UPDATE: MUSCLE INJURIES

When we entered sports medicine over 16 years ago, he was already a long-established figure in the field. We were there when he opened the MW Praxis für Orthopädie & Sportmedizin (his orthopedics and sports medicine practice) and agreed that we would one day work with him on a project in the service of sports medicine. Of course we followed this man’s career as it developed—a career that often placed him in critics’ crossfire and equally as often found him misunderstood. Nevertheless, he has always had many advocates, athletes and friends who believe in his work.

All the more reason for us to be pleased when Robert Erbeldinger and Masiar Sabok Sir had an opportunity in the summer of 2021 to meet with him in person and discuss his ideas and the story behind his Munich practice. The discussion had been scheduled for one hour, but lasted instead for nearly two hours of lively, emotional sports medicine in an exceptionally relaxed, pleasant atmosphere. We are grateful for his many interesting insights and would now very much like to give Dr. Müller-Wohlfahrt the floor.

Experience & Expertise

“MY KEY CONCERN WAS ALWAYS TO DO ALL I COULD TO AVOID SURGERIES.”

Meine Laufbahn als Teamarzt begann Mitte der 1970 er Jahre bei Hertha BSC Berlin. Als junger Assistent schlug mich mein Chef vor, der mir eine so große Verantwortung zutraute. Damals war die Hertha mit mehreren Nationalspielern bestückt und eines der starken Teams in der Liga. Ich sagte

My career as a team physician began in the mid-1970s with the Hertha BSC Berlin soccer club. My boss recommended me as a young assistant, trusting me with a such a big responsibility. Back then, Hertha had a number of national team players and was one of the strongest teams in the league. I’m going to go for it, I told myself. So I jumped right in. The Bavarians noted that and probably thought, This guy must be crazy, we could use him. So I ultimately ended up with Munich’s FC Bayern München. My key concern from the very beginning was to do all I could to avoid surgeries. To opt for conservative treatments whenever possible and responsible.

And without taking any risks with patients’ health.

Even though it maybe seems a little cocky—which it absolutely isn’t—after 45 years of treating elite athletes, I felt the need to tell my story to colleagues too. That was basically what motivated me to write the new booklet, “Update: Muscle injuries after 45 years of professional sports care. Diagnosis and therapy of neurogenic muscle hardening, muscle strain, muscle fiber tear and muscle bundle tear.” I wanted to do it for German sports physicians and physical therapists and to reach as many people as possible. I’ve been very pleased that interest in my classification system—and in the end, that’s what it’s all about—and in therapy is extremely high. My muscle book has since been translated into several languages and has been published internationally.

Due to the ongoing coronavirus pandemic, no group photo was taken.

Natural medications & biological medicine

“THE MUSCULATURE LOOSENS UP AND RELAXES,
AND THE HEALING PROCESS GOES FASTER.”

When I joined Bayern München, I thought, If I give Franz Beckenbauer the wrong shot and something happens, then I’m finished. So I made a very conscious decision to use natural medications and to practice biological medicine, which has no side effects.

I noticed that muscles contract when injured, becoming highly tense in order to protect themselves, and that hinders circulation. So I thought, why not use Actovegin as my primary response to muscle injuries—back then it had just been introduced as the “Munich Development.” Studies had shown that it promotes blood flow. And what happened? The musculature loosened up and relaxed, and the healing process went visibly faster. That’s how my medical regimen came to include that medication: intramuscular injection of Actovegin and Traumeel.

I was attacked for that for a long time, because they thought it couldn’t work.

But I stood my ground anyway, and was vilified by a lot of colleagues. They said none of it had been scientifically proven. But then two scientists (from LMU Munich and German Sport University Cologne) took a look at it and found that it did promote healing; only then did the critics quiet down. I still remember when the two researchers called to congratulate me.

I’d found something that demonstrably promoted the healing process. They discovered that Actovegin activates the satellite cells on the muscle cell membranes. These in turn form new muscle fibers and no scar tissue forms – no collagen fibers, in other words (see also the study from Dr. Stefan Mattyasovszky: Effect of Actovegin® and Traumeel®S on Human Skeletal Muscle Cells.)

“ACTOVEGIN HAS BEEN PROVEN TO PROMOTE REGENERATION.”

And the second scientific study shows that Actovegin inhibits inflammation. I prescribe two, three treatments for Achilles tendinitis, for example. Usually the inflammation is in the tendon sheath, not so much in the tendon itself, and adhesions often form.

