**9. T.E.CA.R. THERAPY (Transfer Energetic Capacitive and Resistive)**

The diathermy is based on application of electromagnetic waves; those oscillations induce a transfer of kinetic energy which is readily converted into heat. This effect of heat production in the tissues is called "Joule effect". The diathermy and every other exogenous form of application of heat is indicated only in the resolution phase of the hematoma and never in the immediate post-traumatic period. The rational application of various forms of diathermy is based on accelerating the rate of absorption of the residual hematoma, due to increased blood circulation induced by the temperature (Costantino et al., 2005).

#### **9.1. Hyperthermia**

Notoriously, heat in depth may be very helpful instrumental in hematomas re-absorption.

Also microwave diathermy (the old Marconi therapy) induced hyperthermia into the tissues and can stimulate the repair processes, allowing more efficient relief from pain, helping in the removal of toxic metabolites, reducing the muscles and joints stiffness. Moreover, hyperther‐ mia induces hyperemia, which improves local tissue drainage, increases metabolic rate and induces alterations in the cell membrane. The biological mechanism that regulates the relationship between the thermal dose and the healing process of soft tissues with low or high water content or with low or high blood perfusion is still under study. Microwave diathermy treatment at 434 and 915 MHz can be effective in the short-term management of musculoskeletal injuries (Lehmann et al., 1993) also combined with massage therapy.

#### **9.2. Massage therapy**

Massage therapy and intense eccentric exercise, practical and non-invasive forms of therapy, also seem to have certain usefulness in preventing fibrosis.

Several studies have also shown that vascular endothelial growth factor (VEGF) can increase the efficiency of skeletal muscle repair by increasing angiogenesis and, at the same time, reducing the accumulation of fibrosis. The biological mechanism(s) behind the beneficial effect of massage are still unclear and require further more investigations and randomized human clinical studies (Best et al., 2012).

Validated therapeutic protocols for the treatment of injuries with laser = 1064 nm according to the criteria of Evidence Based Medicine are defined in number of sessions, power density, time

The Treatment of Muscle Hematomas http://dx.doi.org/10.5772/56903 215

Medical Nd Yag laser devices, without thermal control, can't be used early in presence of intense hematoma, but only after needle drainage and not before third / fifth day from the

Today there is a new innovative therapeutic method: laser FP3 SYSTEM. In presence of hematoma and surrounding edema, it is necessary to drain with circular manual scanning with continuous emission at a distance of 10 cm from the skin, draining with high power and low density and many times in a day with breaks of about 30 minutes, divided into mini-sessions

The patient should not perceive "heat". The Fp3 System,with Temperature Control System ®

If the hematoma is over 2,5 cm deep from the skin, laser is set at 4 watt x150-200 joules at minisession, if it is below 2,5 cm depth from the skin, it is set at 6.5 watt x 150/200 joules at mini-

The amount of energy will be a function also of the size of the lesion, but with FP3 it is possible to immediately begin a biostimulating treatment in the first day without fear to clot the

Physical therapies must act in the depth of the lesion, neither above nor below, and on that

TPU (Therapeutic Pulsed Ultrasound) presents beneficial effects on the muscular healing process, inducing a reduction in the production of ROS and also the expression of proinflammatory molecules (Victor et al., 212). Other authors conclude that, although treatment with pulsed ultrasound can promote the satellite cell proliferation phase of the myoregener‐ ation, it does not seem to have significant effects on the overall morphological manifestations

Extracorporeal Shockwave Therapy (ESWT) is an alternative to surgery in calcific shoulder tendinitis when conservative treatments such as non-steroidal anti-inflammatory drugs, steroidal injections, and physiotherapy fail to relieve symptoms. It has been hypothesized that ESWT is effective in the midterm for reducing pain and improving function for patients with chronic calcific myositis or fibrosis and that a dose-response relationship exists in the treatment

detecting T in the first mm deep, respects the absence of heating (T max = 42 ° C).

of application for spot in function to the depth.

session, giving about a total of 800/1000 joules.

tissue in that precise phase.(M Conforti, 2003).

of muscle regeneration (Rantanen et al., 1999).

parameters for effectiveness (Galasso et al., 2110).

trauma due to danger of blood clotting.

(500Joule for session).

hematoma.

**9.5. ESWT**

**9.4. Pulsed ultrasound**

#### **9.3. Lasertherapy**

For a correct use of high power laser therapies, a practical classification is based on the precise localization in depth and on presence-absence of hematoma in muscular injuries.

On the basis of this, the following classification can be purposed:

A) Injury to a depth of 0.5 to 2.5 cm, without hematoma

B) Lesion to a depth of 0.5 to 2.5 cm, with hematoma

C) Injury to a depth of more than 2.5 cm, without hematoma

D) Injury to a depth of more than 2.5 cm, with hematoma (Conforti et.al. 2004)

High energy **laser therapy** had developed in the last twenty years and offers today an effective help by acting in all phases of inflammation and regeneration. At the basis of biological reparative processes is a photochemical reaction able to speed up the reabsorption of intra‐ muscular or intermuscular hematoma and repair processes like capillarization and neoangio‐ genesis (Algeri et al., 2011).

