**7. Treatment**

The first aid for any kind of muscle injury is the **RICE** (Rest, Ice, Compression and Elevation) principle or **PRICE** (Protection, Rest, Ice, Compression and Elevation) principle. The aim of RICE is to stop the injury-induced bleeding into the muscle tissue and thereby to reduce the extent of the injury (Thorsson et al., 1997).

#### **7.1. Rest**

Rest is recommended during the first 24-72 hours following the traumatic event (Reström and Peterson, 2001), in order to prevent further bleeding and exacerbation of fibrillar necrosis at the site of the lesion, thus allowing a better scar (Reström, 2003). Some authors recommend, in case of important hematoma in the lower limb, the total abstention from the load for 48 hours (Lachmann and Jenner, 1994; Reström, 2003). The duration of the rest period depends on the extent of the trauma and the pain symptoms of the patient.

#### **7.2. Elevation**

The elevation of the injured limb may contribute to the resolution of the hematoma reducing blood pressure and increasing venous return (Gray, 1977; Williams, 1980; Peterson and Reström, 2001; Reström, 2003;).

#### **7.3. Compression**

The aim for applying a compression bandage on the injured area is to limit a further haemor‐ rhage (O'Donoghe, 1984; Klein, 1990; Peterson and Reström, 2001). The compression bandage should be maintained for a period of 2 -7 days, but not neglected until a substantial decrease in the swelling and a fluctuation reduction of the palpable mass is obtained (Thorsson et al., 1987; Thorsson et al., 1997). The amount of compression due to the different types of bandage causes different responses at the site of the lesion: high compression, approximately 85 mmHg, obtain an immediate stop of intramuscular blood flow, while a low compression, in the order of 40-45 mmHg, reduces blood flow about 50%. In the bibliography there are not studies on the optimal compression intensity in the case of intra-or intermuscular hematoma. Certainly the patient should not feel pain or have ischemia symptoms.

#### **7.4. Ice**

The cooling of a body area involves a complex of physiological responses that Fu et al. (2007) summarized in: Vasoconstriction-Analgesia-Reduction of edema - Muscle contracture. This initial response induces respectively:


Aside from the different degrees of seriousness in muscle damages, it is necessary to consider the anatomical location where the damage occurred in order to plan the most proper rehabil‐

The first aid for any kind of muscle injury is the **RICE** (Rest, Ice, Compression and Elevation) principle or **PRICE** (Protection, Rest, Ice, Compression and Elevation) principle. The aim of RICE is to stop the injury-induced bleeding into the muscle tissue and thereby to reduce the

Rest is recommended during the first 24-72 hours following the traumatic event (Reström and Peterson, 2001), in order to prevent further bleeding and exacerbation of fibrillar necrosis at the site of the lesion, thus allowing a better scar (Reström, 2003). Some authors recommend, in case of important hematoma in the lower limb, the total abstention from the load for 48 hours (Lachmann and Jenner, 1994; Reström, 2003). The duration of the rest period depends

The elevation of the injured limb may contribute to the resolution of the hematoma reducing blood pressure and increasing venous return (Gray, 1977; Williams, 1980; Peterson and

The aim for applying a compression bandage on the injured area is to limit a further haemor‐ rhage (O'Donoghe, 1984; Klein, 1990; Peterson and Reström, 2001). The compression bandage should be maintained for a period of 2 -7 days, but not neglected until a substantial decrease in the swelling and a fluctuation reduction of the palpable mass is obtained (Thorsson et al., 1987; Thorsson et al., 1997). The amount of compression due to the different types of bandage causes different responses at the site of the lesion: high compression, approximately 85 mmHg, obtain an immediate stop of intramuscular blood flow, while a low compression, in the order of 40-45 mmHg, reduces blood flow about 50%. In the bibliography there are not studies on the optimal compression intensity in the case of intra-or intermuscular hematoma. Certainly

The cooling of a body area involves a complex of physiological responses that Fu et al. (2007) summarized in: Vasoconstriction-Analgesia-Reduction of edema - Muscle contracture. This

on the extent of the trauma and the pain symptoms of the patient.

the patient should not feel pain or have ischemia symptoms.

itation treatment.

