If you have ever seen the TV show The Office, you are familiar with the infamous safety training episode. In this episode, Dwight fakes a fire and scares the whole office into thinking they are going to die. Michael, the manager and main character, says in an aside interview, “I knew exactly what to do, but in a much more real sense I had no idea what to do”. I think this pretty much sums up how most people feel about handling muscle strains. Let's change that!
So you decided to play basketball this weekend after not playing in 10 years, and you jack your calf up. Perhaps you decided to see how many times you can rep 250 on bench press even though you are feeling a little crummy that night and feel your pec pop (I plead the fifth on this one!). Maybe, like my dad, you were chasing a butterfly in the yard with a grandkid and you felt a pop in the back of your leg and it turned purple overnight. All of these situations are common examples of what happens when someone strains a muscle. What is the first thing most people who come in to see me say they have been doing to fix it? Stretching that muscle. Is this a great idea?? Wellllllll not necessarily.
First off we need to dissect what a muscle strain is. Muscles are made up of millions of small units called sarcomeres, that make larger units called myofibrils, that make up larger fibers that make up each muscle. Each sarcomere has small components called actin and myosin that contract and relax to make the muscle shorten and lengthen. When we strain a muscle, we essentially overstretch the muscle fibers to the point where they actually tear and are not able to produce as much force. This process is typically painful, can cause inflammation, and at times severe bruising if bad enough. There are 3 grades of muscle strains. Grade 1 strains are slightly over stretched muscles. This can be a bad case of DOMS (delayed onset muscle soreness) that you feel after a brutal session at the gym. If you have done a leg day only find yourself unable to get up off the toilet two days later, you have experiences DOMS. Grade 2 strains are more involved and oftentimes can involve feeling a small pop or tear. These are larger separations of the muscle fibers but they are still intact. Grade 3 strains are complete tears in which the muscle fibers physically separate the muscle leaving it in two pieces, or very close. Typically grade 1 strains heal fairly quickly on their own as long as you don't overdo it again while you are very sore. If so, you set yourself up for a potential grade 2 strain. Grade 2 strains are more involved and typically require some kind of physical therapy intervention to help return to full function, and grade 3 strains or tears are almost always surgical.
So let's say you encounter a grade 2 strain when you are lifting, running, or playing a match of quidditch. Yes, you can actually buy kits to play quidditch. No, I do not have one unfortunately. What do you do first? You should not stretch it, at least not at first. The reason we don't want to stretch a strained muscle is because as we discussed, that muscle has already been overstretched. We don't want to start stretching the damaged fibers more because this can cause more tearing and slow down the healing process of those fibers connecting back together. We do, however, want to keep the muscle moving to encourage blood flow to the area and prevent it from stiffening up too much. For example, if you strain your hamstring, this can look like doing some walking or other lower body exercises like bridges or some 90/90 knee extensions staying below any stretch or stiffness feeling. It just keeps the muscles moving but not overly stressing it.
The other thing we want to do is try to work on activating surrounding stabilizing musculature. This goes hand in hand with the idea of keeping it moving but not over stressing the muscle. For the hamstring example, I often try to help people find a few exercises in which they can control some lumbar flexion (targeting core muscles) and activate their glutes. Typically with a hamstring strain, we find underlying core and glute issues that lead to the problem in the first place. By working on these things we keep you moving and are able to start addressing motor control issues your body may have. This can also help take stress off the strained muscle by moving around since you are activating others to come in and help stabilize the joint. For a pec strain, this could be some light farmer's carries, banded rows or external rotation, or KB arm bars. All of these will activate shoulder and scapular stabilizing musculature to help take stress off the pec. This also helps the body realize it can still move and everything will be fine! It sounds silly but when our bodies sense injury, not moving can increase the pain perceived by the injured area.