It was demonstrated that laser promotes an increase in collagen IV immunolabeling in skeletal muscle in the first 7 days after acute trauma caused by cryoinjury, but does not modify the duration of the tissue-repair process. Even with LLLT (low-level laser therapy), the injured muscle tissue needs ∼21 days to achieve the same state of organization as that in the noninjured muscle (Baptista et al., 2011).

The laser therapy, in the first 48 h, reduces the intensity of inflammation, in a second phase, about two weeks, it accelerates the healing process and in the third stage, about third and fourth week, of proliferative and restorative healing, it helps to avoid fibrosis, scarring or inelastic metaplasia. Distinction in soft, mid and laser power is no longer accepted, it is preferable to classify laser depending on the wavelength, the power density and the density of energy transferred for unity of surface. The choice of treatment is not empirical but based on the study of Laser radiation interaction -tissue.

The Nd-YAG laser, with 1064 nm, continuous emission is, since fifteen years, the most accredited and used method for treatment of muscle injuries due to its penetration ability, not absorption in Hb and low coefficient of water and melanin absorption (Castellacci et al., 2003)

It is known for effective possibility of transferring the right amount of energy to the injured tissue until 4 or 5 cm in depth in a short time (8-50 sec.).

Validated therapeutic protocols for the treatment of injuries with laser = 1064 nm according to the criteria of Evidence Based Medicine are defined in number of sessions, power density, time of application for spot in function to the depth.

Medical Nd Yag laser devices, without thermal control, can't be used early in presence of intense hematoma, but only after needle drainage and not before third / fifth day from the trauma due to danger of blood clotting.

Today there is a new innovative therapeutic method: laser FP3 SYSTEM. In presence of hematoma and surrounding edema, it is necessary to drain with circular manual scanning with continuous emission at a distance of 10 cm from the skin, draining with high power and low density and many times in a day with breaks of about 30 minutes, divided into mini-sessions (500Joule for session).

The patient should not perceive "heat". The Fp3 System,with Temperature Control System ® detecting T in the first mm deep, respects the absence of heating (T max = 42 ° C).

If the hematoma is over 2,5 cm deep from the skin, laser is set at 4 watt x150-200 joules at minisession, if it is below 2,5 cm depth from the skin, it is set at 6.5 watt x 150/200 joules at minisession, giving about a total of 800/1000 joules.

The amount of energy will be a function also of the size of the lesion, but with FP3 it is possible to immediately begin a biostimulating treatment in the first day without fear to clot the hematoma.

Physical therapies must act in the depth of the lesion, neither above nor below, and on that tissue in that precise phase.(M Conforti, 2003).

#### **9.4. Pulsed ultrasound**

TPU (Therapeutic Pulsed Ultrasound) presents beneficial effects on the muscular healing process, inducing a reduction in the production of ROS and also the expression of proinflammatory molecules (Victor et al., 212). Other authors conclude that, although treatment with pulsed ultrasound can promote the satellite cell proliferation phase of the myoregener‐ ation, it does not seem to have significant effects on the overall morphological manifestations of muscle regeneration (Rantanen et al., 1999).

#### **9.5. ESWT**

Several studies have also shown that vascular endothelial growth factor (VEGF) can increase the efficiency of skeletal muscle repair by increasing angiogenesis and, at the same time, reducing the accumulation of fibrosis. The biological mechanism(s) behind the beneficial effect of massage are still unclear and require further more investigations and randomized human

For a correct use of high power laser therapies, a practical classification is based on the precise

High energy **laser therapy** had developed in the last twenty years and offers today an effective help by acting in all phases of inflammation and regeneration. At the basis of biological reparative processes is a photochemical reaction able to speed up the reabsorption of intra‐ muscular or intermuscular hematoma and repair processes like capillarization and neoangio‐

It was demonstrated that laser promotes an increase in collagen IV immunolabeling in skeletal muscle in the first 7 days after acute trauma caused by cryoinjury, but does not modify the duration of the tissue-repair process. Even with LLLT (low-level laser therapy), the injured muscle tissue needs ∼21 days to achieve the same state of organization as that in the non-

The laser therapy, in the first 48 h, reduces the intensity of inflammation, in a second phase, about two weeks, it accelerates the healing process and in the third stage, about third and fourth week, of proliferative and restorative healing, it helps to avoid fibrosis, scarring or inelastic metaplasia. Distinction in soft, mid and laser power is no longer accepted, it is preferable to classify laser depending on the wavelength, the power density and the density of energy transferred for unity of surface. The choice of treatment is not empirical but based

The Nd-YAG laser, with 1064 nm, continuous emission is, since fifteen years, the most accredited and used method for treatment of muscle injuries due to its penetration ability, not absorption in Hb and low coefficient of water and melanin absorption (Castellacci et al., 2003)

It is known for effective possibility of transferring the right amount of energy to the injured

localization in depth and on presence-absence of hematoma in muscular injuries.