210 Muscle Injuries in Sport Medicine

**7. Treatment**

**7.1. Rest**

**7.2. Elevation**

**7.3. Compression**

**7.4. Ice**

Reström, 2001; Reström, 2003;).

initial response induces respectively:

extent of the injury (Thorsson et al., 1997).


The lowering of the temperature causes an increase in blood viscosity with a reduction of blood flow and a reduction of vascular permeability in the cooling area. This physiological effect induced by cold is the key mechanisms in the reduction of edema due to the increasing of venous diameter and of the inflammatory reaction (Smith et al., 1993; Low and Reed, 2000).

A crucial point in cryotherapy application is the duration of cooling. The cooling of a healthy body area initially causes a reflex vasoconstriction, for a period between 9 to16 minutes, followed by a vasodilatation phase between 4 and 6 minutes, after which vasoconstriction reappears. For this reason the application of cold pack on a hematoma should have a duration between 12 and 15 minutes, with interruption of about 10 minutes. The total duration of treatment cryotherapy, however, must be appropriate to the level of the lesion (Lindsey, 1990), because unfortunately is based on empiricism (Bleakeley et al., 2004). We recommend ice bag for 20 minutes (Meaney et al., 1979) or airjet cryotherapy at -3°C for 5 minutes applied several times in a day. The muscle becomes tenser, stiffer, and less elastic as a result of cooling, and the mechanical properties are not fully recovered even after 15 min. So, in results of muscle injuries, warming-up is suggested after cooling to enable normalization of mechanical properties of the muscle.In any case cryotherapy appears particularly indicated in the first 24 hours post-trauma (Gray, 1977; Williams, 1980; Klein, 1990; Lachmann and Jenner, 1994; Renström and Peterson, 2001; Prentice, 2004).

Cryotherapy is used to prevent muscle damage, ( Bailey et al 2007) either separate or associated to stretching in the stretching -spray technique (Taylor et al., 1995). Cryoultrasound (cryo‐ therapy with ultrasound) therapy has more scientific evidence in treatment of tendonitis thank in muscle injury (Costantino et al., 2005).

#### **7.5. Mobilisation**

In the treatment of injured skeletal muscle, an immobilization should immediately be carried out or, at least, an avoidance of muscle contractions should be encouraged. The key to a right therapy consists in the appropriate timing between immobilization and mobilization. How‐ ever, the duration of immobilization should be limited to a short period, sufficient to produce a scar able to bear the forces induced by re-mobilization, thus avoiding to mobilize a lesion healed with type I collagen fibers that would facilitate re-injury. The muscle activity (mobili‐ zation) should be started gradually respecting the physiological phases of wound healing and with the limits of not pain. On the other hand, early return to activity is desirable to optimize the regeneration of healing muscle and recovery of the flexibility, elasticity and strength of the injured skeletal muscle to pre-injury levels.

The interval to muscle repair might be shortened by certain adjuvant therapies which induce higher metabolic turnover.

In case of a not yet organized blood mass, it may be appropriate, from the seventh to twelfth day, to drain the hematoma, under ultrasound guidance. This is possible when blood is melted (Sofka et al., 2001; Del Cura et al., 2010; Zabale and Corta 2010 ).

Ultrasound is the most appropriate tool for interventional procedures on the hematoma when the lesion is visible with this methodology. The target area is easily identified with ultrasound and needle or catheter position is easily and efficacy documented (fig 7). Advantages of USguided procedures include the absence of ionizing radiation, real-time monitoring during needle placement, decreased risk of injury to vessels and nerves, real time confirmation of procedure success of complete fluid aspiration. Complications are rare and can be avoided by using proper sterile technique and evaluate for potential contra-indications to the procedure.

**Figure 8.** Evolution of the lesion after 3days

**9.1. Hyperthermia**

**9.2. Massage therapy**

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

circulation induced by the temperature (Costantino et al., 2005).

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

The Treatment of Muscle Hematomas http://dx.doi.org/10.5772/56903 213

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

skeletal injuries (Lehmann et al., 1993) also combined with massage therapy.

also seem to have certain usefulness in preventing fibrosis.

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 musculo-

Massage therapy and intense eccentric exercise, practical and non-invasive forms of therapy,
