Physiotherapy and rehabilitation
Below we present the most common muscle and tendon injuries. Every muscle and tendon pathology or injury has a description of general features, the cause of the injury, the characteristics of the symptoms, diagnostics, and the course of treatment.
A pulled muscle is an injury caused by overstretching or overloading a muscle, which leads to damage to muscle fibres, and, at the anatomical level, there is a lesser degree of damage to smaller blood vessels and nerve endings.
A pulled muscle most often occurs during sudden movements, especially when pushing off, sprinting, swinging, throwing, or landing.
Muscle groups that are typically prone to pulling are: hamstring, calf muscle groups, adductors (hip adductors) and iliopsoas (hip flexors).
The cause of a pulled muscle is most often poor physical preparation for the activity being performed, fatigue, or a poor warm-up routine combined with rapid load. Muscles have poorer blood circulation at rest and are therefore more rigid – warming up increases the elasticity of muscles and tendons, thereby reducing the possibility of muscle fibre damage.
The symptom of a pulled muscle is sudden pain, which can vary in intensity, with patients most often describing the injury as feeling like they felt burning in a specific spot. The pain is specific, localised, burning, and typically intensifies after sports activity, when the affected muscle group cools down.
After the injury, mild stiffness is typical, and the pain intensifies when the affected muscle is put under load, but does not prevent sports activities, instead limiting them. Swelling is not present in the case of a pulled muscle.
Pulled muscle groups are treated without medical assistance; in the acute phase, the injured muscle must be prevented from bearing any load for a period of two to four days, complete immobilisation of the injured area is not necessary.
Special care should be taken with progressive loading of the injured muscle when returning to sports activities, with specialised kinesiology.
Pulled muscle group is an injury with high rate of recurrence and a high probability of causing muscle tears, so it is crucial to perform the training part of rehabilitation with appropriate strength exercises, as this prevents the formation of a weak zone.
A muscle spasm is a sudden, involuntary, and uncontrolled contraction of a muscle or multiple muscles that causes severe, sharp, and burning pain.
Muscle spasms are characterised by an individual’s predisposition: some people have frequent problems with spastic muscles, while others experience them extremely rarely. It is also important to note that the frequency of muscle cramps increases with age.
The pain is extremely unpleasant and disturbing, but does not pose any major danger. When a muscle spasm lasts for a long time, we speak of a muscle cramp. Muscle spasms and cramps most often occur as a result of overuse of a specific muscle group, fatigue, electrolyte disturbances (lack of certain minerals), and dehydration.
Severe muscle cramps basically occur due to a sudden change in the functioning of the central nervous system, which controls the contraction and relaxation of muscle groups, which means that overuse and fatigue cause errors in the transmission of nerve signals, which trigger uncontrolled muscle contractions.
Muscle cramps do not pose a major risk to our health; in the most severe cases, pain at the site of the cramp can remain present for several days after it occurs. If muscle cramps frequently occur in a specific muscle group, there is a greater risk of developing muscle fibre tears in the same muscle. In this case, it is sensible to increase strength and strength endurance capacity locally in the problematic area through individually targeted kinesiology training.
The protocol for preventing muscle cramps should primarily include adequate physical preparation for the activities we perform and a gradual increase in load, as acute overload is the main trigger for neurological muscle disorders that cause spasms.
Individually targeted kinesiology training to increase strength and strength endurance capacity locally in the problematic area.
A partial muscle tear refers to an injury to a muscle group where there is local damage to individual fibres, but a complete rupture of the muscle is not present. Depending on the number of torn muscle fibres or the extent of muscle damage, there are several grades of muscle tears.
Grade I muscle tear means that several fibres of the muscle are damaged, there is mild swelling and pain, muscle contraction is possible but accompanied by pain, so strength is limited.
