management of calf hematomas

introduction

Muscle injuries are common in almost any sports medicine practice.  They are commonly reported in athletes involved in contact sports and can be a source of significant pain and limitation.  Muscle contusions and strains can result in hematoma formation.  The consequences of a failed treatment can be very serious, postponing an athlete’s return to sports for weeks or months because of possible recurrences and complications. 

The muscle hematoma can be the consequence of an impact against an external blunt or against a bone or of an excessive or uncoordinated contraction (indirect trauma). In a direct trauma, when the muscle is contracted, the contusion will impact more superficial tissues while, in a relaxed muscle, the structural damage and the consequent hematoma, generally occur in depth, nearest the bone. The severity of the lesion depends on the site of impact, the activation status of the muscles involved, the age of the patient, and the presence of fatigue [2].

Hematoma formation within the muscle may be intramuscular, intermuscular, or mixed. Intermuscular hematomas appear striking due to visible bruising and swelling, but intramuscular hematomas are considered more serious because as the hematoma enlarges, it occupies space within an intact muscle fascia.  This can create increased pressure that can lead to decreased muscle contractility, extensibility, and function [1].  Intramuscular hematomas have a greater potential to develop post-traumatic myositis ossificans and fibrosis, and thus it is recommended that intramuscular hematomas be drained [1].

Hematoma classifications

Image 1: Hematoma classifications. Adopted from [3].

Optimal treatment of skeletal muscle injuries begins with the correct diagnosis [3]. The clinical diagnosis of a surface hematoma is easier due to the detection of a bruised area of ​​variable extension and depends on the extent of the trauma, contextual to swelling and loss of muscle function. On the other hand, the clinical diagnosis of deep hematomas may be more challenging. 

Point of care ultrasound can be very useful if there is suspicion of a hematoma.  The formulation of a precise and definitive diagnosis in case of an intramuscular hematoma, becomes possible only after 12-72 hours from the detrimental event, since the formation of the hematoma may also appear over three days after the trauma, thereby preventing a possible early diagnosis [1]. Intermuscular hematomas tend to be sent for further evaluation more quickly due to their appearance.

Current treatment for muscle injury is mainly conservative, consisting of rest, cold packs on the area, elevation, compression, pain medications, and rehabilitation [2].  Primary treatment has been widely advocated to include the Protection, Rest, Ice, Compression and Elevation (the acronym “PRICE”), despite the lack of any high-quality studies to support its evidence [8]. 

calf hematoma exam

Image 2.  Image of calf hematoma roughly one week old.

Medical interventions to date lack strong evidence to prove efficacy in calf injury. Biologic therapy with platelet rich plasma, whole blood or stem cells has not demonstrated benefit to date. Biologic modification with topical nitroglycerin has moderate supporting evidence for benefit in Achilles injury but has not been studied in calf injury [1].

A decrease in swelling and reduction in pain along with a recovery in muscle function in the first 24 hours post-traumatic are indicators of a favorable prognosis. On the contrary, an increase or a persistent swelling after 48-72 hours, an increase in pain, a decrease of peripheral pulses, a prolonged or progressive limitation of joint caused by pain or muscle weakness, a numbness and a sense of paresthesia below the area of injury are all negative prognostic factors [1].

calf MRI hematoma

Image 3: MRI of lower leg hematoma of athlete in image 2.  This was heterogeneous on ultrasound examination.

Video: Point of care ultrasound in short axis showing large calf hematoma.

Initially, compression wraps or stocking can be helpful.  The aim for applying a compression bandage on the injured area is to limit a further hemorrhage [4]. The compression bandage should be maintained for a period of 2 -7 days, but not neglected until a substantial decrease in the swelling and a fluctuation reduction of the palpable mass is obtained. The amount of compression due to the different types of bandage causes different responses at the site of the lesion: high compression, approximately 85 mmHg, obtain an immediate stop of intramuscular blood flow, while a low compression, in the order of 40-45 mmHg, reduces blood flow about 50% [4].   The goal of ice, compression, and elevation is to reduce hematoma formation or worsening and to improve blood, lymphatic, and interstitial flow at the cellular and regional levels to promote healing. In more severe injuries, a few days of crutch walking may be required.

Ultrasound is the most appropriate tool for interventional procedures on the hematoma when the lesion is visible. The target area is easily identified with ultrasound and needle or catheter position is easily and efficacy documented. Advantages of US-guided procedures include the absence of ionizing radiation, real-time monitoring during needle placement, decreased risk of injury to vessels and nerves, real time confirmation of procedure success of complete fluid aspiration. Complications are rare and can be avoided by using proper sterile technique and evaluating for potential contraindications to the procedure [3].

An aspiration can lead to faster reduction of pain, decrease in heterotopic ossification, and earlier return to sports activities compared with conservative therapy [9-11].  The literature is conflicting regarding an ideal time to attempt aspiration. Some have suggested timing the aspiration to within the two weeks to increase the likelihood of decompression [11-12], because of the liquid appearance of hypoechogenicity and compressibility of the hematoma [9], whereas others have reported greater difficulty aspirating younger rather than older hematomas [13].

