radiation. It can also be used for comparison with other muscle groups( for example, the opposite limb), and with a skilled operator, can be used dynamically to study contraction and relaxation of the muscle in real time. 14

MRI use is increasing as it allows for the thorough assessment of musculoskeletal pathology due to its excellent tissue contrast and high definition of all soft tissues. 14

However, it currently remains a second-line option because of its high cost( usually no Medicare rebate), limited availability, and various rare, but important, contraindications. 14

Treatment and intervention Traditionally, first-aid teaching supports the RICE / RICER( Rest, Ice, Compression, Elevation, ± Referral) method for the acute management of soft tissue injuries.

This protocol focuses on the protection of the damaged muscle in the inflammatory phase, reduction of injury-associated bleeding and swelling, and the reduction of scar tissue formation. 13 It is believed that this is achieved by local vasoconstriction and reduction of

Recommended order of analgesia for acute muscle injuries

1. Paracetamol or topical NSAIDs

2. NSAIDs – COX2 selective then non-selective

3. Opioids

secondary hypoxic damage, due to a decrease in the metabolic demands of the injured tissue. 15

Immobilisation then allows granulation tissue to form between the injured muscle fibres to withstand contraction-induced forces applied, minimising risk of re-injury. 16

Recently, these protocols have been challenged by the development of‘ early mobilisation’ protocols, where tissue loading is initiated within the limits of pain, to accelerate capillary in-growth, and to promote regeneration of the soft tissue. 16

Immediately after the inflammatory phase, mobilisation occurs 3-7 days postinjury to reduce the risk of poor organisation of regenerating myofibres and atrophy of healthy tissue adjacent

17, 18

to the injured area. Early mobilisation should be started gradually with range-of-motion exercises, progressing to isotonic exercises, with clinical judgement essential to minimise the risk of further injury. 17

Splinting / crutches Splinting, crutches or frames may be used in the initial inflammatory and reparative stages to protect the injured muscle and to prevent falls. Gait aids are recommended if weight-bearing is painful, as they assist in optimal loading and range of motion of the affected soft tissues and reduce the development of a limp. 19 Once pain subsides, normal weight-bearing and walking gait should resume as soon as possible.

Stretching Stretching has long been recommended post-injury, particularly during the reparative and maturation phases, where stretching is thought to increase the extensibility of scar tissue and flexibility and aid with alignment of collagen. 6

However, expert opinion is divided due to poor quality research and mixed results.

The two main types of stretching are: dynamic stretching, where the joint and muscles are actively stretched through the full range of motion( often repeatedly); and static stretching, where the muscles are lengthened and held at the end point for a specific duration.

During the early stages of healing, basic pathophysiology dictates that stretching musculotendinous units to their limit is likely to induce re-injury and should be avoided.

Once the individual has reached the maturation / remodelling stage, dynamic stretching may be commenced as indicated and be included pre-exercise. It should be noted that prolonged stretching does not reduce risk of injury, and often does not reduce recovery times for activities with a high level of overuse injuries. 20-22

Medications Pain and swelling are mediated by the inflammatory process and as a result, pain is maximal during the inflammatory phase, then declining rapidly thereafter. 23

Traditionally, NSAIDs are the first-line treatment, due to their analgesic and anti-inflammatory effects. However, their use has been questioned because of potential interruption of the inflammatory cascade, which

23, 24

is vital to healing.

Despite the paucity of evidence to support these claims, NSAIDs should be used judiciously due to their well-publicised side-effect profile. 24

CPD POINTS

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26 | Australian Doctor | 2 June 2017 www. australiandoctor. com. au