Grade II muscle tear means that a moderate part of the muscle fibres is damaged, but a complete rupture of the muscle is not present. A grade II tear is characterised by more severe pain, swelling, and the presence of subcutaneous bleeding; full muscle contraction is not possible, and even minor muscle tension causes intense pain.
If a muscle tear is suspected, it is recommended to undergo an ultrasound (US) scan to accurately determine the extent of muscle damage or confirm the suspected muscle injury. In any case, if a sudden sharp, burning pain occurs in a muscle, sports activity should be stopped and the RICE protocol should be applied.
If the diagnosis of torn muscle fibres is confirmed, the injured extremity is prevented from bearing any load in the first few days after the injury, with additional instrumental therapies to accelerate healing. The use of a therapeutic laser and TECAR therapy is recommended. It is important to start tailored training early in the rehabilitation process. In the case of partial muscle tears, it is recommended to start low-intensity therapeutic training on the third day after the injury.
The programme should progressively increase in load until the 21st day after the muscle injury occurs. After three weeks, high-intensity exercises are included in the secondary rehabilitation programme; in the case of athletes, this is followed by a return to the regular training process, but with a gradual increase in training intensity. It is important to implement return-to-sport protocols to prevent recurrence of muscle injuries at the location of the tears, as muscle fibre tears have a high rate of recurrence. Before returning to high-intensity sports activities, it is necessary to establish adequate muscle strength and muscle symmetries.
Surgical treatment is not necessary for grade 1 and 2 torn muscle fibres. The entire treatment is carried out with a conservative approach of physiotherapy and kinesiology, the healing window of the injury lasts between four and eight weeks, depending on the extent of muscle damage and the presenting symptoms.
The entire treatment is carried out with a conservative approach of physiotherapy and kinesiology, the healing window of the injury lasts between four and eight weeks, depending on the extent of muscle damage and the presenting symptoms.
Before returning to high-intensity sports activities, it is necessary to establish adequate muscle strength and muscle symmetries.
Muscle injuries are most prevalent in sports and everyday life, have a high rate of recurrence, and are often not adequately treated. Approximately a third of all sports injuries are muscle tissue injuries.
Muscle injuries can be either contact injuries (impact, collision) or non-contact injuries (acute or chronic overuse, insufficient warm-up, poorly treated past injuries). A complete rupture of muscle or torn muscle is classified as grade 3 on the three-level muscle fibre damage assessment scale, which is characterised by severe pain, a haematoma that may be present in the muscle or on its surface, and complete muscle dysfunction with inability to activate or contract the affected muscle group.
A complete rupture of muscle most often occurs after intense exercise combined with a cold, unwarmed muscle group, after a poorly treated previous muscle tear or rupture, high muscle fatigue, or a contact injury where the muscle is physically deformed due to an external cause (cuts, strong blows, traffic accidents).
A muscle group tear can be diagnosed by manual inspection of the tissue, as it involves an outwardly visible deformation of an otherwise normal muscle shape and a larger haematoma on the surface. In any case, MRI and ultrasound scans are recommended to accurately assess the extent of muscle fibre damage and the location of the rupture, as tissue deformation and haematoma often make it difficult to accurately determine the site of the injury.
After a muscle rupture, it is important to immediately stop the sports activities and immobilise the area where the rupture occurred.
Muscle rupture involves tearing of muscle fibres, intense inflammation, and resorption of bleeding. Muscle fibre tears have a high self-healing potential, which is divided into regeneration with new muscle fibres and the formation of scar tissue (granulation tissue).
The goal of surgical treatment of a ruptured muscle group is to minimise the formation of scar tissue, minimise structural deformation of the muscle, and restore full function to the affected muscle group.
In the first 24 hours after a muscle rupture, it is important to reduce the formation of haematoma, prevent additional microinjuries to the muscle, and normalise the patient’s pain. The injured extremity is elevated off the ground and immobilised – in the case of a complete muscle rupture, it is important to immobilise the two adjacent joints. The damaged muscle is wrapped with an elastic bandage over the entire surface, and cooling is applied to the site of the rupture.