Yoon et. al has had one of the largest cohorts with musculoskeletal hematomas published with 148 patients. A total of 165 aspirations were performed because there were 12 repeated aspirations and five patients with hematomas at more than one site.  One hundred patients at follow up reported no infections and all reported symptomatic relief.  Twelve of the 100 patients presented with reaccumulation of hematomas from 1 to 4 weeks after the initial aspiration attempt and a larger bore needle was used. 

The study showed success of the aspiration regardless of the hematoma being hyperechoic or complex versus hypoechoic.  Saline lavage was helpful regardless of the appearance of the hematoma when the initial attempts at aspiration yield little or no decompression. Dave et al. [9] also mentioned the use of saline or anesthetic lavage. The concept of lavage is to dilute thick blood and to mechanically break up organizing clots for easier aspiration. The amount of lavage fluid depends on the size of the hematoma.  Their study showed that the ultrasound guided aspiration was safe and effective, regardless of the age.  Hypoechoic hematomas were rated as easier to aspirate than hyperechoic or complex hematomas [14]. 

Standard eccentric calf raises from a step to facilitate the rehabilitation of Achilles tendon injury were described by Mafi et al. and have evidence to support efficacy [6]. These have been used for calf injury rehabilitation because the calf and Achilles are part of a continuous musculotendinous complex. Another study demonstrates that the concentric progressive resistance calf raises effectively rehabilitate Achilles injury and also could be applied for calf injury based on the same rationale [7].

At present, studies on the surgical intervention of muscle contusion are limited and agreement on a gold standard for the management of muscle hematomas has not yet been reached. There is no consensus on the indication and timing of hematoma evacuation, and its benefits for muscle recovery and athletes’ return to play are yet to be determined. Myositis ossificans is also one of the complications of muscle hematomas, and it is still not known whether evacuation of muscle hematoma will promote or prevent its formation.

Summary

In summary, calf hematomas will be encountered in sports and orthopedics practices.  There is paucity of evidence on recommended management and many providers abide by the standard “PRICE” principles with initial management.  It is important to correctly diagnose calf hematomas and the ultrasound is a great tool for evaluation and management.  Many practitioners can utilize compression and physical therapy and serially monitor progress.  Other providers may elect to aspirate.  Surgical intervention is fairly rare and no gold standard procedure exists for hematoma evacuations of the calf.

– Read More @ Wiki Sports Medicine: https://wikism.org/Calf_Strain

– More Calf/ Ankle Pain: https://www.sportsmedreview.com/by-joint/ankle/

References

  1. Conforti, Maria. “The treatment of muscle hematomas.” Muscle Injuries in Sports Medicine, InTech (2013): 203-220.
  2. Sisk, T. David. “DeLee and Drez’s Orthopaedic Sports Medicine: Principles and Practice.” (2004): 890.
  3. JärvinenT. AJärvinenT. LKääriäinenMKalimoHMuscle injuries: biology and treatment. Am J Sports Med. 2005May;33574564
  4. Thorsson O, Lilja B, Nilsson P, Westlin N. Immediate external compression in the management of an acute muscle injury. Scand J Med Sci Sports. 1997 Jun;7(3):182-90
  5. Royall NA, , Farrin E, , Bahner DP, , Stawicki SP. Ultrasound-assisted musculoskeletal procedures: a practical overview of current literature. World J Orthop 2011; 2: 57–66. doi: 10.5312/wjo.v2.i7.
  6. Mafi N, Lorentzon R, Alfredson H. Superior short-term results with eccentric calf muscle training compared to concentric training in a randomized prospective multicenter study on patients with chronic Achilles tendinosis. Knee Surg. Sports Traumatol. Arthrosc. 2001; 9:42.
  7. Fahlström M, Jonsson P, Lorentzon R. Chronic Achilles tendon pain treated with eccentric calf-muscle training. Knee Surg. Sports Traumatol. Arthrosc. 2003; 11:327.
  8. Hotfiel T, Carl HD, Swoboda B, Heinrich M, Heiss R, Grim C et al (2016b) Current conservative treatment and management strategies of skeletal muscle injuries. Z Orthop Unfall 154:245–253
  9. Dave RB, Stevens KJ, Shivaram GM, McAdams TR, Dillingham MF, Beaulieu CF. Ultrasound-guided musculoskeletal interventions in American football: 18 years of experience. AJR 2014; 203:[web]W674–W683 
  10. Sales RM, Cavalcante MC, Cohen M, Ejnisman B, Andreoli CV, de Castro Pochini A. Treatment of acute thigh muscle injury with or without hematoma puncture in athletes. Rev Bras Ortop (Sao Paulo) 2019; 54:6–12 
  11. De la Corte-Rodriguez H, Rodriguez-Merchan EC. Treatment of muscle haematomas in haemophiliacs with special emphasis on percutaneous drainage. Blood Coagul Fibrinolysis 2014; 25:787–794
  12. Orlandi D, Corazza A, Arcidiacono A, et al. Ultrasound-guided procedures to treat sport-related muscle injuries. Br J Radiol 2016; 89:20150484
  13. Szopinski KT, Smigielski R. Safety of sonographically guided aspiration of intramuscular, bursal, articular and subcutaneous hematomas. Eur J Radiol 2012; 81:1581–1583