SOCCER INJURIES 0278-5919/98 $8.00 + .

OO

MUSCLE INJURIES ASSOCIATED

WITH SOCCER
Tonu Saartok, MD, PhD

Muscle injuries are prevalent in soccer. Almost one third of soccer

injuries may occur in skeletal muscle.22Arnasson' reported that 28% of
the injuries in five elite male soccer teams were muscle contusions. In
youth soccer, the frequency of muscle injuries, especially contusions,
may be even higher.23If an injury is defined as an athlete's absence from
practice or game for more than a week: the proportion and incidence
of muscle injuries in soccer may be diminished. This may be due to the
benign nature of most muscle injuries, thus making it possible for the
player to return to training within a week.

CLASSIFICATION OF MUSCLE INJURIES

Muscle injuries in sports may be divided into delayed onset of

muscle soreness (DOMS), strain (distraction) injuries and contusions
(compression injuries).

DOMS

Delayed onset of muscle soreness (DOMS) can be regarded as a

supraphysiological overload of the skeletal muscle in unaccustomed,
preferably eccentric, exercise. Muscle ischemia may enhance the training
effect in skeletal m~scle,2~ and, therefore, the limit of muscle capacity
may be passed when athletes heavily train. The incidence of this condi-

From the Department of Surgery, Section of Orthopaedics, Visby Hospital, Visby Sweden

CLINICS IN SPORTS MEDICINE

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VOLUME 17 NUMBER 4 * OCTOBER 1998 811
812 SAARTOK

tion in soccer is not scientifically clarified. Many players and coaches

agree that almost all players will experience immediate (4-24 hours)
postexercise muscle stiffness and pain after heavy training periods that
can be regarded as normal overload.
DOMS may be the more serious form of postexercise overload
injury however, if the injury is due to biochemical events, e.g., ischemia,
or mechanical insufficiency, is not known. Clinically, the symptoms of
DOMS consist of delayed onset of muscle stiffness and pain peaking at
1 to 3 days after the exercise. The muscle weakness following may last
for a week or even more. Morphological studies have revealed that this
injury is due to the breakage and disorganization of the Z-bands and
the cytoskeleton of the muscle sar~omere.~ Additionally, eccentric exer-
cise (active contraction while lengthening or stretching) in muscles with
a high proportion of fast type I1 fibers appears to be a prerequisite,for
this type of i n j ~ r yThe
. ~ treatment of this injury has not been scientifically
evaluated, however, empirically light stretching and ROM training dur-
ing the period with most pain can be followed by gradual return to
isometric and eccentric training.

Muscle Strain Injuries

Muscle strains, or pulls, can clinically appear as different entities

rather than a continuum of injury severity from sudden cramps or total
muscle ruptures. These injuries usually occur in two-joint muscles (e.g.,
the hamstrings) and during eccentric contractions.6, In most cases, the
injury occurs at the myotendinous junction (MTJ).6, For example, in
thigh injuries, the muscle strain apparently occurs in the midbelly of the
muscle, but anatomical studies and MR imaging have revealed that the
tendon may extend almost the whole length of the muscle belly? lo that
supports the usual MTJ location. A minor strain injury may precede a
more severe one6 or other i n j ~ r i e sInactive
.~ as well as fatigued muscles
can absorb less energy and is, therefore, less resistant before reaching
the stretch or strain that may cause a strain injury.6,13, 14, l7 Theref ore,
conditioning the muscles to absorb more energy, including constantly
refilling the energy stores (e.g., glycogen) to avoid fatigue is part of the
prevention of strain injuries.6* In recovery after a strain injury, the
contractile force generation is almost normal after one week in a nonrup-
tive partial strain injury, whereas the contractile ability is decreased for
several weeks.6, The strain injury may possibly be due to concentric
action in one part and a simultaneous eccentric action in another part of
a two-joint muscle. In hamstring muscles, the muscle may be strained
when the muscle is concentrically contracted over the hip joint at the
same time when it is actively stretched (eccentrically) over the knee
joint, as in foot strike in running.
Ekstrand4 pointed out that poor flexibility of soccer players was
associated increased risk for strain injuries. Watsonz8 has added that
soccer players who suffered muscle strains often had increased lumbar
 MUSCLE INJURIES ASSOCIATED WITH SOCCER 813

lordosis, sway back, and abnormal knee interspace. The two-jointed

thigh muscles (rectus femoris, hamstrings) as well as the adductor mus-
cles in the groin area are often injured in soccer.6, In rare cases, the
muscle strain may sometimes be a complete muscle The pain
in ruptures is severe and sudden and usually results in a fall when
running. Immediate investigation reveals poor muscle contraction ability
and quick swelling. In children and youngsters with open physes, this
type of injury most often leads to an avulsion fracture of the muscle-
tendon origin. Therefore, all sudden muscle strain injuries in young
players should have a plain radiograph. In minor strains, the athlete
may only feel a sudden cramp, that often results in limping when trying
to run.