Until surgery is performed, warm compresses are applied at night, over which we place an additional protective elastic bandage. Instrumental physiotherapy, especially therapeutic laser, is recommended in the period leading up to surgery.
For successful postoperative healing of the injury, preoperative physiotherapy care is essential. The entire rehabilitation of a complete muscle rupture with surgical treatment lasts between seven and nine months, and up to 12 months in the case of a rupture of a larger muscle group.
After surgical treatment, combined outpatient physiotherapy with a controlled transition to therapeutic training is required. It is important that the muscle regains full function and strength before applying greater sports loads. For athletes, it is mandatory to perform a sport-specific return-to-sport phase of rehabilitation, in which an intensive training programme is carried out, which prepares the injured muscle for the specific loads of the trained sport.
Tendons are fibrous tissue – their primary function is to transfer mechanical forces generated by muscles to bones. Tendons have the ability to withstand high forces, even five times their own weight. The most common causes of tendon injuries are poor blood supply, microtrauma, repetitive stress, and severe contact trauma.
Spontaneous tendon ruptures in most cases occur due to repetitive microtrauma, mechanical overload at the site, poor vascularisation, or past injury. This means that prior to rupture, certain local conditions must have existed for the stimuli to trigger the injury. If the blood supply to the tendon is healthy and functional, the tendon will regenerate properly after mechanical stress.
For athletes, an appropriate conditioning and regeneration protocol plays a key role in preventing tendon injuries. The time window for regeneration is crucial; if it is too short, tendon regeneration after load will not be complete. Tendon ruptures most often occur in elite athletes who are subjected to high loads and in the elderly population due to poorer vascularisation of the fibrous tissue of the tendons.
This injury is often caused by direct trauma or a sudden, strong stretch with eccentric loading and a fixed point of attachment – often in basketball (Achilles tendon rupture).
Symptoms of a tendon rupture depend on the extent of the rupture and the type of tendon injured.
The tendons most commonly injured are:
General symptoms of a tendon rupture include an audible and palpable pop with sudden severe pain.
Severe swelling and visible deformation of the muscle appear at the site of the injury, and the muscles becomes non-functional. With an Achilles tendon rupture, walking is impossible, and downward plantar flexion is dysfunctional. With a rotator cuff tendon rupture, it is often impossible to raise the arm to the side and above shoulder height. With a rupture of the long head of the biceps, it is impossible to raise the arm with the palm facing up.
A ruptured tendon is diagnosed after a physical examination. An MRI scan is performed to accurately assess the location of the injury and the extent of the deformity. An MRI scan is key to determining damage in partial tendon ruptures, which are the most common.
Acute care after tendon rupture should include complete immobilisation of the injured area with double-joint isolation. Immediately after the injury, it is recommended to cool the injury to reduce intense pain, with a combination of mild compression and elevation until surgery or until physical therapy begins in the case of conservative treatment.
Partial ruptures are treated conservatively for a period of 6–12 weeks to fully restore the functional capacity of the tendon. In the case of surgical treatment and/or complete tendon rupture, complete rehabilitation takes between eight and twelve months. The longest treatment is for a complete rupture of the Achilles tendon, which is often the cause of a premature end to a career in top athletes. Rotator cuff tendon ruptures are characterised by the fact that in 90% of cases they arise from degenerative causes and in this case do not require surgical treatment.
In the case of a traumatic rupture of the rotator cuff tendon, surgical treatment is performed; when the extent of the injury is less than 50% of the tendon thickness, the damaged (dead) tissue is arthroscopically removed. In the case of a complete rupture, the tendon is sutured. Ruptures of the long head of the biceps are of a specific nature; unless it is a top athlete, surgical treatment is not performed, as the long head of the biceps itself contributes only 10–15% of the function in elbow flexion. In athletes, surgical repositioning of the attachment site of the long head of the biceps is often performed with a tenodesis procedure.