So I insert the injection needle between the tendon and its sheath. You have to have an instinctive feel for that. I administer an anesthetic, and if I notice that the needle isn’t positioned right, I’ll proceed with a 5 mL infiltration of Actovegin in order to distend the paratenon, potentially breaking up adhesions and inhibiting inflammation.

Palpation is critical for muscle injuries: Where exactly is the injury? Which muscle is affected? Only after palpation will I insert several needles filled with anesthetic into the center of the injury along with needles (two each) positioned proximally and distally from the center.

That does indeed have a relaxing effect. Once that step is complete, I use the needles I’ve positioned to introduce a mixture of Actovegin and Traumeel to promote healing. In the case of neurogenic muscle injuries, treatment is most effective when you palpate the irritated motor nerve tracts that are causing overexcitation of the muscle and then bathe these with an anesthetic. This procedure results in isometric relaxation of the muscles supplied by the nerves. Only after that do I administer an infiltration of Actovegin and Traumeel to accelerate the full healing process.

Feeling with your hands & training your hands

Unfortunately, an MRI often prompts people to overinterpret the images. And athletes are often shoved into the tubes much too early. I’ve seen a lot of Bundesliga athletes that no one’s even touched—just sent them straight to an MRI. Too few colleagues feel, sense and listen to the athletes. Case history, diagnostics—it all starts with your relationship to the patient, with a conversation, with communication. Patients can provide so much information during a conversation – after all, they know where and how it hurts, and I build on that. I give myself plenty of time.

I would highly recommend this to everyone. It builds trust. Symptoms vary quite a bit from one muscle injury to another. And if you’ve learned how to listen precisely, then the patient will basically lead you to the diagnosis. You hardly ever see that kind of dialog. They say that the average doctor takes just 18 seconds to go from the initial meeting to saying, Yup, let’s get you to the MRI!

“DON’T SHY AWAY FROM TOUCH.”

One thing that’s helped me a lot through all of these years is that I’m not shy about palpating and examining the patient. For me it started when I took massage courses when I was a student. No one forced me to, and, to be honest, I didn’t really know why I did it.

Some friends just took me with them so that I could have a look and maybe even participate. And I’m grateful to them for that to this day. That was how I came to know and understand muscles. I could recognize deviations from the norm, especially when I compared the healthy, uninjured side with the injured side—which, by the way, is still what I do today. Those massage courses were really worth their weight in gold. I would even go so far as to say that, in my case, the massage courses served as a basis for palpation.

“45 YEARS OF EXPERIENCE TREATING ELITE ATHLETES – THAT’S SOMETHING YOU HAVE TO SHARE AND PASS ON!”

And just so no one later on can accuse me of keeping it all to myself, I also give people the chance to observe my work. A lot of physicians do come visit me in my practice—physicians from abroad too—I’m completely open to that. In addition to that, now I’ve also decided to host a weekend seminar once a month beginning in September. A certain number of doctors will also be admitted who can bring a patient with them; I’ll examine the patient with no prior information and say what I feel, what I think. That’s going to be exciting for everyone involved, and I’m already looking forward to the lively exchange with colleagues.

Other treatment options

“A LOT OF THINGS ARE GOOD AND HELPFUL, BUT YOU DON’T HAVE TO JUMP ON EVERY BANDWAGON EITHER. WHAT’S IMPORTANT IS THAT, IF YOU’RE GOING TO APPLY SOMETHING, YOU HAVE TO BE ABLE TO DO IT RIGHT!”

With other treatment options and combination therapies, it’s always a question of experience and dosage, depending on the injury or symptoms: laser therapy can be helpful for muscle injuries, intermittent vacuum therapy is a good option, and magnetic field therapy yields good results too. These treatments belong in the hands of experienced doctors and therapists. But with all of these additional technologies, you mustn’t forget that palpation always has to be your starting point; only after that can you decide which type of physical therapy makes sense. I also really appreciate working with osteopaths, chiropractors, manual therapists, etc., and I know how fruitful collaboration between doctors and these therapists can be. That creates trust with the patient as well. I’ve been working with Hub Westhovens for several years now, for example, and I consider him to be the best osteopath I’ve ever met.

We first met through Arjen Robben, and Hub comes from Holland every week to visit my practice for 1 – 2 days.