D) Injury to a depth of more than 2.5 cm, with hematoma (Conforti et.al. 2004)

On the basis of this, the following classification can be purposed:

A) Injury to a depth of 0.5 to 2.5 cm, without hematoma

C) Injury to a depth of more than 2.5 cm, without hematoma

B) Lesion to a depth of 0.5 to 2.5 cm, with hematoma

clinical studies (Best et al., 2012).

genesis (Algeri et al., 2011).

injured muscle (Baptista et al., 2011).

on the study of Laser radiation interaction -tissue.

tissue until 4 or 5 cm in depth in a short time (8-50 sec.).

**9.3. Lasertherapy**

214 Muscle Injuries in Sport Medicine

Extracorporeal Shockwave Therapy (ESWT) is an alternative to surgery in calcific shoulder tendinitis when conservative treatments such as non-steroidal anti-inflammatory drugs, steroidal injections, and physiotherapy fail to relieve symptoms. It has been hypothesized that ESWT is effective in the midterm for reducing pain and improving function for patients with chronic calcific myositis or fibrosis and that a dose-response relationship exists in the treatment parameters for effectiveness (Galasso et al., 2110).

#### **9.6. Rehabilitation programme**

The rehabilitation programme should be built around progressive agility and trunk stabiliza‐ tion exercises, as these exercises seem to yield better outcome for injured skeletal muscle than programs based exclusively on stretching and strengthening of the injured muscle. (Järvinen et al., 2007),

The mass is surrounded by a rim of hyalinized fibrous tissue with a chronic inflammatory infiltrate and granulation tissue (Nakano et al., 2010). Histologically, the mass is composed of necrotic debris, fibrin and blood clots. The lesion can be treated by hyperthermia, ultrasound

The Treatment of Muscle Hematomas http://dx.doi.org/10.5772/56903 217

Sport can be resumed when the extensibility, isotonic and isometric and isokinetic stretch tests

The recovery of competitiveness is possible when were recovered in field skills specific sport. We think that prevention is the best thing, but it is often difficult to eliminate the risk of intrinsic and extrinsic damage. We recommend an appropriate warm-up, an appropriate training, balancing agonist-antagonist, to recognize stages pre-lesion as contracture or fatigue and do not underestimate the lesion or his scar, do not administer medications inappropriately, do not perform incomplete or too aggressive rehabilitation and especially to properly use the

Muscle hematomas can have a significant impact on an athlete's performance, ranging from short-term performance impairment, muscle deconditioning and compartmental syndromes, to long-term problems, such as myositis ossificans and possibly muscle re-injuries. We recommend the use of protectors, well tolerated by all people, except in hot conditions, when

We conclude by suggesting to the physician to better delineate the depth of the lesion on ultrasound imaging, because all high energy treatments require precise localization in depth

[1] Algeri, G, & Conforti, M. Laserterapia-Trattato di Medicina Fisica e Riabilitazione a

cura di G.N. Valobra.Vol II Terapia. UTET (Ed). Torino, (2000).

therapy or shock waves or, finally, by excision (Silveira et al., 2010)

are balanced and when the contraction is painless.

means at our possession like physical therapy.

they were uncomfortable (Mitchell,. 2000).

in order to provide the right energy level.

2 Customer Point INAIL, Milan, Italy

Address all correspondence to: maria@mariaconforti.it

1 Sports Physician and Physical Therapies Physician, Bergamo, Italy

**Author details**

Maria Conforti1,2\*

**References**

**11. Conclusions**

In order to assess joint ROM and muscle strength, we used isokinetic dynamometer with concentric contractions (CIBEX Norm) at proposal speeds of each joint, following International accredited protocols. Very important is the dramatic effect of eccentric strength training on muscle strength, both isotonic and isokinetic. It is known that eccentric training reduces the severity of a possible indirectly occurred muscle damage.

The prognosis, returning to the initial concept, is better if the diagnosis is accurate and protocols adequate

Early active exercise in the rehabilitative process is essential for


#### **9.7. Proprioception**

Arthrogenic muscle inhibition not only slows strength gains during rehabilitation, it also slows gains in proprioception and increases susceptibility to further injury. Receptors involved in proprioception are located in skin, muscles, and joints. Information about limb position and movement is not generated by individual receptors, but by populations of afferents. Afferent signals generated during a movement are processed to code for endpoint position of a limb. The afferent input is referred to a central body map to determine the location of the limbs in space. A contribution from central feedback mechanisms to the sense of effort is relevant to muscle rehabilitation and prevention re-injuries. Positive feedback is often associated with instability and oscillation, none of which occurs in normal locomotion (Riva, 2013).