The rehabilitation programme should include outpatient physiotherapy in the first phase and a progressive regimen of individually targeted kinesiology training to improve muscle capacity, adapt the tendon to load, and establish muscle symmetries in the second phase. Tendon ruptures carry a high risk of injury recurrence and occurrence of chronic tendopathies, so it is important that rehabilitation is carried out with a final return-to-sport phase, where we apply high loads and specific training to the tendon to adapt it to the patient’s sports and recreational goals.
The Achilles tendon (AT) is a tendon that connects shin muscles to the heel bone (calcaneus) behind the ankle joint, and transmits mechanical loads to the triceps surae muscle, which is formed by the gastrocnemius muscle and the soleus muscle. Most Achilles tendon ruptures occur in top athletes who participate in agility-based team sports and in sports of a highly explosive nature.
Achilles tendon rupture in the non-sports-active population is most common in men between the ages of 30 and 50. An Achilles tendon rupture can be partial or complete. As many as 90% of Achilles tendon ruptures occur in the area 2–7 centimetres above the tendon’s attachment point on the heel bone, where an degenerated area with poor blood supply usually develops. The combination of degenerative and ischemic changes in the tendon is believed to be the main risk factor for Achilles tendon rupture during ankle loading. With repetitive stress and a physically poorly prepared Achilles tendon, microtraumas begin to occur, leading to local pathological changes in collagen fibres and poor tissue vascularisation, which represents a weak spot that will rupture in a single extreme event.
When the Achilles tendon ruptures, the injured person feels severe pain and hears a loud, echoing pop that can be loud enough to be heard by others nearby. The pop is similar to a whip crack. A haematoma is usually visible in the area of the tendon rupture.
Injured people often describe the feeling of a complete rupture of the Achilles tendon as if someone had hit them hard on the heel with a hard object. A third of those injured with partial Achilles tendon ruptures do not report any pain. In the case of a complete rupture, plantar flexion of the foot is impossible, as is stepping or any kind of weight-bearing on the injured extremity. A visible cavity appears in the Achilles tendon area, usually in the area 2–5 centimetres above the heel; on manual inspection, there is a significant deformation of the normal shape of the Achilles tendon.
Clinical diagnostics include the Simmonds-Thompson test, which is simple and most important for clinical use. It is positive when squeezing or manual pressure does not elicit reflex plantar flexion in the injured person.
In any case, MRI and ultrasound scans are recommended to confirm the diagnosis and accurately determine the location and extent of the trauma.
A complete Achilles tendon rupture is treated surgically. A tendon repaired with a surgery without complications regains 90% of its original natural capacity. If the bone surface of the calcaneus was damages with the Achilles tendon rupture, the torn piece of bone is screwed back onto the heel bone. After the operation, it is necessary to wear an orthosis with a lifted heel to protect the stitches. Intensive outpatient physiotherapy and adapted kinesiology training gradually reduce pain symptoms and develop normal tendon extensibility and optimal alignment of collagen fibres.
For most athletes, a return-to-sport phase is mandatory, which should last at least three months before the athlete returns to their previous training level. After a tendon rupture, an intensive programme of individualised rehabilitation of 10–12 months is recommended before the athlete returns to competitive level. The highest risk of Achilles tendon re-injury is between the eighth and tenth week, so special attention to the kinesiology training programme is recommended at that time.
After a tendon rupture, an intensive programme of individualised rehabilitation of 10–12 months is recommended before the athlete returns to competitive level.
Tendinopathies are the most common overuse injuries of soft tissues, often occurring at specific known sites – tendon attachments. Tendinopathies are overuse degenerative pathologies and can be present for several months to several years.
Tendinopathy occurs due to chronic microtraumas to the collagen structure of the tendon, which also causes poor tissue vascularisation, inflammation, and local thickening. The main causes of tendon overuse are acute excessive mechanical exertion, poor strength and strength endurance of a muscle group, previous injury, incorrect sports or training technique, and most often a combination of the above.
