I would never have dreamt that at my age (45) I would actually be writing about my own muscle injury as a case report, but unfortunately, I was finally caught out at the end of 2023. My clinic was still very busy before the Christmas holidays, so a colleague from Radiology had to come and help quickly and my team and I quickly got down to treating me… with excellent results! But first things first…
Case History
On 10 December 2023, I sustained a type 3b myofascial injury to my left gluteus medius muscle when doing a turn-and-shoot move as an assistant coach during my nine-year-old son’s football training session. Immediately after the injury, I was initially incapable of even standing and was indeed unstable on my left leg during lateral stabilisation movements. At first even walking was not possible without help as I had developed a Trendelenburg walking pattern. Immediately after the injury, I could unfortunately only apply ice and cold-water baths (8° Celsius) for analgesia and for reducing the bleeding, and “elevate” as best I could; proper compression was not possible at this point and would certainly have been too painful. On the evening of the accident, it was impossible for me to lift my left leg sideways (in the sense of abducting the hip) while in the right lateral position due to the severe pain, which really worried me. A left-lateral position for the purpose of compression was also out of the question. An enormous haematoma developed at the base of the iliac crest within two days.
Clinical Examination findings prior to initial treatment on 11.12.2023
Pain on pressure, stretching and tensing pain in the entire region of the gluteus medius and over the entire left side of the iliac crest, anteriorly and laterally. There was also numbness of the skin over the gluteus medius immediately after the injury. Positive Trendelenburg gait pattern on the affected left side. Abduction of the left hip was not possible in the right lateral position and very significantly restricted when standing. VAS at rest 5 points, on loading 8 – 9!
MRT on 11.12.2023
- extensive myofascial oedema (just over 9 mm) with haemorrhages from the proximal gluteus medius muscle (series 8 image 26, series 7 image 26) associated with partially amorphous and partially absent visualisation of the muscle fascia
- focal detachment (5 mm) of the gluteal fascia from the iliac crest
- partial, fascial avulsion of the muscle fascicles with an elongated wavy appearance (series 3 image 14).
Most likely, the following treatment would normally be initiated in a case with such severe pain, severe haematoma, and oedema as well as massive functional impairment of the injured muscles: NSAIDs for two to three weeks for pain management, continued cooling with ice packs in the usual manner plus manual lymphatic drainage by a physiotherapist, physical rest, possibly non-weight bearing on forearm crutches due to the instability (in which case, possibly even injections for thrombosis prevention). Later, pain adapted increase of load, assisted by a physiotherapist.
Treatment
Despite the severe pain, I refrained from taking painkillers (NSAIDs) because I am absolutely convinced of the scientifically
proven effect of NSAIDs in reducing tendon and muscle healing, and I did not want this for myself in such a situation. On establishing the diagnosis by MRI and excluding any indication for surgery, I opted for the following combination of conservative, regenerative treatment which was performed daily from 11.12. until 19.12.23 by my clinic team (whom I would like to thank from the bottom of my heart!!! You are simply great!!!):
High-power laser (DolorClast High Power Laser, Power Laser, 300 W, Electro Medical Systems, Nyon, Switzerland): Daily anti-inflammatory treatment at three adjacent sites in the area of injury, each for 5 minutes (i.e. a total of 15 minutes per session)
Therapeutic nuclear magnetic resonance (MBST (molecular biophysical stimulation therapy), Medtech, Arthro Spin Flex, treatment chip card for 7 tendon sessions): A total of 7 sessions of 60 minutes each with a tendon-torso chip card, once daily.
Radial shock wave therapy (Swiss DolorClast, (Swiss DolorClast, radial shock waves, Electro Medical Systems, Nyon, Switzerland): rESWT in the region of the injury and with increasing application pressure to the maximum tolerable pain limit and application until the pain is noticeably reduced (approx. 10,000 impulses, 25 Hz, 40-mm and 20-mm applicator)
Neuroreflectory hyperbaric CO2 cryotherapy (Cryolight, ELMAKO, Iffezheim, DE): The whole of the affected, swollen and painful region of the gluteus medius extending to the entire iliac crest; 3 x cooled down to 0 – 4 degrees
As early and as much movement as possible (whatever the pain allows within the tolerable range!). Autonomous athletic training to stabilise and promote control.
Anti-inflammatory combination comprising Insumed PhytoShake 1 x daily 10 g, Traumeel 6 x 2 tabs. and Wobenzym 3 x 3 tabs. during the entire treatment period.
