Terminology and classification of muscle injuries in sport: the Munich consensus statement

Hans-Wilhelm Mueller-Wohlfahrt, Lutz Haensel, Kai Mithoefer, Jan Ekstrand, Bryan English, Steven McNally, John Orchard, C Niek van Dijk, Gino M Kerkhoffs, Patrick Schamasch, Dieter Blottner, Leif Swaerd, Edwin Goedhart, Peter Ueblacker, Hans-Wilhelm Mueller-Wohlfahrt, Lutz Haensel, Kai Mithoefer, Jan Ekstrand, Bryan English, Steven McNally, John Orchard, C Niek van Dijk, Gino M Kerkhoffs, Patrick Schamasch, Dieter Blottner, Leif Swaerd, Edwin Goedhart, Peter Ueblacker

Abstract

Objective: To provide a clear terminology and classification of muscle injuries in order to facilitate effective communication among medical practitioners and development of systematic treatment strategies.

Methods: Thirty native English-speaking scientists and team doctors of national and first division professional sports teams were asked to complete a questionnaire on muscle injuries to evaluate the currently used terminology of athletic muscle injury. In addition, a consensus meeting of international sports medicine experts was established to develop practical and scientific definitions of muscle injuries as well as a new and comprehensive classification system.

Results: The response rate of the survey was 63%. The responses confirmed the marked variability in the use of the terminology relating to muscle injury, with the most obvious inconsistencies for the term strain. In the consensus meeting, practical and systematic terms were defined and established. In addition, a new comprehensive classification system was developed, which differentiates between four types: functional muscle disorders (type 1: overexertion-related and type 2: neuromuscular muscle disorders) describing disorders without macroscopic evidence of fibre tear and structural muscle injuries (type 3: partial tears and type 4: (sub)total tears/tendinous avulsions) with macroscopic evidence of fibre tear, that is, structural damage. Subclassifications are presented for each type.

Conclusions: A consistent English terminology as well as a comprehensive classification system for athletic muscle injuries which is proven in the daily practice are presented. This will help to improve clarity of communication for diagnostic and therapeutic purposes and can serve as the basis for future comparative studies to address the continued lack of systematic information on muscle injuries in the literature. WHAT ARE THE NEW THINGS: Consensus definitions of the terminology which is used in the field of muscle injuries as well as a new comprehensive classification system which clearly defines types of athletic muscle injuries.

Level of evidence: Expert opinion, Level V.

Figures

Figure 1
Figure 1
Anatomic illustration of the location and extent of functional and structural muscle injuries (eg, hamstrings). (A) Overexertion-related muscle disorders, (B) Neuromuscular muscle disorders, (C) Partial and (sub)total muscle tears (from Thieme Publishers, Stuttgart; planned to be published. Reproduced with permission.). This figure is only reproduced in colour in the online version.
Figure 2
Figure 2
Anatomic illustration of the extent of a minor and moderate partial muscle tear in relation to the anatomical structures. Please note, that this is a graphical illustration, there are variations in extent. (From Thieme Publishers, Stuttgart; planned to be published. Reproduced with permission.). This figure is only reproduced in colour in the online version.