Contusions

Muscle contusions imply a nonpenetrating blunt impact to the mus-

cle tissue resulting in a crushing of muscle tissue. The severity is defined
by the impact energy (i.e., the speed of the collision or the muscle
compression) but also the state of the muscle. A contracted, nonfatigued
muscle makes the contusion less severe and thus more resistant to
injury3,6,
After the introduction of anterior shin guards in soccer, the contu-
sion injury to the anterior shin muscles has nearly disappeared. Thus,
the most common muscle to be contused in soccer are the quadriceps. If
the training or game is continued after a minor contusion injury, the risk
for a more severe muscle injury is increased.6, The contusion injury
most often affects the muscle adjacent to the bone (e.g., the deep vastus
muscles in the thigh). The injury may be intermuscular-with ruptured
fascia-or intramuscular. In the first case, a hematoma caudal of the
injury usually appears the next day, and the swelling and stiffness
gradually disappears. In the intramuscular contusion, however, injury is
associated with intramuscular compartment syndrome and a higher risk
for myositis ossificans.

DIFFERENTIAL DIAGNOSES AND COMPLICATIONS

In most acute cases of muscle injury, the diagnosis is simple. The

athlete provides a history of a sharp, sudden pain in a muscle group,
either due to a sudden strain or a contusion. This leads to pain on
movement and maximal muscle effort, and subsequent swelling and
stiffness. Muscle testing reveals weakness and pain on activation. In late
cases, however, the diagnosis may be extremely difficult. The athlete
does not remember the injury mechanism but presents an often painless
lump in his or her muscle. This may be the first sign of a tumor ( e g , a
sarcoma of the muscle). Diagnosis with ultrasound or MR imaging may
be misleading and thus a biopsy may be needed. If a plain radiograph
814 SAARTOK

reveals calcification in the muscle, this may signify the late appearance
of a muscle injury that has turned into rnyositis ossificans, however,
malignant tumors may have a very similar appearance. Therefore, a
lump in a muscle with no clear history of muscle injury should be
discussed with and sometimes referred to a specialist in soft tissue
tumors, to follow a proper diagnostic algorithm.
Intramuscular bleeding, within an intact muscle fascia, may lead to
local compartrnent syndrome. Progressively increased and severe pain and
swelling with loss of range-of-motion (ROM) within a couple of days
after a muscle injury, without eccymosis on the skin, should be investi-
gated for possible compartment syndrome. Surgery in these cases is
suggested, since evacuation of the hematoma and fascia1 opening will
promptly decrease the pain and pressure.
In athletes using nonsteroidal anti-inflammatory drugs (NSAIDs) in
high doses or for long periods, there is an increased risk of peripheral
nerve palsy, since bleeding in a muscle injury may be more pronounced
and, therefore, increase the risk for compression of a nerve passing in
the muscle. In rare occasions, the nerve itself may be injured. Especially
in severe muscle contusions, the nerve axons to the injured fibers at the
neuromuscular junctions, usually located in the middle part of the fiber,
or at the nerve entrance into the muscle belly (the motor point), may be
a part of the injury. The slow regenerating ability of nerve fibers com-
pared with muscle fibers may then be the reason for prolonged recovery
and rehabilitation.
The hamstring syndrome, with chronic gluteal sciatic or rear thigh
pain, is not really a muscle injury, but a fibrosis near the hamstring
muscle origin, resulting in chronic pain with effort and sometimes symp-
toms of sciatic nerve c o m p r e s ~ i o n2o. ~ ~ ~

