Classification of muscle injuries
and return to play
Jerome Renoux, MD
Head of Imaging P24 & INSEP
Background
• Why is imaging so important ?
• Major technical improvements in the 3 last decades (MRI, US)
• Increased weight of money in professional sports enabled teams to have
better medical services
• Issues :
• The benefits of this high diagnostic accuracy often outstrips our hability to
clinically evaluate the patients
• Imaging became the mainstay in the diagnosis : we overlooked the patient for
its image
• However, it is important to understand the value of reproducible and reliable
diagnostic elements in their management.
Manual for sport imaging :
feedback after three Olympics
• Athletes were followed years before this culmination event in the French National
Sport Institute (INSEP), sometimes from childhood
• The medical team shared their hopes, doubts and difficulties until this climax
point of their carreer
First goal : performance
• Medical management does not finish after Olympics :
• Some athletes aimed for the next one
• Many of them had to come back to normal life
Overall goal : Healthy life on the long term
Imaging of the Traumatized Muscle
• For whom ?
• Athletes :
• These injuries account for one-third of high-level athletes' trauma (1)
• Sporting et economic impact
• Sedentary individuals :
• They are less frequent.
• ... but often more severe (serious functional sequelae).
• Pourquoi ?
• Adapter la prise en charge et optimiser les délais de reprise
• Dépister les lésions graves chez tous les sujets
(1) Guermazi A, Roemer FW, Robinson P, Tol JL, Regatte RR, Crema MD. Imaging of Muscle Injuries in Sports Medicine: Sports Imaging Series. Radiology.
2017 Mar;282(3):646-663. doi: 10.1148/radiol.2017160267. Review. Erratum in: Radiology. 2017 Dec;285(3):1063
Imaging of the Traumatized Muscle
• For whom ?
• Athletes :
• These injuries account for one-third of high-level athletes' trauma (1)
• Sporting et economic impact
• Sedentary individuals :
• They are less frequent.
• ... but often more severe (serious functional sequelae).
• Why ?
• Adapt management and optimize recovery times
• Detect serious injuries in all subjects
(1) Guermazi A, Roemer FW, Robinson P, Tol JL, Regatte RR, Crema MD. Imaging of Muscle Injuries in Sports Medicine: Sports Imaging Series. Radiology.
2017 Mar;282(3):646-663. doi: 10.1148/radiol.2017160267. Review. Erratum in: Radiology. 2017 Dec;285(3):1063
Critical point : assessing the prognosis
Return To Play
• First thing to understand : we cannot wait for the complete
histological healing of the damaged structure (it would represent
around 100 days for the muscle and 300 days for a tendon). But most
of the athletes go back in less than 20 days.
• Same ascertainment for imaging : pathologic findings remain for a
long time.
• Can we rely on lesion imaging classifications ?
Critical point : assessing the prognosis
Return To Play
• Does the lesion classification helps ?
• The muscle injuries example : more than 30 classifications
Classification of traumatic muscle injuries
A major misunderstanding maintained by the literature.
• These classifications may have different names, they all say more or
less the same thing with some unique features:
• Differentiation between muscle and connective tissue
• Concept of functional impairment
• Importance of the tension state of the musculo-tendinous unit
…
Terminology also tends to merge
Classification of traumatic muscle injuries
A major misunderstanding maintained by the literature.
• Differences concern the methods of assessing severity (grading)
• Emergence of lesion classes (the famous grades) and attempts to
correlate them with prognosis.
Nosology = Classification
Prognosis = Grading
Classification: mechanism and mode of
occurence
• Acute lesions :
• Direct trauma (extrinsic lesions) : external damaging agent
• Indiret trauma by stretching (intrinsic lesions)
• Subacute lesions :
• DOMS
• Chronic lesions :
• Muscle pain due to traumatic aftereffects
• Chronic exertional compartment syndrom
• Muscle herniation
(1) Guermazi A, Roemer FW, Robinson P, Tol JL, Regatte RR, Crema MD. Imaging of Muscle Injuries in Sports Medicine: Sports Imaging Series. Radiology.
2017 Mar;282(3):646-663. doi: 10.1148/radiol.2017160267. Review. Erratum in: Radiology. 2017 Dec;285(3):1063
Classification: mechanism and mode of
occurence
• Acute lesions :
• Direct trauma (extrinsic lesions) : external damaging agent
• Indiret trauma by stretching (intrinsic lesions)
9 times more frequent (1)
• Subacute lesions :
• DOMS
• Chronic lesions :
• Muscle pain due to traumatic aftereffects
• Chronic exertional compartment syndrom
• Muscle herniation
(1) Guermazi A, Roemer FW, Robinson P, Tol JL, Regatte RR, Crema MD. Imaging of Muscle Injuries in Sports Medicine: Sports Imaging Series. Radiology.
