**4. Chronic lesions in muscle injuries**

When a muscle is subject to a trauma (either direct or indirect) the subsequent inflammation is meant to repair the damage tissue in order to allow its complete recovery.

Sometimes, however, the complete recovery does not take place giving raise to complication and conditions which for an athlete can be a serious problem as the performance can be severely limited.

**Case 2** 

Example of a professional footballer

Example of a goalkeeper who during jump was kicked in the side of his **Figure 39.** US image of lesion due to a contusion in a professional footballer

Figure 39: US image of lesion due to a contusion in a professional footballer

Differently from the classification above a definition of muscle injury complication appears to be universally recognized and more simple. abdomen receving a contusion and subsuequent injury of the Obliquus Abdominis Muscle

These include: The Ultrasound revealed a large anaechoic area of the Obliquus Abdominis

**•** Fibrosis Muscle.( Fig.39 )

Only a correct history of the injury can help in understanding the stages in the level of the

Only a correct history of the injury can help in understanding the stages in the

 **Case 1** 

Example of a professional footballer

Figure 38: US image of lesion due to a contusion in a professional footballer

Example of a goalkeeper who during jump was hit with a knee on his thigh receving a

Example of a goalkeeper who during jump was kicked in the side of his abdomen receving a

The Ultrasound revealed a large anaechoic area of the ObliquusAbdominis Muscle. (Fig.39)

When a muscle is subject to a trauma (either direct or indirect) the subsequent inflammation

Sometimes, however, the complete recovery does not take place giving raise to complication and conditions which for an athlete can be a serious problem as the performance can be

Example of a goalkeeper who during jump was hit with a knee on his thigh receving a contusion and subsuequent injury of the Vastus Intermedius muscle

The Ultrasound revealed a large anaechoic area.( Fig.38 )

contusion and subsuequent injury of the ObliquusAbdominis Muscle

is meant to repair the damage tissue in order to allow its complete recovery.

contusion and subsuequent injury of the VastusIntermedius muscle

**Figure 38.** US image of lesion due to a contusion in a professional footballer

The Ultrasound revealed a large anaechoic area. (Fig.38)

Example of a professional footballer

**4. Chronic lesions in muscle injuries**

**Direct Muscular Injuries** 

This typically are injuries by contusion followed by hoematoma which by

ultrasound revealed no difference from intrinsic hoematoma

A large anechoic area was revealed due to haematoma associated to retraction of the muscle head as from a complete tear of the Tendon of the Pectorali Major

fluid. **Case 1**

**Case 2**

severely limited.

Example of a professional footballer

muscle.( Fig.37 )

level of the fluid.

124 Muscle Injuries in Sport Medicine


#### **4.1. Fibrosis**

33

It is the most frequent complication.

It reduces the muscle elastic and functional capacities (the capacity to develop strength) as it replaces the normal tissue.

It is usually caused by early mobilisation or prolonged immobilisation with excessive forma‐ tion of abnormal, hypertrophic retracting fibrous tissue which affect the functionality of the muscular area involved.

The Ultrasound reveals a hyperechoic area which represents fibrous tissue in the injured muscle injured muscle

**CASE 1** 

The Ultrasound reveals a hyperechoic area which represents fibrous tissue in the

**FIBROSIS**

It reduces the muscle elastic and functional capacities ( the capacity to develop

It is usually caused by early mobilisation or prolonged immobilisation with excessive formation of abnormal, hypertrophic retracting fibrous tissue which

#### **Case 1**

Example of a professional footballer Example of a professional footballer

It is the most frequent complication.

strength ) as it replaces the normal tissue.

