DEAD LEG (QUADRICEPS CONTUSION)

PHYSICAL MEDICINE AND REHABILITATION

MURAT KO

WHAT IS A THIGH CONTUSION (DEAD LEG)?

This type of injury is very common in contact sports. An impact to the muscles can cause more damage than you might expect and should be treated with respect. The muscle is crushed against the bone. If not treated correctly or if treated too aggressively then Myositis Ossificans may occur. There are two types of contusion: Intramuscular which is a tearing of the muscle within the sheath that surrounds it. This means that the initial bleeding may stop early (within hours) because of increased pressure within the muscle however the fluid is unable to escape as the muscle sheath prevents it. The result is considerable loss of function and pain which can take days or weeks to recover. You are not likely to see any bruising come out with this type - especially in the early stages. Intermuscular which is a tearing of the muscle and part of the sheath surrounding it. This means that the initial bleeding will take longer to stop especially if you do not ice it. However recovery is often faster than intramuscular as the blood and fluids can flow away from the site of injury. You are more likely to see bruising come out with this one.

REHABILITATION OF A QUADRICEPS CONTUSION

Aims of rehabilitation Control pain and swelling. Maintain and improve both mobility and flexibility. Restore muscle strength. Return to full fitness.

Reducing pain and swelling Ice, Compress and Elevate (R.I.C.E.) immediately.Use a compression bandage to help reduce swelling and give support until pain has gone. Rest from activity. This may only be for a day or two for a grade one contusion but grade two contusion may require 3 to 5 days rest and a grade three a week or more. Use crutches if necessary. A grade 3 contusion may require use of crutches for a week. It is very important to apply cold and compression to a contusion. Applying heat or deep massage in the acute stage may cause further injury or lead to Myositis Ossificans. Improving mobility and flexibility Gentle stretching if it is not painful - hold for 30 secs, repeat 5 times daily. This may be started after the initial acute stage - usually 48 hours. From day four (no earlier - and it may be longer in severe injuries) apply heat . After the acute stage apply gentle sports massage techniques. For a grade two or three contusion, sports massage should be avoided until the acute stage is complete. Heat treatment and massage can cause serious muscle damage if performed on an acute contusion.

Restoring muscle strength For a grade one contusion, strengthening exercises may be performed as soon as they can be done without pain. Start with the easier exercises on a daily basis and progress as soon as you feel comfortable onto the more difficult exercises which should be done three times a week. For a grade two contusion, it may be a week before strengthening is possible and a grade three even longer. All strengthening sessions should start with a gentle warm up and stretch and finish with a good stretch. Strengthening should continue for weeks after you feel the injury has healed. If the athlete is unable to continue with normal training, then swimming or cycling can be done instead, or if this is not possible work on the upper body strength. It is important to continue a training routine of some description. Return to full fitness This is a gradual process. For a grade one contusion normal training may be resumed with a few days. It is important to maintain a stretching and strengthening programme alongside training to ensure full strengthening and mobility of the muscle. Gentle jogging may be started and built up until the athlete can run comfortably for 40 minutes. Speedwork should be introduced gradually for example: 10 x 60m at 50% of top speed, next session might be 10 x 60m at 70% top speed and so on.

STRETCHING FOR THIGH CONTUSION

Quad stretch Stand on one leg holding the leg to be stretched behind you. Pull the heel in towards the buttocks. Try to keep the knees together to avoid twisting the knee. Hold on to something if you need to balance. If you can't feel a stretch, tilt the pelvis backwards to further lengthen the quads. Hold for 20-30 seconds and repeat 3-5 times. Stretch at least 3 times a day.

Hip flexor stretch Place the knee on the floor and the other foot on the floor in front of you. Push your hips forwards, keeping the back upright. Once you feel a stretch at the front of the hip, hold the position for 20-30 seconds. Repeat 3-5 times and do this at least 3 times a day. Combined hip flexor and quad stretch In the same position as above, lift the back lower leg off the floor and pull the heel towards your buttocks. This will stretch all of the quad muscles and the hip flexors as well. Some people may find this stretch uncomfortable on the knee. Make sure you do it on a padded area and if its still uncomfortable, just do the two above. Again hold for 20-30 seconds, repeat 3-5 times and perform three times a day.

SPORTS MASSAGE FOR THE QUADS

Technique 1: Effleurage to the thigh Aim - light stroking to warm up the area in preparation for deeper techniques. With the hands stroke lightly but firmly upwards from just above the patella to to the top of the thigh. Try to cover as much of the surface as possible with the hands. Always stroke upwards towards the heart in the direction of blood flow. Veins have valves which prevent blood from flowing back the wrong way. Forcing it through with massage can damage the veins. Then lightly bring the hands down the outside of the leg keeping them in contact but do not apply pressure. Use slow, smooth movements. Many beginners tend to rush the massage techniques. Repeat the whole movement using slow stroking techniques, trying to cover as much of the leg as possible. Repeat this technique for about 2 to 5 minutes, gradually applying deeper pressure on the up strokes.

Technique 2: Petrissage Aim - To start to loosen the muscles and really increase the warmth. A kneading type technique. Move the muscles one way with one hand and the other way with the other. Try to cover the whole area of the thigh. Gradually apply more pressure.

Techniques 3 and 4: Stripping the muscle and Circular frictions. Aim - to apply sustained pressure to the muscle, ironing out any lumps, bumps and knots. With the thumb of the right hand (for the left leg), apply deep sustained pressure along the full length of the muscle. This technique should be slow and deliberate to 'feel' the muscle underneath. A good therapist will gradually build up a mental picture of exactly where the tension and scar tissue is in the muscle. The thumb can be reinforced using the thumb or two fingers of the other hand. Repeat this 3 to 5 times in a row, alternating with petrissage for 5 to 10 minutes. If the therapist comes across any tight, tender knots in the muscle (usually at the point of strain or rupture), these can be worked out with deep circular frictions to the knot. Massage should be deep but not so deep that the athlete tightens up with pain. Technique 4: Stripping the Iliotibial Band Apply sustained pressure with the heel of the hand along the length of the iliotibial band. This technique can be uncomfortable or even painful so start gently.

Technique 5: Trigger points Any lumps and bumps or particularly sensitive spots can be treated with deep, sustained pressure to these points using the thumbs. Increase the pressure on the spot until it ranks 7/10 on the pain scale (10 being painful). Hold this pressure until it eases off to 4/10 on the pain scale (usually about 5 seconds). Without easing off with the pressure, increase again until it reaches 7/10 on the pain scale once more. Hold until it eases, repeat once more. This technique is very hard on the thumbs. It is important to keep the thumb slightly bent (flexed) when applying pressure to avoid damaging the joints. Finger nails need to be short to apply this technique correctly.

Finishing off The therapist can finish off with more petrissage techniques and then finally effleurage again. The whole process need not last more than half an hour. Massage therapy can be applied every day if it is performed lightly however deeper techniques may result in a days recovery period to allow tissues to 'recover' just like they would after a training session. For rehabilitation of muscle strains, sports massage is very important in softening / preventing scar tissue forming at the site of injury and re-aligning the new healing fibres in the direction of the muscle fibres. This will help prevent reinjury.