**5. Injective therapy**

treatment is mainly to reduce hemorrhage. However, there are no randomized control trials (RCTs) which have proven the effectiveness of using RICE for soft tissue injury. However there

Rest prevents an increase in the lesion gap which can occur as a consequence of the fibrotic tissue that forms with healing of the muscle lesion [4,6]. Rest also reduces the hemorrhage

There is evidence that ice utilization in the early stages of soft tissue injury is associated with a reduced haematoma and inflammatory process and therefore a quicker regenera‐

Despite the fact that compression it has been demonstrated to reduce the blood flow in the injured area, its effectiveness is still controversial. In fact, there is no evidence,, that compres‐

However, the clinical recommendations are usually to perform a combination of icing and compression for a period of 15-20 minutes, repeated in 30-60 minute intervals. This protocol has been demonstrated to reduce the intramuscular temperature to between 3° and 7° C, thus

It is advised to elevate the injured body part in order to decrease the hydrostatic pressure and

Experimental animal models of muscle injury have been used to examine the effect of NSAIDs on healing. These models have mostly demonstrated no effect on muscle healing, no reduction

Studies conducted on humans subjects examining the effect of short courses of NSAIDs on

While some investigations have not found any effect of NSAID administration on muscle recovery, there are several reports supporting a protective effect of NSAID medication, typically characterized by a lesser degree of muscle damage and functional deficit in the early

in muscle strength and no altered cytoarchitecture after injury (Jarvinen et al, 1992).

sion may accelerate the healing process in a muscle strain.

decreasing the blood flow by approximately 50% [9,10].

therefore the interstitial fluid within the lesion itself.

acute muscle injury are contradictory [12,13,14,15,16].

is evidence on the effectiveness of the single components of the RICE regime [3,5].

**3.1. Rest**

**3.2. Ice**

tive process [7,8].

**3.3. Compression**

**3.4. Elevation**

**4. NSAIDs**

period after injury.

associated with the lesion.

158 Muscle Injuries in Sport Medicine

Many injection protocols have been proposed for the treatment of muscle lesions. Cortico‐ steroid injections, Muller-Wolfart protocol, prolotherapy, classic mesotherapy, mesothera‐ py with omeophatic products and others have been suggested. However, no protocol has strong scientific evidence, as there are no RCTs supporting their use. Although anecdotal clinical data and expert opinion can be found on each technique and their use in athletes [21], unfortunately, currently there is insufficient scientific evidence to support the use of such protocols..

Further research is required to assess the efficacy of these injection therapies preferably with the integration of various techniques in order to obtain a holistic approach.

#### **5.1. Corticosteroids**

The use of corticosteroids in the treatment of muscle injuries is controversial. There are concerns due to the risk of incomplete healing or rupture of the healing tissue. Moreover, any injection carries the risk of introducing infection. Experiments on animal models have been promising. Anaccelerated recovery of contractile tension after a single dose injection of corticosteroids provided soon after a muscle strain, was proven effective in rats, with‐ out any major adverse effects recorded [22].

**6. Mesotherapy**

**7. Prolotherapy**

**8. Antifibrotic agents**

lack of strong scientific evidence supporting its use.

techniques in the region of the lesions.

Mesotherapy is a term that derives from Greek mesos (middle) and therapeia (therapy). It employs multiple injections of pharmaceutical and homeopathic medications, plant extracts, vitamins, and other ingredients into subcutaneous fat. This technique has been purposed and implemented by Michel Pistor (1924–2003), a French physician which performed the first clinical research on this treatment. Mesotherapy is quite a diffusely used treatment method, especially in the sport medicine field. However there are concerns over its efficacy due to the

Medical Treatment of Muscle Lesion http://dx.doi.org/10.5772/56329 161

In particular, there is no scientific research on the use of mesotherapy for muscle strains. However, international guidelines purpose weekly sessions to be started as soon as possible after the lesion. Common substances proposed are an anesthetic, a vasodilator and an antiinflammatory with deep injection techniques and a miorelaxant with superficial injection

