Contusions

Contusions aka Bruise

Crush injury to a muscle is called contusions that usually comes with bruising

Cause

Contact sports
Motor vehicle accident
Fall
Fracture
Dislocation of the joint

Symptoms

Acute
Mild: Minimal local edema, heat and bruising are present
5-20% loss of ROM
Minimum or no loss of strength
They could continue activity

 Moderate:Crushing of several or many fibres of the muscle
Local swelling d/t hematoma, heat and bruising are present
Mild tenderness on site of lesion20-50% loss of ROM

Severe: Crushing of mxl fibres
Local marked, rapid swelling d/t hematoma, edema, heat and bruising
Severe pain at the lesion site
over 50% loss of ROM and Functional loss of strength
Unable to continue any activities
Bruising: Red, black and/or blue

Symptoms shows up rapidly
Risk of bleeding again in the first 10 days
Decreased ROM of joint crossed by affected mxl as bandaged to prevent from further swelling

Early subacute
Mild contusion with little to no pain
Moderately reduced strength with RROM
Bruising: Black and Blue
Pain, edema and inflammation are still present
Adhesion developing around the injury
TrP on synergists and antagonists


Late subacute
Bruising: Yellow, green, brown
Pain, edema, heat are diminishing
Adhesions are maturing around the injury
Hematoma diminishes
 ROM and mxl strength are reduced
Peripheral nerves may be compressed by edema and swelling from contusion

Chronic
Bruising are gone!
Adhesions have matured around the injury
Hypertonicity and TrP are present in the affected Mxl and any compensating structures especially from crush use etc.
Tissue may be cool d/t ischemia
Full ROM and strength of the affected Mxl may be reduced
Some hematoma calcify into myositis ossificans (Bone formation in the muscle or other tissues) within 3-6 weeks after the injury
There is reduced strength and local inflammation
If bone formation within the Mxl belly, it may be surgically removed

What do you need to know?

Of course! We need to know the Health Hx of them

How did it happen?

Any swelling or edema?

Did they see a doctor?

Do they have pain now?

Palliative / Provocative

TTTT

How's their ADL?

Nerve damage?

Myositis ossificans?

Nerve damage?

Observation

Acute: Check gait if lower limb is affected
Do they use crutches?
Antalgic posture?
Edema 
Swelling of hematoma at the lesion sigte
Bruise: Red, Black, Purple over the site is visible
May present some redness

Early and late subacute:Check gait if lower limb is affected
Antalgic posture may occur
Edema diminishes
with moderate or severe contusion, the swelling of a hematoma is present at the lesion site
Bruising over the injury site changes from purple and black in the early subacute stage
Bruise: Brown, yellow and green

Chronic:Possible habituated antalgic Gait and posture in a weight bearing limb
Maybe an alteration in the contour of the Mxl
Tissue may be indented d/t adhesions
With more superficial myositis ossificans deposit, the area may be raised and locally inflamed

Palpation

Acute: Heat over the injured mxl and surroundings
Tenderness
Edema is firm
Hematoma is palpable as a clearly demarcated lump
Protective mxl spasm is present 
in the affected mxl Synergist and the antagonist

Early and late subacute: Heat on the site diminishes
Testure of edema is less firm
Swelling of hematoma diminishes
Tone of the affected mxl, synergist and antagonist changes from spasm in the early subacute stage to tightness and hypertonicity in late subacute
TrP may present

Chronic: Cool to touch d/t hematoma
Tenderness at local to the lesion site
Adhesions and fascial restrictions are present locally
Hypertonicity and TrP are present
If myositis ossificans is present, there is local inflammation and the body island is palpable as hard, unyielding nodule

Testing

Acute: 
Girth measurement test (Circumference test)
ARROM
If moderate or severe contusion is suspected, other testing is CI in acute stage
CI: Swelling
Difficulty continuing the activity or being unable to continue activity
By the result of ARROM

If they have these sxs above, seek medical attention!


Early and late subacute: ARROM, PROM, Isometric testing
to check ROM and strength

Chronic: ARROM, PROM
to check ROM and strength

Special test for Chronic: Length test for rectus femurs, gastrocnemius, soles, adductors, or hamstrings with a moderate or severe contusion reveals shortness of these mxl

Contraindication
ROM for Acute severe contusion
On site work for acute stage
NM tech on site
Avoid removing the protective mxl splinting of acute contusions
Stretching and NM tech for the first week to 10 daysDistal circulation massage may increase congestion through the injured area
Passive stretch beyond the onset of discomfort or pain
Friction with Rx (anti-inflammatories or blood thinners)
Myositis ossificans
Nerve damage

Treatment Plan

Acute: RICE
Affected limb is elevated without a stretch on mxl
Cold hydrotherapy
PROM
DO NOT TREAT THE SITE OF INJURY AT THIS STAGE

Outcome: Reduce pain
Decrease sympathetic Nervous system firing
 Treat any compensating structures
Reduce swelling/edema

Early subacute: Reduce inflammation
Diaphragmatic breathing to decrease sympathetic nervous system firing
 Treat any compensating structures

Proximal lymphatic drainage proximal to the site to reduce edema

Maintain local circulation proximal to the injury only

Reduce spasm with GTO release

TrP on proximal mxl

You may treat the site if the contusion is mild

PROM

Late subacute: At this stage, the healing tissue is less fragile
Prone or supine position could be chosen to their comfort
Hydrotherapy-warm/cold
Outcome: Reduce pain, decrease sympathetic nervous system firing
Time to spend for lymph drainage could be less
Proximal limb is treated to reduce hypertonicity and increase drainage and venous return
Reduce adhesion
TrP, Stripping, ischemic compression to their pain tolerance 
Petrissage can be used to flush the circulation through the mxl
Vibration, stroking, fingertip kneading
Direction: Peripheral to center
Joint play to the proximal and distal joints are introduced in the late subacute stage!

Chronic: Hydrotherapy(Deep moist heat)
Reduce high tone, TrP
Effleurage, Petrissage, ischemic compression
Cross-fibre friction to any remaining adhesions followed by passive stretcher post-isometric relaxation of the mxl to realign the fibres
Don't forget to ice it after this friction tech above!
PROM proximal and distal to the site of injury
Effleurage, Petrissage will increase local venous return

Self care

Hydrotherapy:Once early subacute stage has passed, contrast hydrotherapy can be used

Self-massage: Late subacute to chronic stage could be maintained with gentle frictions within their pain tolerance
Remedial exercise could be given depending on the severity of the injury and stage of healing

Acute: Maintain ROM: Pain free AROM Pain free active resisted isometrics
Early subacute: Maintain strength of affected mxl in a pain free manner: AROM of distal and proximal joint of the site of injury
Gradually increase the free active resisted isometrics
Late subacute: Increase the strength: Once sxs of inflammation and pain have ceased, stretching and activity could be gradually introduced
Chronic: Increase strength and encourage activity: ARROM with isotonic concentric and eccentric exercise to gradually strengthen the affected mxl
They are encourage to return to the activities without a signifiant increase in pain.

Treatment frequency

Shorter and more frequent treatment is recommended for acute and subacute stages (30mins/tx for 3tx/week)
weekly tx for chronic stage (60mins/tx weekly)

How long does it take to get back to before their injury?

This is depending on their age, health condition, any Rx (SE could prevent from their recovery such as blood thinner)