We know from treating a large number of patients for the same or similar indications that the combination of these forms of therapy for muscle or tendon injuries has very often led to rapid relief of pain and better and faster regeneration than usual. Descriptions of the combined use of all of the above treatment methods for this type of clinical picture and, above all, with this severity are, of course, not available in the literature to date. High-energy laser was always applied directly before the MBST and therefore 60 minutes before the ESWT treatment as indicated above, as it has been proved scientifically that laser produces pain relief (reaching its peak after approx. 60 minutes), which means that significantly higher working pressures are then tolerated during the subsequent radial ESWT, rendering this therapy even more efficient. In my experience, this rapid pain-relieving effect also applies to MBST, which meant that the working pressure during ESWT could be increased very quickly and very strongly. Although pressures of only around 1.3 to 1.6 bars were possible on the 1st day of treatment, we were already able to apply 3.0 bar on the 2nd day and even 4.0 bar on the 3rd day using the large 40-mm applicator. From the 4th day on, this was even easily possible with the 20-mm applicator. However, much more important to me than pain relief was the well-known tissue-regenerating effect of MBST, which I have observed countless times in my own patients. Added to this is the synergism of the three forms of therapy, as laser (applied directly after injury) not only reduces oxygen radicals in the injured tissue and thus has an anti-inflammatory and anti-oedematous effect, but also inhibits collagen remodelling in the injured muscle and thus counteracts rapid scarring. This, in combination with the clearly scientifically proven, strong muscle-regenerating effect of radial shock wave therapy and also MBST, results in a perfect combination for muscle and tendon injuries. Hyperbaric CO2 cryotherapy was applied to the treated region three times after each session up to a temperature of 0 to 4 ° Celsius. It results in a rapid restoration of the semi-permeability of the cell membranes after injury and has an anti-inflammatory and very rapid pain-relieving effect. The injured muscles were trained as early as possible with abduction exercises, walking training, and stabilisation exercises from the first day of treatment with a rapid increase in intensity.
Clinical Course
These measures led to a very rapid improvement of the symptoms. Even after the 3rd treatment session, that is, on the 3rd day after the injury, I was able to fully abduct the left hip almost without pain while lying in the right lateral position and walk with such a feeling of stability that I was able to fully return to work. On the 4th day, I was already able to walk normally and without pain again, and on the 5th day do one-legged squats and stabilisation exercises. Jogging was possible on the 6th day, and on the 7th day I could sprint upstairs without any problems. As an assistant coach in my son’s football team, I was also able to pass balls to the players again while warming up before a tournament. On the 10th day, I was able to jump with both legs and land one-legged on the affected leg as well as jog 3 km at speed without pain and with full stability.
By the 11th day I was already able to participate in my son’s training sessions again. On the 15th day, I was able to play football with the adults’ team again and felt stable and completely free of pain.
MRI FOLLOW-UP ON 22.12.2023 (11th DAY AFTER INJURY)
MRI follow-up 22.12.2023 (11th day after injury)
- The myofascial contours are more clearly defined. Partial demasking of well-circumscribed myofascial seromas without space-occupying effect (series 8 image 27 and series 7 image 27; previous scan series 8 image 26 and series 7 image 26).
- Today the avulsion from the iliac crest is no longer evident
- The previously documented elongated muscle fascicles once again show a more defined course with contact to the partially more distinct muscle fascia. (series 3 image 16 as compared with series 3 image 14 of the previous scan).
It should be noted here that the result of the MRI follow-up examination on completion of the combination therapy usually does not quite reflect the actual clinical course. In our experience, however, this is not necessary either. We always concentrate on the clinical course and not just on the MRI scan. In our view, too much emphasis is placed in sports medicine, and especially in professional sports, on complete recovery as shown on the MRI scan, which is, however, not necessary. In our experience, there is definitely no higher re-injury rate if you are guided by the clinical course, ultrasound follow-up examinations and, for example, EMG measurements of the affected muscles.
Conclusion
The combination of high-energy laser therapy, rESWT, MBST, hyperbaric CO2 cryotherapy, anti-inflammatory therapy comprising phyto-pharmaceuticals and enzyme therapy as well as early athletic training can achieve a very satisfactory and rapid result with weightbearing stability, associated with freedom from pain and the return to sport, even in the presence of such marked findings.