“I DIDN’T JUST PULL THAT OUT OF THIN AIR – IT’S NOT HOKUS-POKUS! I’VE SPENT YEARS WORKING ON IT!”

Development of Profelan ointment is another one of those stories. When I started out with Bayern München, I used a plant-based ointment called Spolera, as well as Enelbin paste and Chomelanum ointment. In those days they were the three best products on the market for me. I would mix all three together, which was a lot of work of course and was particularly impractical in the treatment room. So I wanted to take the actives from each of the three products and combine them into one ointment. That was the beginning of Profelan. It was easier said than done. Ultimately we added arnica, zinc, vitamins A, C and E, mint and frankincense to this highly effective ointment for alleviating injuries, hardening or swelling.

The back

“I ALWAYS LIKE TO TELL ATHLETES: THIS IS THE COMMAND CENTER FOR YOUR LEG MUSCLES. EVERYTHING IS CONTROLLED FROM HERE. EVERYBODY KNOWS THAT!”

The lumbar spine plays an absolutely critical role in the musculature of the lower extremities. Take, for example, a herniated disk or a case of impingement syndrome in the lumbar spine area. What does a nerve do when it’s irritated? It fires signals into the leg. In some cases that falls below the pain threshold, so that the player often doesn’t even know or doesn’t notice it at first. The muscle tenses up, and patients feel like their legs are “heavy.” If a player keeps on training, probably everything will feel fine, but then when the coach switches the focus to speed training and the muscle is pushed to its limits over and over, that tension will keep increasing, the muscle will grow rigid and end up completely inelastic. Then comes a scrimmage, a sprint, and suddenly it happens. Far too often, physicians fail to recognize this context and/or chain of cause and effect, and the treatment isn’t adapted accordingly or the root cause of the injury goes untreated.

“NEUROGENIC MUSCLE HARDENING? UM… OK. MUSCLE SHUT DOWN? THAT MAKES SENSE!”

I have an anecdote from the 1980s that illustrates the point: at the Bayern München training facility in Bahrain, Lothar Matthäus was suddenly on the sidelines. He couldn’t keep going, he wanted out. I took a look and examined him—nothing was torn, no hematoma, no structural damage. But I could feel that the muscle was severely contracted and hard. I found a thin line of fluid that had collected along the fascia surrounding the muscle bundle, and it felt weirdly soapy. One or two more sprints and the muscle fibers could tear. The painful muscle was no longer elastic—it was supplied by a motor nerve extending from the lower lumbar spine, and that nerve was sending it too many signals, to which the muscle was responding. For Lothar Matthäus, the question now was what to say to the media. Why wasn’t he on the field? So to explain it to him, I told him that the muscle had “shut down” and that he had done the right thing. He understood that and told the media that “Mull” had told him his muscle had shut down. The phrase caught on, and ever since everybody can picture what that means. Neurogenic muscle hardening? Um… OK. Muscle shut down? That makes sense. A lot of muscle injuries are neurogenic in nature, and so it of course makes sense to examine and treat the back. Once we have eliminated the cause of the muscle overexcitation or, for instance, used Hub Westhovens’ osteopathic methods to restore the desired function of the vertebral and/or iliosacral joints, then the neurogenic muscle hardening quickly recedes.

Nutrition

“MY GOAL IS TO PREVENT DEFICIENCIES. YOU HAVE TO GET ENOUGH OF EVERYTHING!”

We always have nutrition in our sights. People often have a vitamin D deficiency, for example. Research is still underway on how it behaves in combination with K2. Similarly, our magnesium and zinc levels are often too low, but never too high. We also monitor amino acids like arginine, lysine and proline. Glutamine too. These are fundamentally important for healthy connective tissue and for muscle and tendon regeneration. Enzymes like bromelain, which inhibit inflammation, represent another important area. In all of these cases, it isn’t that I want to give particularly high doses. My goal is to prevent deficiencies. You simply have to get enough of everything! That’s why I recommend regular lab testing. 

