Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

Featured on Channel NewsAsia

Intermuscular Hematoma

Bleeding may occur between muscles when a muscle fascia and its adjacent blood vessels are damaged. After an initial increase, causing the bleeding to spread, the pressure falls quickly. Typically, bruising and swelling, caused by a collection of blood, appear distally to the damaged area 24–48 hours after the injury, due to gravity. Because there is no sustained increase in pressure, the swelling is temporary and muscle function returns rapidly. Provided immediate treatment is available, recovery can be expected to be speedy and complete.

Treatment of acute injury

The athlete or trainer should stop or control muscle bleeding in the acute phase irrespective of its cause, by
use of the following measures:
– encouraging rest;
– bandaging the injured part—compression is the most effective way to limit bleeding;
– cooling the affected area to limit pain;
– elevating the limb;
– relieving load on the limb. If the injury affects the leg, crutches should be used until a definite diagnosis has been made. When an arm is involved, splinting may help during the acute phase.

The body’s defense against bleeding (coagulation or clotting) comes into action as soon as the injury occurs and continues to function for several hours. The repair mechanism, however, is unstable during the first 24– 36 hours, so that further bleeding may occur as a result of another impact, vigorous muscular contraction or unprotected weightbearing. If there is any suspicion of a major muscle rupture or significant bleeding, a doctor should be consulted as soon as possible. The doctor’s action will depend upon the extent of the injury. If the injury is severe, admission to hospital for observation may be indicated as the bleeding and swelling may increase, impairing the blood supply and raising the intramuscular pressure; this can be dangerous if left unmonitored. If the bleeding is not extensive, or if there is any uncertainty about the nature or extent of the injury, 48–72 hours’ rest may be prescribed. Precise diagnosis can be difficult in the acute phase and for the first 2–3 days an injury should be considered as potentially serious.

If there is any suspicion of a major muscle rupture or significant bleeding, a doctor should be consulted as soon as possible. The doctor’s action will depend upon the extent of the injury. If the injury is severe, admission to
hospital for observation may be indicated as the bleeding and swelling may increase, impairing the blood supply and raising the intramuscular pressure; this can be dangerous if left unmonitored. If the bleeding is not extensive, or if there is any uncertainty about the nature or extent of the injury, 48–72 hours’ rest may be prescribed. Precise diagnosis can be difficult in the acute phase and for the first 2–3 days an injury should be considered as potentially serious.

After 48–72 hours the following questions should be answered:

1. Has the swelling resolved? If not, intramuscular hematoma is probably present.
2. Has the bleeding spread and caused bruising at some distance from the injury? If not, hematoma is probably intramuscular.
3. Has the contractile ability of the injured muscle returned or improved? If not, the injury probably involves an intramuscular hematoma.
4. Is the hematoma a symptom of a total or partial muscle rupture?
It is important that an accurate diagnosis be made, because premature exercise of a muscle affected by extensive intramuscular hematoma or a complete rupture can cause complications in the form of further bleeding and sometimes increased scar tissue formation. This in turn is likely to lead to a more protractedhealing process and possibly even permanent disability. Treatment beyond the first 72 hours depends upon
the diagnosis.
Treatment after 72 hours
After initial acute treatment, minor partial ruptures, intermuscular hematomas and minor intramuscular hematomas should be managed by the following measures:
– support with an elastic bandage;
– local application of heat; contrast treatment using heat and cold may sometimes be of value.

Exercises should adhere to specific principles and be carried out in the following order:
1. Static exercises without load.
2. Static exercises with light load.
3. Limited dynamic muscle training with exercises within the active range of motion to the pain threshold.
4. Dynamic exercises with increasing load. Ice treatment can be applied after the exercise program to limit pain and swelling.
5. Stretching exercises to improve range of movement. It is important not to neglect exercising the muscles that act in the opposite direction (antagonists) to the one that has been injured.
6. Functional and proprioceptive training.
7. Gradually increasing activity and load to the injured muscle. If a lower limb is affected, it may be advisable to replace running by cycling and swimming and other types of water training.
8. Sport-specific training. If the symptoms caused by the injured muscle are serious initially or fail to improve, it is important to exclude intramuscular hematoma and tissue damage. To elucidate the situation, the doctor may take one or more of the following steps:
– carry out a further local examination;
– measure intramuscular (intracompartmental) pressure;
– puncture and aspirate the injured area with a needle if fluctuation is present;
– carry out an ultrasound or MRI examination; ultrasound examination is the most accurate way to evaluate a muscle injury and to follow healing;
– undertake surgery. When the diagnosis is established, there are a number of options:
– an elastic support bandage, a program of muscle exercises as outlined above, and anti-inflammatory medication;
– surgery may be considered in cases of extensive bleeding, especially when it is intramuscular and involves complete or partial rupture affecting more than half the muscle belly. It is particularly important when the damaged muscle is unique in the function it performs or is without agonists (muscles with similar function), e.g. pectoralis major. The aim of surgery is to remove any intervening blood clots and repair the torn muscle fibers by suturing them together; this procedure minimizes scar tissue formation. A period of immobilization in a brace is usually necessary after muscle surgery.
Rehabilitation
Rehabilitation after surgery is planned jointly by the athlete and the treating team, taking into consideration the location and severity of the injury. When rehabilitation is started early, healing is more rapid, with restoration of circulation and improvement in strength. The athlete can begin static muscle exercises and motion with the doctor’s agreement, soon after the operation, and later progress to dynamic strength and flexibility training.
Return to sporting activity
A muscle injury can be considered completely healed when there is no pain or tenderness on full contraction of the muscle. Once complete muscle function, full flexibility in adjacent joints, and a normal pattern of movement are regained, a full training program can be resumed. The time taken for a complete muscle rupture to heal is 3–16 weeks, depending on the location and extent of the injury. In cases of intramuscular hematoma, in which tissue damage is often a feature, the healing time may be 2–8 weeks or even longer, whereas sporting activity can often be resumed only 1–2 weeks after an intermuscular hematoma. Conditioning exercises and gradually progressive muscle exercise against resistance should take priority over explosive training exercises when sporting activity is resumed.

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