We are often told not to treat any acute injury for the first 24-28 hours due to swelling and the potential to make it worse. The problem with this is that people often go untreated and end up in a worse situation than if they had treatment applied earlier. Contusions are a prime example of this. A contusion is a relatively common musculoskeletal injury that is caused by blunt trauma to the soft tissue. It is characterized by pain, localized tenderness, swelling, loss of strength and range of motion, and ecchymosis. Contusions are graded according to how impaired the range of motion is:
- First-degree contusions cause few or no limitations.
- Second-degree contusions produce a noticeable change in range of motion.
- Third-degree contusions cause severe restrictions in range of motion.
The primary result of a contusion is the formation of a hematoma, or local accumulation of blood, in the tissue space because of the biomechanical failure of the muscle and connective and vascular tissues. There are two types of hematomas that can form, depending on the severity of the trauma:
- Intramuscular hematomas are less severe and consist of damage only to the muscle tissue, with the connective tissue sheath remaining intact, thus localizing the symptoms.
- Intermuscular hematomas are more severe and involve the muscle. They occur when fascia is damaged and bleeding spreads, expanding the area of injury.
Treatment of a contusion will be similar regardless of where the injury is located, but each individual situation must be taken into consideration. The primary goal is to remove the excess blood and fluid from the area as quickly as possible to provide the optimal environment for healing.
Direct manual techniques are contraindicated during this phase; the area is better treated using other modalities such as ice and compression treatment. Once the swelling is under control, meaning that any activity or therapy does not create additional swelling, massage in conjunction with other modalities can be used to hasten the healing process. This may take 1 day or several days, depending on the severity. To treat during this phase:
- Apply ice to the contusion for 10 to 20 minutes, using a barrier between the ice and the skin.
- After the ice has sufficiently cooled the area, apply gentle effleurage strokes, radiating out from the center.
- Once the tissue starts to warm up, reapply the ice and repeat the process two to three times, applying the ice last, followed by a compression wrap.
If additional swelling is generated from this treatment, the injury has not sufficiently begun to heal and only ice and compression should be continued. By expanding the surface area of the hematoma, it is reabsorbed more quickly and less residual scar tissue remains.
Treatment during this phase involves the application of the same radiating strokes over the contusion to expand the surface area. Ice may be necessary only after the massage is performed, but each situation will be different. During this phase of healing, the goal is to facilitate the proper amount and orientation of the new tissue. Because new-tissue formation begins when the hematoma reduces in size, early treatment will lead to faster healing. The accumulated formation of connective tissue and blood vessels is a highly vascularized mass and is transformed into the necessary structures in the third and final phase of healing.
The newly formed mass from the repair phase is transformed into scar tissue in a process that includes decreased fibroblast activity, increased organization in the matrix, reduced vascularity, and a return to normal histochemical activity. Since scar tissue is less elastic, more fibrous, and less vascular than the original tissue, the focus of the treatment should be on creating a functional scar.
A therapist may encounter a contusion in any of these stages of healing. It is important to determine what phase it is in by performing a thorough assessment so that appropriate treatment is administered.
Check out this video I recorded when I visited Oakworks on treating contusions: