference, data collection procedures in studies of football (soccer) injuries. Clin J Sport Med
co-author of final statement; EG: member of Conference, co-author of final 2006;16:97–106.
statement; PU: member of Conference, executive and corresponding author, 29 Orchard J, Marsden J, Lord S, et al. Preseason hamstring muscle weakness
Br J Sports Med: first published as 10.1136/bjsports-2012-091448 on 18 October 2012. Downloaded from http://bjsm.bmj.com/ on February 16, 2023 at Centro Universitario de
50 Garrett WE Jr, Rich FR, Nikolaou PK, et al. Computed tomography of hamstring 53 Beiner JM, Jokl P. Muscle contusion injuries: current treatment options. J Am Acad
muscle strains. Med Sci Sports Exerc 1989;21:506–14. Orthop Surg 2001;9:227–37.
51 Hughes Ct, Hasselman CT, Best TM, et al. Incomplete, intrasubstance strain injuries 54 Kary JM. Diagnosis and management of quadriceps strains and contusions. Curr
of the rectus femoris muscle. Am J Sports Med 1995;23:500–6. Rev Musculoskelet Med 2010;3:26–31.
52 Schuenke M, Schulte E, Schumacher U. Atlas of Anatomy. Stuttgart, Germany, 55 Ryan JB, Wheeler JH, Hopkinson WJ, et al. Quadriceps contusion. West Point
New York: Thieme, 2005. update. Am J Sports Med 1991;19:299–304.