Future Prospects
In the future, the combination therapy described here or – if not all the components are available – at least some of them should, in my view, play an important role in the treatment of muscle injuries in both professional and amateur athletes. Unfortunately, the amazing regeneration potential with regard to the much faster healing of muscle, tendon and ligament injuries, the lower re-injury rate, as well as the prevention prospects, especially for muscle injuries, do not yet seem to have found their place in general sports medicine or orthopaedics, and unfortunately not in many areas of professional sports either. We are trying to change this via the “sportärztezeitung” network – for all those who are prepared to think outside the box. I really like this form of treatment; we have enjoyed incredible success for our patients, and now it has even saved me weeks, if not months, of problems myself.
I would like to draw two things to the attention of all colleagues who are interested:
1.“thesportgroup academy’s” guided education training courses – face-to-face or online! The upcoming dates can be found here…
2. The importance of workplace training in the field of sports medicine: We have in no way exhausted the conservative therapeutic options of modern treatment and prevention. Even though the realities of healthcare in our medical system and the individual patient’s actual situation always have to be taken into account of course, our aim is to develop new standards for better sports medicine together with our colleagues and in collaboration with the “sportärztezeitung.”
Video documentation of the case
INPUT FROM A RADIOLOGIST…
In the diagnostic work-up of acute muscular injuries, MRI has the advantage over high-resolution ultrasound of showing the anatomy of the involved, but also non-injured, neighbouring structures more clearly. This applies to primary diagnostics, but also especially for the follow-up examinations. The severity of the injury, which is so important for the prognosis, but also its relationship to the biomechanical transmission chains (myofascial, myotendinous, purely muscular or combined) can be well documented. In the acute phase of the injury, however, MRI may overestimate the muscle injury due to the extensive oedema and haematoma. Here, image quality with a resolution that does justice to muscle anatomy is of crucial importance for the correct diagnosis! In the present case, myofascial injury to the gluteus medius muscle was clearly documented and was distinguishable from oedema and haematoma. The follow-up scan after 11 days already showed the reparative processes with fibrotic reorganisation of the fascia and re-attachment of the traumatic myofascial separation of the muscle fascicles. This is particularly well illustrated by the straighter course of the muscle fascicles, which had initially retracted after the injury and had demonstrated an elongated wavy course. This case well illustrates the rapid recovery capacity of an injured muscle.
Dr. med. Peter Mundinger, is a Consultant for Diagnostic Radiology, with an additional qualification in Neuroradiology and is also a specialist for musculoskeletal imaging studies / Private practice for radiology H15
INPUT FROM AN ORTHOPAEDIC SURGEON…
Actionism? Yes, but with common sense: In today’s sports medicine landscape, so highly pressured to achieve recovery, it is common to aspirate these injuries, infiltrate PRP (platelet rich plasma), administer Actovegin, local anaesthetics, Traumeel or similar medications, and get out the forearm crutches for 7 days. Peter impressively demonstrates that it is also possible to successfully treat a serious muscle injury very quickly without invasive measures. Apart from appropriately coordinated physical measures to modulate inflammation and healing, early pain-adapted mobilisation and avoidance of NSAIDs also appear to have made a significant contribution towards the successful outcome. It is particularly worth mentioning the MRI diagnostic workup during the course of management. This made it possible to reproduce the structural changes which developed after the multimodal therapy. This is what we need for the future of sports medicine. As said in the radiological commentary – “This case well illustrates the rapid recovery capacity of an injured muscle” – we and Peter Stiller were able to exert a significant positive effect on this with the therapy and nutrition (!) mentioned.
It is exciting to see that, despite our inclination towards invasive treatment methods, we can also act “differently” in a promising way and thus set an impressive example for physical measures in sports care.
Dr. med. Alberto Schek, is a Consultant for Trauma and Orthopaedic Surgery with additional qualifications in Special Orthopaedic Surgery, Sports Medicine and Manual Medicine with a diploma in Sports Osteopathy / Paracelsus Sports Medicine & Prevention Bremen
Autoren
ist Facharzt für Allgemeinmedizin und Notfallmedizin in der Praxis Allgemeinmedizin Lechhausen & MedWorks – Privatärztliche Praxis, Augsburg. Er ist ehemaliger Mannschaftsarzt des Profiteams des FC Augsburg und wiss. Beirat der sportärztezeitung.