The next step on this fun little journey is isometrics. Isometrics are exercises in which we contract a muscle while keeping our body in a fixed position so we are not actually moving a joint or really changing the length of the muscle. A wall sit or a plank are classic examples of isometrics. The reason we work on isometrics is because they can help reduce pain, help strengthen muscles and tendons, and are a simpler form of strength work that a muscle can handle after an injury. It takes a lot for our body to properly figure out the perfect length tension relationship that each muscle needs to be at while performing different strength and athletic movements. When we have injuries to a muscle, we often lose some coordination and motor control to that muscle until it has healed. Through training, we restore its normal function. Isometrics are a simple way the muscle that just got laid out can put its helmet back on and get back in the scrimmage to get some practice reps in. Ultimately, I start fairly light with these having people contract the muscle gently resisting into an object for 10 seconds, repeating 5-10 times. There is some research out there to suggest holding isometrics for 30-45 seconds if you are addressing pain, but in my experience most people do better starting smaller and slowly, progressing the amount of force they produce and the length of time they hold it. It is not uncommon to have some soreness when you first start these, but after you do 5-10 reps, a good response is the muscle feels better and may even have more ROM pain free. Everyone is different but it is usually at least a week if not two before I have people start working on these. It depends on the severity of the strain and the pain level, but usually this is not something I have people work on the day after a strain.
Alright, now is when we get to start doing some stretching (and there was great rejoicing!). After giving it 2-4 weeks working on the above mentioned things, depending on the severity and irritability of the injury, I typically will start having people do some very light stretching of the involved muscle group. The key word here is light. This is not aggressive end range stretching for 2 minutes; I am talking about gentle stretching for 20-60 seconds. If we don't stretch at all, the tissue can stiffen up and lose some range of motion (ROM). The main focus of this kind of stretching is simply to prevent over stiffening of the tissue, not to try to improve ROM and become more flexible. That is why it is light stretching to the point of feeling a small stretch in the muscle completely pain free.
The final main step of this recovery process is strengthening. This is classically done with eccentric training. An eccentric exercise is when we have a muscle actively resisting load while it is being lengthened. Think of doing a heavy bicep curl in which you slowly lower the bar down from the top position forcing yourself to slowly control the descent. Eccentrics are great for stimulating muscle growth and tendon repair, but they can be aggressive. These are the gold standard exercises after a muscle strain, but I find a lot of people can’t handle these early in the process. It is usually 2-4 weeks before I have people begin eccentric exercises so as to avoid restraining the muscle, or increasing pain. Eccentrics are one of the hallmark focuses of training after a hamstring strain in the current clinical practice guideline for hamstring strains.(1) For eccentrics I have people start small doing 2-3 sets of 5-10 reps of a particular exercise, depending on their current pain and mobility status. This is slowly progressed until they are able to handle some serious load pain free for multiple sets. This is not an everyday exercise either. Eccentrics are damaging to muscle fibers the same way any strength exercise is, but this damaging nature drives the stimulus that repairs the muscle. Typically I have people do these every other day as long as they are feeling fine and pain is not increasing. This goes down to 2-3 times a week as the intensity of the exercise increases.
After and to some extent during the eccentric phase, we begin the process of return to sport or whatever activity you are trying to get back to. We need to ensure proper motion and strength of the muscle, and surrounding areas, before jumping right back into aggressive activity, especially athletics. This is careful process or ensuring our body is ready to return to high demands with as little risk of injury or recurrence as possible. This is not just about the strained muscle, but rather the whole movement system. Our bodies don't move in isolation, and therefore the process of returning to activity needs to be comprehensive.
I'm sure this is a lot to take in and may seem overly complex, but muscle strains are no joke. It is not simply a tear that heals and never causes problems again. If strains are not addressed properly, they can predispose you for repeat injuries of the same muscle or at times other regions. Our bodies are incredibly complex and have been designed in such a way that they remember injury; our nervous system is different after every injury we incur. If we do not properly help guide the muscle through the healing process and restore proper motor control and stability to the muscle and surrounding regions, we leave ourselves vulnerable. If you have an injury currently or a nagging problem you can’t seem to shake, please come see me or another PT you trust to help you walk through this process to get you back in the game!
References
Martin RL, Cibulka MT, Bolgla LA, et al. Hamstring Strain Injury in Athletes. Journal of Orthopedic Sports Physical Therapy. Published online 2022.