References

    1. Ekstrand J, Hagglund M, Walden M. Epidemiology of muscle injuries in professional football (soccer). Am J Sports Med 2011;39:1226–32
    1. Andersen TE, Engebretsen L, Bahr R. Rule violations as a cause of injuries in male Norwegian professional football: are the referees doing their job? Am J Sports Med 2004;32:62S–8S
    1. Arnason A, Sigurdsson SB, Gudmundsson A, et al. Risk factors for injuries in football. Am J Sports Med 2004;32:5S–16S
    1. Brophy RH, Wright RW, Powell JW, et al. Injuries to kickers in American football: the National Football League experience. Am J Sports Med 2010;38:1166–73
    1. Hagglund M, Walden M, Ekstrand J. Injuries among male and female elite football players. Scand J Med Sci Sports 2009;19:819–27
    1. Hawkins RD, Hulse MA, Wilkinson C, et al. The association football medical research programme: an audit of injuries in professional football. Br J Sports Med 2001;35:43–7
    1. Walden M, Hagglund M, Ekstrand J. UEFA Champions League study: a prospective study of injuries in professional football during the 2001–2002 season. Br J Sports Med 2005;39:542–6
    1. Alonso JM, Junge A, Renstrom P, et al. Sports injuries surveillance during the 2007 IAAF World Athletics Championships. Clin J Sport Med 2009;19:26–32
    1. Malliaropoulos N, Isinkaye T, Tsitas K, et al. Reinjury after acute posterior thigh muscle injuries in elite track and field athletes. Am J Sports Med 2011;39:304–10
    1. Malliaropoulos N, Papacostas E, Kiritsi O, et al. Posterior thigh muscle injuries in elite track and field athletes. Am J Sports Med 2010;38:1813–19
    1. Lopez V, Jr, Galano GJ, Black CM, et al. Profile of an American amateur rugby union sevens series. Am J Sports Med 2012;40:179–84
    1. Borowski LA, Yard EE, Fields SK, et al. The epidemiology of US high school basketball injuries, 2005–2007. Am J Sports Med 2008;36:2328–35
    1. Feeley BT, Kennelly S, Barnes RP, et al. Epidemiology of National Football League training camp injuries from 1998 to 2007. Am J Sports Med 2008;36:1597–603
    1. Walden M, Hagglund M, Magnusson H, et al. Anterior cruciate ligament injury in elite football: a prospective three-cohort study. Knee Surg Sports Traumatol Arthrosc 2011;19:11–19
    1. Woods C, Hawkins RD, Maltby S, et al. The Football Association Medical Research Programme: an audit of injuries in professional football—analysis of hamstring injuries. Br J Sports Med 2004;38:36–41
    1. Armfield DR, Kim DH, Towers JD, et al. Sports-related muscle injury in the lower extremity. Clin Sports Med 2006;25:803–42
    1. Jarvinen TA, Jarvinen TL, Kaariainen M, et al. Muscle injuries: biology and treatment. Am J Sports Med 2005;33:745–64
    1. Anderson K, Strickland SM, Warren R. Hip and groin injuries in athletes. Am J Sports Med 2001;29:521–33
    1. Noonan TJ, Garrett WE., Jr Muscle strain injury: diagnosis and treatment. J Am Acad Orthop Surg 1999;7:262–9
    1. Bryan Dixon J. Gastrocnemius vs. soleus strain: how to differentiate and deal with calf muscle injuries. Curr Rev Musculoskelet Med 2009;2:74–7
    1. O'Donoghue DO. Treatment of injuries to athletes. Philadelphia: WB Saunders, 1962
    1. Ryan AJ. Quadriceps strain, rupture and charlie horse. Med Sci Sports 1969;1:106–11
    1. Takebayashi S, Takasawa H, Banzai Y, et al. Sonographic findings in muscle strain injury: clinical and MR imaging correlation. J Ultrasound Med 1995;14:899–905
    1. Peetrons P. Ultrasound of muscles. Eur Radiol 2002;12:35–43
    1. Stoller DW. MRI in orthopaedics and sports medicine. 3rd edn. Philadelphia: Wolters Kluwer/Lippincott, 2007
    1. Ekstrand J, Healy JC, Walden M, et al. Hamstring muscle injuries in professional football: the correlation of MRI findings with return to play. Br J Sports Med 2012;46:112–17
    1. Fink A, Kosecoff J, Chassin M, et al. Consensus methods: characteristics and guidelines for use. Am J Public Health 1984;74:979–83
    1. Fuller CW, Ekstrand J, Junge A, et al. Consensus statement on injury definitions and data collection procedures in studies of football (soccer) injuries. Clin J Sport Med 2006;16:97–106
    1. Orchard J, Marsden J, Lord S, et al. Preseason hamstring muscle weakness associated with hamstring muscle injury in Australian footballers. Am J Sports Med 1997;25:81–5