**Figure 40.** US images of Fibrosis in a professional footballer Example of a professional footballer with a fibrosis of the Adductor muscle

Figure 40: US images of Fibrosis in a professional footballer

36 Example of a professional footballer with a fibrosis of the Adductor muscle approximately two months after a severe injury approximately two months after a severe injury Ultrasound reveals a large hyperechoic area in the previously injured muscle

Ultrasound reveals a large hyperechoic area in the previously injured muscle from reparation of the muscular injury with formation of abnormal, hypertrophic retracting fibrous tissue which affect the functionality of the muscular area involved. (Fig.40) from reparation of the muscular injury with formation of abnormal, hypertrophic retracting fibrous tissue which affect the functionality of the muscular area involved.( Fig.40 )

#### **Case 2**

Example of a professional footballer **CASE 2** 

Ultrasound reveals a large hyperechoic area in the previously injured muscle

hypertrophic retracting fibrous tissue which affect the functionality of the

from reparation of the muscular injury with formation of abnormal,

Example of a professional footballer

37

Example of a professional footballer with a fibrosis of the Rectus Femoris muscle approxi‐

Diagnostic Imaging in Muscle Injury http://dx.doi.org/10.5772/56472 127

Ultrasound reveals a large hyperechoic area in the previously injured muscle from reparation of the muscular injury with formation of abnormal, hypertrophic retracting fibrous tissue

It is a reaction process with formation of sero-sanguineus fluid between two muscular fasciae detectable by Ultrasound as a long plate with totally anaechoic or hypoechoisc or echoic

**CASE 1** 

Example of a professional footballer

Figure 42: US images of a Fluid Collection in a professional footballer

completely anaechoic long plate.( Fig.42 )

Example of a professional footballer

Example of a professional footballer

**Figure 42.** US images of a Fluid Collection in a professional footballer

Example of a footballer with residual and totally colliquative fluid collection between Gastrocnemius and Soleus muscles detectable by Ultrasound as a

Example of a footballer with residual and totally colliquative fluid collection between Gastro‐ cnemius and Soleus muscles detectable by Ultrasound as a completely anaechoic long plate.

**CASE 2** 

Example of a professional footballer

Example of a footballer with residual fluid collection partially colliquative and partially

structured detectable by Ultrasound as a completely hypoechoic long plate. (Fig.43)

 **INTERMUSCULAR FLUID COLLECTION** 

It is a reaction process with formation of sero-sanguineus fluid between two muscular fasciae detectable by Ultrasound as a long plate with totally anaechoic

38

which affect the functionality of the muscular area involved. (Fig.41)

mately two months after a severe injury

**4.2. Intermuscular fluid collection**

Example of a professional footballer

or hypoechoisc or echoic structure.

structure.

**Case 1**

(Fig.42)

**Case 2**

**Case 3**

Example of a professional footballer with a fibrosis of the Rectus Femoris **Figure 41.** US images of Fibrosis in a professional footballer

muscular area involved.( Fig.41 )

Figure 41: US images of Fibrosis in a professional footballer

muscle approximately two months after a severe injury

Example of a professional footballer with a fibrosis of the Rectus Femoris muscle approxi‐ mately two months after a severe injury

Ultrasound reveals a large hyperechoic area in the previously injured muscle from reparation of the muscular injury with formation of abnormal, hypertrophic retracting fibrous tissue which affect the functionality of the muscular area involved. (Fig.41)

#### **4.2. Intermuscular fluid collection INTERMUSCULAR FLUID COLLECTION**

It is a reaction process with formation of sero-sanguineus fluid between two muscular fasciae detectable by Ultrasound as a long plate with totally anaechoic or hypoechoisc or echoic structure. It is a reaction process with formation of sero-sanguineus fluid between two muscular fasciae detectable by Ultrasound as a long plate with totally anaechoic or hypoechoisc or echoic structure.

**CASE 1** 

Example of a professional footballer

#### **Case 1**

36

37

The Ultrasound reveals a hyperechoic area which represents fibrous tissue in the injured

**CASE 1** 

Example of a professional footballer

Example of a professional footballer with a fibrosis of the Adductor muscle approximately two

Example of a professional footballer with a fibrosis of the Adductor muscle

Ultrasound reveals a large hyperechoic area in the previously injured muscle

hypertrophic retracting fibrous tissue which affect the functionality of the

Ultrasound reveals a large hyperechoic area in the previously injured muscle from reparation of the muscular injury with formation of abnormal, hypertrophic retracting fibrous tissue

Example of a professional footballer

The Ultrasound reveals a hyperechoic area which represents fibrous tissue in the

**FIBROSIS**

It reduces the muscle elastic and functional capacities ( the capacity to develop

It is usually caused by early mobilisation or prolonged immobilisation with excessive formation of abnormal, hypertrophic retracting fibrous tissue which

muscle

injured muscle

126 Muscle Injuries in Sport Medicine

**Case 1**

Example of a professional footballer

It is the most frequent complication.

strength ) as it replaces the normal tissue.

affect the functionality of the muscular area involved.

