Muscle Hematoma Of the Athlete
A muscle hematoma can develop in athletes especially after a muscle tear or contusion. In my experience, the most common area to see these injuries is the quadriceps muscle group of the leg. The quadriceps muscles are the large muscle on the anterior thigh commonly injured in contact sports such as football. There are two common types of muscular hematomas; one that occurs within the muscle itself (intramuscular) usually due to direct impact and the other that occurs between the muscles (intermuscular) typically due to a muscle tear. Many times a superficial hematoma can be apparent within the first 24 hours, however, in patients that have persistent or severe pain out of proportion for a simple contusion a deeper hematoma should also be considered.
RF= Rectus Femoris, VL= Vastus Lateralis, VMO= Vastus Medialis, VI=Vastus Intermedius (not pictured)
More Painful Than You Think
I want to emphasize that although this does not always occur, intramuscular quadriceps hematoma can be extremely painful and limiting on normal muscular function. When the hematoma collects within the closed covering of the muscle (fascia), it creates swelling, pressure and severe pain. Intermuscular hematomas may present with more obvious bruising, however, pain is typically much less as the hematoma is able to disperse throughout the thigh. The two primary modalities for diagnosis include ultrasound and MRI to best characterize the size and location of the hematoma. Signs of a prolonged recovery include increased pain intensity, extension of pain from site of injury and restricted limb range of motion greater than 2-3 days after the injury.
Key Components of Treatment
Ice - Believed to decrease the hematoma formation by constricted the blood vessels at the site of injury as well as decreasing the metabolic rate of the effect area. It also is thought to reduce pain allowing earlier movement. However there is no evidence on the duration and frequency of treatment
Rest - Recommended within the first 2-3 days to prevent further bleeding and allow any torn muscle fibers to scar down.
Compression - Thought to decrease swelling but no clear evidence in the literature
Heat - Believed to speed the rate of absorption of the hematoma by decreasing the viscosity of the hematoma and promoting blood circulation to the affected area.
Exercise - Includes gentle range of motion and isometric exercises after 2-3 days can help regain movement and encourage hematoma resolution. Athlete typically will continue to progress as pain allows.
Drainage - Controversial as it could cause more trauma to the area and there tends to be a re-accumulation of fluid however in some cases of large hematoma there can be improvement of symptoms.
In my experience, hematoma injuries can be deceiving in that they can be more painful and limiting than one would expect. Additionally, a significant intramuscular quadriceps hematoma can significantly limit return to sports for several months due to persistent pain. Lastly, providers must be aware of complications such as myositis ossificans which is cover more in-depth in another post.
Myositis Ossificans
Reference: Smith TO, Hunt NJ, Wood SJ. The physiotherapy management of muscle haematomas. Phys Ther Sport. 2006 Nov;7(4):201-9. doi: 10.1016/j.ptsp.2006.06.001. Epub 2006 Aug 17. PubMed PMID: 21663833.