DATA FROM BASIC SCIENCE

The skeletal muscle has a high potential for healing due to its rich
vascularity and high metabolic turnover. The repair process is similar
for different types of muscle injury and can be divided into 3 phases:
(1) the destruction phase; (2) the repair phase; and (3) the remodeling
phase.12 The first phase includes the formation of a hematoma, tissue
necrosis, and degeneration. For treatment it is important to limit the size
of the injury since the repair process is inversely correlated to the volume
of injured tissue. The repair process starts with an inflammatory reaction
including phagocytosis of damaged tissue, capillary ingrowth, regenera-
tion of muscle fibers, and the formation of connective tissue scar.12This
normal healing response may be blunted, however, and the repair de-
layed if anti-inflammatory medication is used.Is The regeneration of
muscle fibers includes satellite cell migration into the injured area, form-
ing new myoblasts and later multinucleated myotubes and myofibers.8
The regeneration and the connective tissue formation processes have to
be balanced since they are at the same time supportive and competitive
 MUSCLE INJURIES ASSOCIATED WITH SOCCER 815

with each other.I2A short immobilization is needed for a wound tissue

and collagen network to be established into which the satellite cells then
migrate. Too long of an immobilization leads to excessive connective
tissue and a barrier scar formation. In opposition, too fast of a mobiliza-
tion may disrupt the newly formed scaffold for the satellite cells. Early
mobilization promotes capillary ingrowth and the parallel orientation of
the newly formed myotubes.12Hence, the recommendation from basic
science for the optimal treatment of a muscle injury includes an immedi-
ate immobilization period of no more than 2 to 4 days for the scar tissue
to withstand contraction forces, followed by active mobilization for
optimal orientation and penetration of newly formed myofibers through
the scar tissue.

THERAPEUTIC POSSIBILITIES

The generally recommended immediate care of muscle injuries is

rest-ice-compression-elevation (RICE).The aim is to limit the injury and
optimize the healing process. Immediate compression with a cutaneous
pressure of 85 mm Hg results in almost a complete closure of blood
Local cooling is often used, and reduces the blood flow to about
2 / 3 of normal, but this effect was delayed about 10 to 15 minuteszh
Local cooling does not inhibit the normal inflammatory reaction but
may delay the satellite cell activation6* (i.e., the initiation of regenera-
tion). Aronen et a12have suggested that the initial (24 hour) immobiliza-
tion after muscle contusion injury should be local compression in maxi-
mal passive tension of the injured muscle, thereby decreasing the risk
for complications and shortening the return to play. StretchingI6 may
stimulate muscle healing by the tension stimulus and increases the
recovery of normal ROM after heavy training and is thereby preventive
for soccer inj~ries.~,
29
Rantanen et alZ1have studied the effect of therapeutic ultrasound.
This seems to promote the regeneration, but no effect of the final out-
come was detectable in their animal model. Massage may be analgesic
in muscle injuries,ls but if applied within the first days to a deep muscle
contusion injury, it may increase the risk for myositis ossificans. Anti-
inflammatory medication as NSAIDs are widely used for soft tissue
injuries. Even if a small beneficial effect can be seen the first days after
muscle injury,I2 the healing process may be markedly delayed the first
month.'* Glucocorticoids may in a similar manner lead to delayed regen-
eration.I2Therefore, these drugs should probably be avoided in injuries
where the enhancement of muscle regeneration is preferred.
Only a few types of muscle injuries need surgery. Bony avulsion of
a muscle origin or a total rupture with no remaining muscle function
may need surgery. In addition, surgery may be considered where the
injured muscle lacks agonistic muscles. Technically, the aim is to evacu-
ate the hematoma and adapt the ruptured muscle ends to each other. In
816 SAARTOK

late cases, surgical excision of scar tissue and painful adhesions between
muscle and fascia may be considered.

CONCLUSION

Skeletal muscle has a high potential for regeneration and healing.

After injuries to this tissue the treatment should focus on the limitation
of the injury and optimization of the inherent regeneration capacity. This
includes a short immobilization period, preferably in tension, followed
by early mobilization. The recovery is gradual, usually over a 1- to 12-
week period, depending of the severity.

References

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Icelandic elite soccer players. Med Sci Sports Exerc 26(suppl):82, 1994
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 MUSCLE INJURIES ASSOCIATED WITH SOCCER 817

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Address reprint requests to

Tonu Saartok, MD, PhD
Section of Orthopaedics, Department of Surgery
Visby Hospital
S-621 84 Visby
Sweden