2017 Mar;282(3):646-663. doi: 10.1148/radiol.2017160267. Review. Erratum in: Radiology. 2017 Dec;285(3):1063
Pejorative prognostic elements
common to several classifications
• Tendon (or connective tissue) involvement :
Pejorative prognostic elements
common to several classifications
• Tendon (or connective tissue) involvement :
Normal common tendon Partial tear of common tendon
Pejorative prognostic elements
common to several classifications
• Tendon (or connective tissue) involvement :
• British Athletic Muscle Injury Classification (BAMIc) : C (tendinous) type
• INSEP classification (French National Sport Institute) : C (connective) type
• Munich and ISMuLT : grade 4
Pejorative prognostic elements
common to several classifications
• Loss of tension (distal waviness aspect) :
• INSEP : grade 3
• BAMIc : C or B types
Pejorative prognostic elements
common to several classifications
• Hematoma :
• INSEP : grade 3
• Pedrets & al. : Type 2 and above
Pejorative prognostic elements
common to several classifications
• Complete rupture :
• Grade 4 for almost everyone (3 when it is the highest grade)
BAMIc
• grade 0
• grade 0a: focal neuromuscular injury with normal MRI
• grade 0b: generalized muscle soreness with normal MRI or MRI findings typical of delayed onset muscle soreness (DOMS)
• grade 1 (mild): high STIR signal that is <10% cross-section or longitudinal length <5 cm with <1 cm fiber disruption
• grade 2 (moderate): high STIR signal that is 10-50% cross-section; longitudinal length 5-15 cm with <5 cm fiber
disruption
• grade 3 (extensive): high STIR signal that is >50% cross-section or longitudinal length >15 cm with >5 cm fiber
disruption
• grade 4: complete tear
• Grades 1-3 are subclassified depending on site:
• a: myofascial (peripheral)
• b: myotendinous junction / muscular
• c: tendinous
• For grade 4 (complete tears), the distinction is only made between tears involving muscle versus those solely
involving the tendon, as follows:
• grade 4: myofascial, muscular, or myotendinous
• grade 4c: tendinous
INSEP classification
• Myoconjonctive lesion are M type
• (pure or mainly) conjonctive lesion are C type
Intrinsic muscular
lesion
Myo-conjonctive Conjonctive
Grade 1m Grade 1c
Grade 2m Grade 2c
Grade 3m Grade 3c
Grade
Grade 44
muscle injury classification
• M lesions :
• 1M : isolated focal muscle edema
• 2M : focal disorganization
• 3M : larger disorganization or
hematoma
• 4M : rupture
muscle injury classification
• M lesions :
• 1M : isolated focal muscle edema
• 2M : focal disorganization
• 3M : larger disorganization or
hematoma
• 4M : rupture
muscle injury classification
• M lesions :
• 1M : isolated focal muscle edema
• 2M : focal disorganization
• 3M : larger disorganization or
hematoma CSA >33%
• 4M : rupture
Length > 50%
muscle injury classification
• C lesions :
• 1C : focal thickening of a connective
element
• 2C : partial rupture of a connective
element
• 3C : complete rupture of a connective
element with loss of tension
• 4C : complete rupture with retraction
muscle injury classification
• C lesions :
• 1C : focal thickening of a connective
element
• 2C : partial rupture of a connective
element
• 3C : complete rupture of a connective
element with loss of tension
• 4C : complete rupture with retraction
muscle injury classification
• C lesions :
• 1C : focal thickening of a connective
element
• 2C : partial rupture of a connective
element
• 3C : complete rupture of a connective
element with loss of tension
• 4C : complete rupture with retraction
Percent of patient with 100% of recovery
Percent of patient with 100% of recovery
100 100
80 80
60 Myofascial 60 grade 1
Pure fascial grade 2
grade 3
Classification and prognosis
40 40
20 20
0 0
0 5 10 15 20 0 5 10 15 20
Time to recovery (weeks) Time to recovery (weeks)
20
15
Time to recovery (weeks)
10
0
grade 1 grade 2 grade 3
BAMIC INSEP
1- Pollock N, James SL, Lee JC, Chakraverty R. British athletics muscle injury classification: a new grading system. Br J Sports Med. 2014 Sep;48(18):1347-51.
2- Renoux J, Brasseur JL, Wagner M, Frey A, Folinais D, Dibie C, Maiza D, Crema MD. Ultrasound-detected connective tissue involvement in acute muscle injuries in
elite athletes and return to play: The French National Institute of Sports (INSEP) study. J Sci Med Sport. 2019 Jun;22(6):641-646.
Test yourself : how long is the RTP?
• Soccer player (forward player - Ligue 1, France)
• Sudden onset pain on the posterior thigh
• MRI and US performed :
Answer : 3 days (and played 90 min.)
• Why :
• Isokinetics testing were OK
• Almost no pain at day 3
• Striker position and quite a lazy pattern of play
• Final of Ligue 1 +++
Imaging informations : what’s the point ?
Can I play ??!!
• For the athletes, the question is simple :
• Yet the answer is not uniquevical. Many variables have to be considered :
• Clinical status, muscle involved
• Timing (Olympic final vs. end of season)
• Sport/position
• Psychological status
• Other injuries
• Individual hability to heal quickly
• Will future health be compromised?
How to deal with imaging informations ?
Decision
• Keypoint is teamwork
Athlete Radiologist Physio Team doctor Coach
Take home points
• Classification is a communication tool but it is not the only
prognosis factor
• Imaging informations are just a part of the diagnosis and merely helps
for the prognosis
• Remember the team works : we use to say the medical point of vue is
just one third of the decision
• However, a wise use of the imaging toolbox will confort the right
diagnosis and help to correct the wrong ones
Rosetta Stone
for muscle
classification