Figure 40: US images of Fibrosis in a professional footballer

which affect the functionality of the muscular area involved. (Fig.40)

Figure 41: US images of Fibrosis in a professional footballer

muscle approximately two months after a severe injury

muscular area involved.( Fig.41 )

**Figure 41.** US images of Fibrosis in a professional footballer

Example of a professional footballer with a fibrosis of the Rectus Femoris

Ultrasound reveals a large hyperechoic area in the previously injured muscle

hypertrophic retracting fibrous tissue which affect the functionality of the

from reparation of the muscular injury with formation of abnormal,

from reparation of the muscular injury with formation of abnormal,

**Figure 40.** US images of Fibrosis in a professional footballer

approximately two months after a severe injury

months after a severe injury

Example of a professional footballer

muscular area involved.( Fig.40 )

**CASE 2** 

**Case 2**

Example of a professional footballer

**Figure 42.** US images of a Fluid Collection in a professional footballer

Example of a footballer with residual and totally colliquative fluid collection between Gastrocnemius and Soleus muscles detectable by Ultrasound as a completely anaechoic long plate.( Fig.42 ) Example of a footballer with residual and totally colliquative fluid collection between Gastro‐ cnemius and Soleus muscles detectable by Ultrasound as a completely anaechoic long plate. (Fig.42)

**CASE 2** 

#### **Case 2**

Example of a professional footballer Example of a professional footballer

Example of a footballer with residual fluid collection partially colliquative and partially structured detectable by Ultrasound as a completely hypoechoic long plate. (Fig.43)

#### **Case 3**

Example of a professional footballer

 **CASE 3**

Figure 43: US images of a Fluid Collection in a professional footballer

Example of a footballer with residual fluid collection partially colliquative and **Figure 43.** US images of a Fluid Collection in a professional footballer

Example of a professional footballer

Figure 44:US images of a Fluid Collection in a professional footballer **Figure 44.** images of a Fluid Collection in a professional footballer

Example of a footballer with totally structured fluid collection between Gastrocnemius and Soleus muscles detectable by Ultrasound as a completely anaechoic long plate.( Fig.44 ) Example of a footballer with totally structured fluid collection between Gastrocnemius and Soleus muscles detectable by Ultrasound as a completely anaechoic long plate. (Fig.44)

#### **4.3. Cyst sero-sanguineus**

39 It is the consequence of a badly treated hoematoma which is not completely absorbed and which is encapsuled by newly formed fibrous tissue which separates it from the surrounding muscular tissue.

It originates from reaction process of the badly treated hoematoma which leads to the forma‐ tion of sero-sanguineus fluid structured as a cyst capsuled in newly formed fibrous tissue. Figure 44:US images of a Fluid Collection in a professional footballer Example of a footballer with totally structured fluid collection between

Ultrasound reveals a completely anaechoic round shaped structure with posterior acoustic enhancement. Gastrocnemius and Soleus muscles detectable by Ultrasound as a completely anaechoic long plate.( Fig.44 )

39

40

Diagnostic Imaging in Muscle Injury http://dx.doi.org/10.5772/56472 129

41

**CYST SERO-SANGUINEUS**

It is the consequence of a badly treated hoematoma which is not completely absorbed and which is encapsuled by newly formed fibrous tissue which

It originates from reaction process of the badly treated hoematoma which leads to the formation of sero-sanguineus fluid structured as a cyst capsuled in newly

Ultrasound reveals a completely anaechoic round shaped structure with

Figure 45: US images of a Sero-sanguineus cyst in a professional footballer

Femoris Muscle approximately three weeks after muscular injury.

Badly treated inflammatory process of the injured muscle usually after contusion of large limb muscles close to the bones which leads to calcium

posterior acoustic enhancement.( Fig.45 )

muscles close to the bones which leads to calcium deposit.

approximately three weeks after muscular injury.

enhancement. (Fig.45)

deposit.