    1. Brooks JH, Fuller CW, Kemp SP, et al. Incidence, risk, and prevention of hamstring muscle injuries in professional rugby union. Am J Sports Med 2006;34:1297–306
    1. Askling CM, Tengvar M, Saartok T, et al. Acute first-time hamstring strains during high-speed running: a longitudinal study including clinical and magnetic resonance imaging findings. Am J Sports Med 2007;35:197–206
    1. Askling CM, Tengvar M, Saartok T, et al. Proximal hamstring strains of stretching type in different sports: injury situations, clinical and magnetic resonance imaging characteristics, and return to sport. Am J Sports Med 2008;36:1799–804
    1. Verrall GM, Slavotinek JP, Barnes PG, et al. Clinical risk factors for hamstring muscle strain injury: a prospective study with correlation of injury by magnetic resonance imaging. Br J Sports Med 2001;35:435–9
    1. Hagglund M, Walden M, Bahr R, et al. Methods for epidemiological study of injuries to professional football players: developing the UEFA model. Br J Sports Med 2005;39:340–6
    1. Brooks JH, Fuller CW. The influence of methodological issues on the results and conclusions from epidemiological studies of sports injuries: illustrative examples. Sports Med 2006;36:459–72
    1. Finch CF. An overview of some definitional issues for sports injury surveillance. Sports Med 1997;24:157–63
    1. Junge A, Dvorak J. Influence of definition and data collection on the incidence of injuries in football. Am J Sports Med 2000;28:S40–6
    1. Junge A, Dvorak J, Graf-Baumann T, et al. Football injuries during FIFA tournaments and the Olympic Games, 1998–2001: development and implementation of an injury-reporting system. Am J Sports Med 2004;32:80S–9S
    1. Opar DA, Williams MD, Shield AJ. Hamstring strain injuries: factors that lead to injury and re-injury. Sports Med 2012;42:209–26
    1. Garrett WE., Jr Muscle strain injuries. Am J Sports Med 1996;24:S2–8
    1. Witvrouw E, Danneels L, Asselman P, et al. Muscle flexibility as a risk factor for developing muscle injuries in male professional soccer players. A prospective study. Am J Sports Med 2003;31:41–6
    1. Boening D. Delayed-onset muscle soreness (DOMS). Dtsch Arztebl 2002;99:372–77
    1. Ong A, Anderson J, Roche J. A pilot study of the prevalence of lumbar disc degeneration in elite athletes with lower back pain at the Sydney 2000 Olympic Games. Br J Sports Med 2003;37:263–6
    1. Orchard JW, Farhart P, Leopold C. Lumbar spine region pathology and hamstring and calf injuries in athletes: is there a connection? Br J Sports Med 2004;38:502–4
    1. Orchard JW. Intrinsic and extrinsic risk factors for muscle strains in Australian football. Am J Sports Med 2001;29:300–3
    1. Hoskins WT, Pollard HP. Successful management of hamstring injuries in Australian Rules footballers: two case reports. Chiropr Osteopat 2005;13:4.
    1. Mueller-Wohlfahrt HW. Diagnostik und Therapie von Muskelzerrungen und Muskelfaserrissen. Sportorthop Sporttraumatol 2001;17:17–20
    1. Brenner B, Maassen N. Physiologische Grundlagen und sportphysiologische Aspekte. In: Mueller-Wohlfahrt HW, Ueblacker P, Haensel L, eds. Muskelverletzungen im Sport. Stuttgart, Germany, New York: Thieme, 2010:73–4
    1. Clanton TO, Coupe KJ. Hamstring strains in athletes: diagnosis and treatment. J Am Acad Orthop Surg 1998;6:237–48
    1. Garrett WE, Jr, Rich FR, Nikolaou PK, et al. Computed tomography of hamstring muscle strains. Med Sci Sports Exerc 1989;21:506–14
    1. Hughes Ct, Hasselman CT, Best TM, et al. Incomplete, intrasubstance strain injuries of the rectus femoris muscle. Am J Sports Med 1995;23:500–6
    1. Schuenke M, Schulte E, Schumacher U. Atlas of Anatomy. Stuttgart, Germany, New York: Thieme, 2005
    1. Beiner JM, Jokl P. Muscle contusion injuries: current treatment options. J Am Acad Orthop Surg 2001;9:227–37
    1. Kary JM. Diagnosis and management of quadriceps strains and contusions. Curr Rev Musculoskelet Med 2010;3:26–31
    1. Ryan JB, Wheeler JH, Hopkinson WJ, et al. Quadriceps contusion. West Point update. Am J Sports Med 1991;19:299–304

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