**4. Pectoralis major**

tissue that must act as a scaffold for the repopulation of the lesion by the myoblasts. When the lesion is too large, however, the gap between the proximal and the distal stump is filled with granulation tissue which results in connective tissue scar [6, 7] leaving little room for myoblast proliferation. It is possible that in the final phase (remodeling) structural improvements of the

The healing of the lesion depends not only on cell reactivity and the amount of scar tissue, but is closely linked to many other factors. The innervation of the tissue remaining promotes tissue viability: an excessive presence of denervated myocytes downstream of the lesion impairs proper healing [1]. Other aspects to be considered are the supply of oxygen from the sur‐ rounding tissue, the vascular proliferation and neo-angiogenesis within the lesion in the posttrauma stage, the percentage and the pattern with which the myoblasts go to form the

Unfortunately very few studies are available in literature that scientifically demonstrate the

Traditionally muscle injuries are treated conservatively and surgery is frowned upon by many surgeons for this type of lesions of the musculoskeletal system. It is common belief that surgical treatment gives results similar to, or even worse than conservative treatment [9]. Therefore it is not recommended for the fear of causing damage which would lead to further complications. The presence of hematoma and a palpable gap in the muscle belly make surgical suture difficult to perform because it is often impossible to get the fascial ends to close and the muscle fibers

However, animal studies have shown that surgically sutured muscle heals more quickly and more functionally. The suture in fact decreases the distance between the muscule stumps allowing a more rapid recovery [10], decreasing major defects in scarring [11], improved

Obviously, surgery can lead to numerous, although fortunately infrequent, complications; therefore it is a viable option only when it guarantees clear and obvious improvements for the

Generally, surgical treatment is indicated for severe muscle tears [1, 12], in grade 4 lesions on the Ryan classification [13, 14] or when over 50% of the muscle fibers are involved. Grade 1 refers to injuries of a few muscle fibers; grade 2 - injury of a moderate number of muscle fibers; grade 3 - rupture of a moderate number of fibers associated with partial lesion of the fascia; grade 4 -those that involve injury through the full thickness muscle and the fascia (Figure 2).

From the clinical point of view, a massive rupture of the muscle leads to a loss of its strength which may be acceptable in patients with a low functional demand. However, athletes or people with high functional demands need the full recovery of muscle strength which

patient or when the lesion cannot heal if treated with the conservative approach.

scar may occur but they are only minor [5].

myotubes and the collagen crosslinking [8].

benefits of one treatment rather than another.

healing and a decrease in deep superabundant scar tissue [3].

**3. Indication for surgey**

224 Muscle Injuries in Sport Medicine

are hard to draw back together [5].

A complete lesion of the pectoralis major still allows a normal active mobilization of the shoulder, but will cause an important decrease in strength in adduction and internal rotation of the arm [17] so an early surgical reconstruction is indicated in athletes. In fact, with conservative treatment a significant loss of torque, measured using the isokinetic strength test, has been observed [18, 19] while following surgical treatment a significant increase in isokinetic torque of the muscle has been reported [20, 21]. In addition, the aesthetic damage caused by the gap following injury can cause the end of the career for body-builders and similar profes‐ sionals for whom the aesthetics of the muscle is essential. Conservative treatment is recom‐ mended only in cases of injury at the sternoclavicular origin, in some partial tears, in older or sedentary individuals.

appearance, suffered easy fatigue in repetitive movements of pronation and supination (e.g. use of screwdriver), avoided weight-lifting and in two cases the musculocutaneous nerve was in contact with the skin and not covered by muscle tissue thus easily irritated even by the cuffs

Surgical Treatment

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http://dx.doi.org/10.5772/56736

The mechanism of injury is important for the occurrence of lacerations. In parachutists, the entrapment of the arm in the static-line during the launch determines a subcutaneous trans‐ verse lesion and an almost total one of the muscle belly with the proximal and distal stumps retracted; in this case muscle suture is indicated. In the case of water sports such as water skiing or wakeboarders, the mechanism of injury is similar with the entrapment of the arm in a towline that pulls the athlete at great speed. What differs between the two sports is that the lesion usually reported in water sports causes a tearing injury in the proximal-distal direction of the biceps and is not as clear cut as the paratroopers; this sometimes may preclude the muscle

The injury of the muscle belly of the biceps brachii is rare and closely related to particular sports; the indication for surgery is clear as it prevents functional and aesthetic deficits.

Kragh et al. in [25] with regard to the lesions of the biceps brachii recommend the intervention

No cases of suturing subcutaneous belly lacerations of the quadriceps femoris are described in literature. The only description is in a surgical case report by Straw [28]. The tear had occurred at the proximal musculotendinous junction. With surgery muscular performance

The hamstring is one of the muscle groups most affected by injuries in athletes. They often suffer strains localized in the muscle-tendon junction due to an eccentric contraction. The lesions may occur in different areas: proximal or distal muscle-tendon junction, muscle belly,

Usually hamstring injurues are treated conservatively with rest, ice, physical therapy, NSAIDs and a gradual return to sport. Rarely a lesion in this anatomical site requires surgical treatment. One of the rare occasions when the patient may have to undergo surgery is when the hamstring is detached from the ischial tuberosity. This injury is rare but its incidence is increasing, especially in middle-aged patients who continue to be physically active [30]. The triggering mechanism of injury is a sudden flexion of the hip and extension of the knee that causes a contraction of the hamstring. The patient reports feeling a shot in the rear thigh and walks with his leg straight (stiff-legged gait) avoiding flexing hip and knee in order to relieve the pain.

improved 151% to concentric power after 6 months compared to preoperative levels.

in the case in which the lesion extend more than 95% of the muscle belly.

on the uniform.

suture and require muscle resection [26].

**6. Quadriceps femoris**

**7. Hamstring muscle**

the proximal and distal tendon insertion [29].

This lesion was classified and reported in literature for the first time by Patissier in 1822 and since then over 200 cases have been reported [22]. The number of these lesions has increased and the increase in the last 30 years is due to the increased participation in heavy physical activity such as weight lifting, weight training, wrestling, rugby and waterskiing. Attributable almost solely to males, these lesions occur in an age range from 16 to 91 years with a peak in athletes aged between 20 and 40 years [22]. The most common mechanism is indirect trauma during bench pressing or other weight lifting movements; less frequent injuries are those following abduction-external rotation, extension-adduction and direct trauma [23].

The lesion of this muscle may occur in different zones. Tietjen [24] used a classification divided into 3 groups: type I consists of muscle contusions and sprains; type II partial tears and type III complete lesions. Each of these groups has a subclassification based on the location of the lesion: A - muscle origin; B - belly muscle; C - myotendinous junction; D - tendon. Statistically, insertion tendon injuries are the most frequent (55%), lesions to the belly or muscular-tendon insertion cover about 35% of these injuries [23].

According to the most recent meta-analysis [23] early surgical treatment achieves significantly better results than conservative treatment with an excellent-good result in 90% of cases, compared with 17% of conservative treatment (P = 0.00000001). When surgery is delayed slightly worse results are obtained, especially after 13 weeks from injury.

While for partial lesions treatment with conservative immobilization for 2-3 weeks is indicated, where surgery is required immobilization should be 4-6 weeks and subsequently a gradual lengthening of the muscle must be performed and only after 6-12 weeks strength training can begin.