**4.4. Ossific myositis**

**Case 1**

central and peripheral vessels

Example of a professionale rugby player

posterior acoustic shadows.( Fig.46 )

**Figure 46.** US images of a calcification in a professional rugby player

**Figure 45.** US images of a Sero-sanguineus cyst in a professional footballer

Ultrasound reveals a completely anaechoic round shaped structure with

 **OSSIFIC MYOSITIS** 

Example of a professional footballer with sero-sanguineus cyst of the Rectus

Example of a professional footballer with sero-sanguineus cyst of the Rectus Femoris Muscle

Ultrasound reveals a completely anaechoic round shaped structure with posterior acoustic

Badly treated inflammatory process of the injured muscle usually after contusion of large limb

Two stages can be identified, a pre-calcific stage which is revealed as a pseudo solid mass in Ultrasound with Doppler signal along the edges and a calcific stage represented by a heterogeneous mass with linear hyperechoich imaging showing posterior acoustic shadows and both central and peripheral vessels

Two stages can be identified, a pre-calcific stage which is revealed as a pseudo solid mass in Ultrasound with Doppler signal along the edges and a calcific stage represented by a hetero‐ geneous mass with linear hyperechoich imaging showing posterior acoustic shadows and both

**CASE 1**

Example of a professionale rugby player

Figure 46: US images of a calcification in a professional rugby player

Post contusion injury of the Rectus Femoris muscle approximately two weeks after the injury with hoematoma linked to calcification easily detectable by Ultrasound as a heterogeneous mass with linear hyperechoich imaging showing

**CASE 2** 

Example of a professionale rugby player

**CASE 1** 

Example of professional footballer

separates it from the surrounding muscular tissue.

formed fibrous tissue.

posterior acoustic enhancement.

#### **Case 1**

Example of professional footballer

**CYST SERO-SANGUINEUS**

It is the consequence of a badly treated hoematoma which is not completely absorbed and which is encapsuled by newly formed fibrous tissue which

It originates from reaction process of the badly treated hoematoma which leads to the formation of sero-sanguineus fluid structured as a cyst capsuled in newly

Ultrasound reveals a completely anaechoic round shaped structure with

**CASE 1** 

separates it from the surrounding muscular tissue.

formed fibrous tissue.

posterior acoustic enhancement.

Figure 45: US images of a Sero-sanguineus cyst in a professional footballer **Figure 45.** US images of a Sero-sanguineus cyst in a professional footballer

Example of a professional footballer with sero-sanguineus cyst of the Rectus Femoris Muscle approximately three weeks after muscular injury. Example of a professional footballer with sero-sanguineus cyst of the Rectus Femoris Muscle approximately three weeks after muscular injury. Badly treated inflammatory process of the injured muscle usually after

Ultrasound reveals a completely anaechoic round shaped structure with posterior acoustic enhancement.( Fig.45 ) Ultrasound reveals a completely anaechoic round shaped structure with posterior acoustic enhancement. (Fig.45) contusion of large limb muscles close to the bones which leads to calcium deposit.

#### **4.4. Ossific myositis** Two stages can be identified, a pre-calcific stage which is revealed as a pseudo solid mass in Ultrasound with Doppler signal along the edges and a calcific

 **OSSIFIC MYOSITIS**  Badly treated inflammatory process of the injured muscle usually after contusion of large limb muscles close to the bones which leads to calcium deposit. stage represented by a heterogeneous mass with linear hyperechoich imaging showing posterior acoustic shadows and both central and peripheral vessels

40 Two stages can be identified, a pre-calcific stage which is revealed as a pseudo solid mass in Ultrasound with Doppler signal along the edges and a calcific stage represented by a hetero‐ geneous mass with linear hyperechoich imaging showing posterior acoustic shadows and both central and peripheral vessels

**CASE 1**

#### **Case 1**

39

39

plate.( Fig.43 )

128 Muscle Injuries in Sport Medicine

plate.( Fig.43 )