Tendinopathies most often occur on the inner or outer side of the elbow (golfer’s elbow and tennis elbow), the Achilles tendon, the quadriceps tendon, the patellar ligament (jumper’s knee), the tendons of the rotator cuff muscles, the tendons of the long head of the biceps, and the iliopsoas muscle group.
In progressive stages, tendinopathies can be a highly limiting factor in everyday activities. A telling statistic is that patellar tendinopathy (jumper’s knee) is the reason for career decline and gradual abandonment of sports in 50% of affected athletes. Tendinopathies are innocuous in the early stages and only present occasionally, but it is important to address them correctly early in their development process.
Symptoms are often non-specific, with patients describing stiffness at the site of injury, discomfort, and occasional pain that occurs after exertion. In tendinopathies, the pain often disappears during exertions, but becomes more intense a few hours after the activity has ended. In the reactive stages of tendinopathy, severe, sharp pain is also possible when placing a load on the affected area, but this is more typical of the later stages of tendinopathy.
In the early stages of tendinopathies, pain occurs only occasionally after heavy exertion and subsides within a few days.
The progressive stages of tendinopathy include pain symptoms that are present even during movement, and in extreme cases, they limit everyday activities and persist continuously. Physiological changes in tissue are characteristic, and there may be an externally visible thickening of the tendon in the later stages.
Reduced mobility of the affected area and loss of muscle strength in the final positions of range of motion also often occur.
The treatment of tendinopathies is complex. Preliminary ultrasound scan (US) and clinical testing of the patient are recommended. Treatment is conservative, but highly individualised depending on the patient’s symptoms and the progression of tendinopathy.
With therapeutic laser, TECAR and cooling, we alleviate acute pain and inflammation with the aim of starting a progressive specialised training programme for the affected area as soon as possible. The key to a rehabilitation training programme is the application of eccentric-isometric regimens that stimulate the formation of newly formed collagen fibres.
It is important to perform exercises in isolation unilaterally and gradually progress to complex strength exercises and sport-specific exercises, where it is important that compensatory movements do not occur.
Surgical treatment with removal of the degenerated area of the tendon is performed in rare cases when a tendinopathy does not respond to conservative treatment.
In the case of chronically advanced tendinopathy, injection of activated platelet-rich plasma (PRP) is also possible. The longer a tendinopathy is present, the less likely it is that the symptoms will completely resolve. It is important to start treatment of tendinopathy early and to simultaneously take a break from activities that are symptomatic.
Enthesopathy is a special form of tendinopathy, describing the pathology of the joint or attachment point of the tendon to the bone. Enthesopathy is particularly characteristic of the tendon attachments of the lower extremities, as the tendons of the leg muscles absorb and release a large amount of tensile energy during their function.
Enthesopathy often occurs in the patellar ligament, Achilles tendon, and quadriceps tendon; in the upper body, it can occur in the elbow joints and rotator cuff attachment sites.
The diagnosis of enthesopathies is more challenging, as they often cannot be clearly distinguished from other conditions in the same anatomical areas (e.g. pain in the area of the adductor attachments in athletes).
Enthesopathies are most often the result of overuse, and they occur more frequently in professional athletes and manual workers.
Symptoms of enthesopathy include similar characteristics to tendinopathies, except that they occur exclusively in the area of the tendon’s attachment to the bone, whereas the entire tendon is often symptomatic in tendinopathy.
Treatment of enthesopathy is carried out conservatively with the application of specialised kinesiology training. Eccentric training is an important regimen in the rehabilitation of enthesopathy symptoms and in eliminating the causes of the injury.
Treatment of enthesopathy is carried out conservatively with the application of specialised kinesiology training.
Eccentric training is an important regimen in the rehabilitation of enthesopathy symptoms and in eliminating the causes of the injury.