Prolotherapy derives its name from "proliferation therapy," or "proliferative injection ther‐ apy". It has also been called "regenerative injection therapy" ("RIT"), and some contem‐ porary authors name the therapy according to the injected solution. The precise mechanism of action is not known. It involves injecting a non-pharmacological and nonactive irritant solution into the body. This is hypothesized to reinitiate the inflammatory process which deposits additional new fibers, thereby repairing lax tendons or ligaments and also possibly promote the release of local growth factors. However, the precise mech‐ anism of action still remains unknown. It has been used for approximately 100 years, however, its modern application can be traced to the 1950s.This was when the prolothera‐ py injection protocols were formalized by George Hackett, a general surgeon in the U.S.,and were based on his clinical experience of over 30 years. The concept of creating irritation or injury to stimulate healing has been recorded as early as Roman times when

There are no trials on the use of prolotherapy in a population with acute muscle tears. There is some evidence for its use in chronic pathologies such as LBP [29], groin pain [30], and knee OA [31]. However, existing evidence is inconclusive. Its actual use is based on "expert opinion" and some practitioners advocate a positive impact of the use

Many reports indicate that the overproduction of transforming growth factor (TGF)–β in response to injury and disease is a major cause of tissue fibrosis both in animals and humans.

hot needles were poked into the shoulders of injured gladiators [28].

of prolotherapy in athletes in term of return to play timeframes.

Unfortunately, evidence is lacking on human subjects. To our knowledge, only two stud‐ ies have been performed on athletes, both of which show promising results. However, neither has been confirmed by other researchers. The first research study [23] retrospec‐ tively reviewed American football players treated with corticosteroid intralesional injec‐ tions for acute hamstring strain. The results demonstrated that the return to play time was reduced and that there were no adverse effects. In the second study [24], baseball pitchers were treated with corticosteroid injection for abdominal strains. This treatment resulted in a quicker recovery and return to play, without any reinjuries. Unfortunately, these studies contained many limitations which warrant further research studies before considering an implementation of such treatment.

#### **5.2. Traumheel®**

A frequently used preparation for the symptoms associated with acute musculoskeletal injuries, is Traumeel® (Biologische Heilmittel Heel GmbH, Baden-Baden, Germany). This is an antiinflammatory and analgesic homeopathic remedy combination that contains small amounts of belladonna, arnica montana radix, Aconitum napellus, chamomilla, Symphytum officinale, Calendula officinalis, Hamamelis virginina, millefolium, hepar sulphuris calcar‐ eum, and mercurius solubilis,plus a fixed combination of biological and mineral extracts. Its use in sport medicine is based on its effect on pain (Atropa belladonna), inflammation (Echinacea), bruising (Arnica montana), wound healing (Matricaria recutita, Calendula officinalis), bleeding (Achillea millefolium), edema (Mercurius solubilis), and infection (Hepar sulfuris). All these effects may have a positive effect on muscle strain healing, however, its ability to accelerate healing has not yet been demonstrated [25]. Traumeel is described to be well tolerated and without adverse effects, which are important characteristics for a product to be utilized on athletes.

#### **5.3. Actovegin**

Actovegin® is a deproteinised haemodialysate produced by Nycomed Austria GmbH. It enhances aerobic oxidation in mammals, which improves absorption of glucose and oxy‐ gen uptake in tissue. It does not contain growth factors or hormone-like substances, how‐ ever, since ithas been thought to be aperformance enhancing agent, Actovegin has been banned for a period by WADA. This is despite the fact that there is evidence in the litera‐ ture,that oral Actovegin does not have any anabolic or ergogenic activity in terms of mus‐ cle development [26]. There is also some scientific evidence that Actovegin may facilitate healing and reduce time of return to play following soft tissue injury [27] However, its use in mainly based on expert opinion, which are reporting good results on the use of Actovegin in athletes.