Figure 43: US images of a Fluid Collection in a professional footballer

Example of a footballer with residual fluid collection partially colliquative and partially structured detectable by Ultrasound as a completely hypoechoic long

Example of a professional footballer

Example of a footballer with residual fluid collection partially colliquative and partially structured detectable by Ultrasound as a completely hypoechoic long

Figure 44:US images of a Fluid Collection in a professional footballer

Example of a footballer with totally structured fluid collection between Gastrocnemius and Soleus muscles detectable by Ultrasound as a completely anaechoic long plate. (Fig.44)

Example of a professional footballer

It is the consequence of a badly treated hoematoma which is not completely absorbed and which is encapsuled by newly formed fibrous tissue which separates it from the surrounding

It originates from reaction process of the badly treated hoematoma which leads to the forma‐ tion of sero-sanguineus fluid structured as a cyst capsuled in newly formed fibrous tissue.

Example of a footballer with totally structured fluid collection between Gastrocnemius and Soleus muscles detectable by Ultrasound as a completely

Figure 44:US images of a Fluid Collection in a professional footballer

Ultrasound reveals a completely anaechoic round shaped structure with posterior acoustic

Example of a footballer with totally structured fluid collection between Gastrocnemius and Soleus muscles detectable by Ultrasound as a completely

 **CASE 3**

anaechoic long plate.( Fig.44 )

Example of professional footballer

anaechoic long plate.( Fig.44 )

**4.3. Cyst sero-sanguineus**

muscular tissue.

enhancement.

**Case 1**

**Figure 44.** images of a Fluid Collection in a professional footballer

 **CASE 3**

Figure 43: US images of a Fluid Collection in a professional footballer

**Figure 43.** US images of a Fluid Collection in a professional footballer

Example of a professionale rugby player Example of a professionale rugby player

Post contusion injury of the Rectus Femoris muscle approximately two weeks after the injury with hoematoma linked to calcification easily detectable by Ultrasound as a heterogeneous mass with linear hyperechoich imaging showing

**CASE 2** 

Example of a professionale rugby player

Figure 46: US images of a calcification in a professional rugby player **Figure 46.** US images of a calcification in a professional rugby player

posterior acoustic shadows.( Fig.46 )

Post contusion injury of the Rectus Femoris muscle approximately two weeks after the injury with hoematoma linked to calcification easily detectable by Ultrasound as a heterogeneous mass with linear hyperechoich imaging showing posterior acoustic shadows. (Fig.46)

#### **Case 2**

Example of a professionale rugby player

Figure 47: US images of a calcification in a professional rugby player **Figure 47.** US images of a calcification in a professional rugby player This complication originates from a chronic tendon tear or nerve implication

Example of a post contusion injury approximately seven days after the trauma which shows a pseudo solid mass in Ultrasound.( Fig.47 ) Example of a post contusion injury approximately seven days after the trauma which shows a pseudo solid mass in Ultrasound. (Fig.47) with subsequent muscular adipose infiltration linked to reduction of the muscle volume.

#### **4.5. Muscular atrofia** Ultrasound shows a reduced hyperechoic muscle

This complication originates from a chronic tendon tear or nerve implication This complication originates from a chronic tendon tear or nerve implication with subsequent muscular adipose infiltration linked to reduction of the muscle volume. **CASE 1** 

Example of a professional volleyball player

**MUSCULAR ATROFIA**

with subsequent muscular adipose infiltration linked to reduction of the muscle volume. Ultrasound shows a reduced hyperechoic muscle

Figure 48: US images of reduced hyperechoic muscle in a professional volleyball player

Figure 48: US images of reduced hyperechoic muscle in a professional volleyball player

42

42

**Case 1**

Femoris muscle

**5. Conclusions**

referring clinicians.