Mobility 

If possible, you should check the mobility of the vertebral joints, the iliosacral joints and the joints of the lower extremities and potentially mobilize them before every practice or competition. One example: dorsiflexion of the ankle is blocked all too often, which can lead to a stress situation in the Achilles tendon or increased muscle tone in the calf, which under certain circumstances can become rock hard and susceptible to injury. A second example: dysfunction in the lumbosacral transitional area. Generally speaking, when athletes come to me with muscle problems, I find there is a blockage of the 5th lumbar vertebra; most of the time I also see severe limitation or even a blockage of one or both iliosacral joints. This results in irritation to the root of the nerve (usually S1 or the obturator nerve) and along this nerve I see hypertonia that can become quite painful: neurogenic muscle hardening, in other words, that, if left unaddressed, can lead to a structural muscle injury.

“REGENERATION IS KEY AND IT SHOULD BE CONSIDERED ON A CASE-BY-CASE BASIS.”

Thank you so much, Mr. Erbeldinger, for helpfully reminding me to bring up regeneration. Regeneration gives the body a chance to take the time – both actively and passively – that it needs for repairs and cell renewal. During regeneration, the body “dials down” stress hormones (adrenaline, noradrenaline, dopamine and glucocorticoids), allowing inner calm and relaxation to set in and guaranteeing a quiet, restful sleep. I think 7 hours of sleep are a must, 8 hours are good, and over 8 hours can be helpful, especially for elite athletes. Another issue: breathing. Conscious breathing without the distractions of TV or phones relaxes areas like the musculature of the shoulder girdle. All it takes is just a few minutes. You just need to make sure you’re breathing with your abdomen and avoiding shallow breaths as much as possible. It’s almost like meditation. I recommend James Nestor’s book “Breath” for reading material on this. I also feel strongly about recommending conscious eating. Slowing things down, tasting consciously, being aware of what you’re eating and of the point when you become full. All the while seeking out conversations in a relaxed atmosphere and just generally gaining clarity on the many areas of our lives we should be experiencing more consciously.

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After Dr. Müller-Wohlfahrt left Bayern München, a joint project on artificial intelligence came into being with researchers from the Klinikum rechts der Isar Hospital at the Technical University of Munich (TUM). As we talked, the subject sounded so exciting to us that we wanted more information, so we contacted TUM.

…HOW DID COLLABORATION AND THE AI PROJECT COME ABOUT?

Applying artificial intelligence means identifying complex correlations and patterns—potentially in multiple dimensions—studying them and applying them to new, future data. Apart from IT implementation, the key considerations are the quantity and quality of the data.

MRI testing is used throughout the world for diagnosing muscle injuries. It is exceptionally difficult with MRI, however, to distinguish, say, functional muscle injuries caused by neuromuscular disorders (type 2A; see consensus classification below) from circumscribed, structural muscle injuries (type 3A). If treated correctly, a competitive athlete who suffers a neurogenic injury can return to full performance after a few days. Inappropriate treatment and/or failure to recognize the injury, however, can keep the player off the field for several weeks. Precise diagnosis is therefore of the essence. Dr. Müller-Wohlfahrt gathers highly detailed palpatory findings, which he compares to other important criteria (such as the circumstances surrounding the accident, etc.), allowing him to make these distinctions with considerable precision. In collaboration with international experts he has used this as a basis for developing a consensus classification system for muscle injuries (Müller-W. 2013). But because MRI classification does not take neurogenic-associated lesions into account, this imaging technique can lead to misdiagnoses. In response to this problem, Dr. Müller-Wohlfahrt approached our team of researchers, asking how diagnostic certainty could be improved here going forward. We have therefore proposed taking his outstanding palpatory skills in the form of his diagnosis, and feeding this into a specific AI algorithm along with MRI imaging data. The algorithm will then use neural networks to detect correlations between the image data and the corresponding diagnosis. Initial results will be presented at the 2021 German Congress of Orthopaedics and Traumatology in Berlin in October. Even with very small amounts of data, the algorithm has already identified patterns that can be used for classifying injuries as functional/neuromuscular (type 2A) or structural (type 3A). Given our currently small number of cases, the results are merely preliminary and will have to be confirmed in large cohorts. The long-term idea is to develop a robust algorithm that will model the knowledge and skills of Dr. Müller-Wohlfahrt (as much as possible), serve as a supplementary diagnostic tool for (young) physicians and thus potentially benefit patients with muscle injuries.

TUM researchers collaborating with Dr. Müller-Wohlfahrt on this joint project: Florian Hinterwimmer, Nikolas Wilhelm, Prof. Dr. med. Rüdiger von Eisenhart-Rothe, Prof. Dr. med. Rainer Burgkart