There however some disadvantages.

markedly improved image resolution. [2]

Example of a professional volleyball player (Fig.48)

Ultrasound shows a reduced hyperechoic muscle. (Fig.48)

Example of volleyball player after a severe miotendon injury of the long head of the Biceps

Diagnostic Imaging in Muscle Injury http://dx.doi.org/10.5772/56472 131

Ultrasound is the first-line technique in the study of muscle traumas, as it is readily available, has a good cost-benefit profile, enables assessment of muscle dynamics and provides reliable assessment of the extent of damage. Musculoskeletal Ultrasound has been shown to be effective for many applications related to sports medicine and has proved itself as one of several imaging methods invaluable to the diagnosis of sport medicine–related abnormalities. Some advantages of Ultrasound over MR imaging include portability, accessibility, high resolution, and relative lower cost. More importantly, dynamic imaging under Ultrasound visualization allows diagnoses that cannot be made with routine MR imaging. Additionally, direct imaging correlation with patient symptoms provides important information to the

Among these is the fact that its resolution is limited to the tertiary bundle, it is unable to identify alterations to secondary and primary bundles and myofibrils, and cannot visualise deep muscle planes. For these reasons, Ultrasound may yield negative results in lesions with only

Other disadvantages of Ultrasound include operator dependence and long learning curve.

Musculoskeletal Ultrasound has recently experienced an increase in popularity for several reasons. Advances in technology including the advent of high-frequency transducers have

Additionally, the relative low expense of Ultrasound compared with MR imaging has made this an attractive alternative imaging method for many indications. Ultrasound does have several potential advantages over MR imaging. Evaluation of a soft tissue process near metal orthopaedic hardware is possible with Ultrasound without the artefact that limits MR imaging. Additionally, Ultrasound can immediately guide percutaneous procedures when an abnor‐ mality, such as a joint effusion, is identified. Ultrasound also allows a dynamic evaluation of joints detecting abnormalities that may not be present during MR imaging positioning. Lastly, the improved resolution of superficial structures demonstrates subtle abnormalities that may be difficult to visualize with MR imaging. Current ultrasound technology produces in-plane resolutions of 200 to 450 bm and section thicknesses of 0.5 to 1 mm. For these reasons muscu‐

This can be minimized, however, with proper training and standardized technique.

slight muscle alterations, such as contracture, lengthening and DOMS. [4]

**Figure 48.** US images of reduced hyperechoic muscle in a professional volleyball player

### **Case 1**

42

42

Post contusion injury of the Rectus Femoris muscle approximately two weeks after the injury with hoematoma linked to calcification easily detectable by Ultrasound as a heterogeneous

mass with linear hyperechoich imaging showing posterior acoustic shadows. (Fig.46)

Figure 47: US images of a calcification in a professional rugby player

This complication originates from a chronic tendon tear or nerve implication with subsequent muscular adipose infiltration linked to reduction of the muscle

Example of a post contusion injury approximately seven days after the trauma

Example of a post contusion injury approximately seven days after the trauma which shows

**MUSCULAR ATROFIA**

Figure 47: US images of a calcification in a professional rugby player

Example of a post contusion injury approximately seven days after the trauma

**MUSCULAR ATROFIA**

This complication originates from a chronic tendon tear or nerve implication with subsequent

**CASE 1** 

Example of a professional volleyball player

**CASE 1** 

Example of a professional volleyball player

Figure 48: US images of reduced hyperechoic muscle in a professional volleyball player

Figure 48: US images of reduced hyperechoic muscle in a professional volleyball player

This complication originates from a chronic tendon tear or nerve implication with subsequent muscular adipose infiltration linked to reduction of the muscle

which shows a pseudo solid mass in Ultrasound.( Fig.47 )

Ultrasound shows a reduced hyperechoic muscle

which shows a pseudo solid mass in Ultrasound.( Fig.47 )

muscular adipose infiltration linked to reduction of the muscle volume.

**Figure 48.** US images of reduced hyperechoic muscle in a professional volleyball player

**Figure 47.** US images of a calcification in a professional rugby player

a pseudo solid mass in Ultrasound. (Fig.47)

Ultrasound shows a reduced hyperechoic muscle

Ultrasound shows a reduced hyperechoic muscle

**Case 2**

130 Muscle Injuries in Sport Medicine

volume.

**4.5. Muscular atrofia**

volume.

Example of a professionale rugby player

Example of a professional volleyball player (Fig.48)

Example of volleyball player after a severe miotendon injury of the long head of the Biceps Femoris muscle

Ultrasound shows a reduced hyperechoic muscle. (Fig.48)
