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Dr. med. H.-W. Müller-Wohlfahrt 
Dr. med. L. Hänsel 
PD Dr. med. P. Ueblacker 
Muscle Injuries: 
The Munich Consensus Classification System 
Bryan English 
Peter Ueblacker 
Lutz Hänsel 
Hans-Wilhelm Müller-Wohlfahrt
Dr. med. H.-W. Müller-Wohlfahrt 
Dr. med. L. Hänsel 
PD Dr. med. P. Ueblacker 
Relevance of athletic muscle injuries 
• 31% of all injuries in professional football/soccer 
• cause 27% of absence times in football/soccer 
• most frequent injury in track and field, basketball etc. 
(Malliaropoulos AJSM 2011, Borowski AJSM 2008) 
• 49% of all injuries in American Football 
(Feeley AJSM 2008, Brophy AJSM 2010)
Dr. med. H.-W. Müller-Wohlfahrt 
Dr. med. L. Hänsel 
PD Dr. med. P. Ueblacker 
Previous classification systems 
O’Donoghue 1962 
Ryan 1969 
(initial for quadriceps) 
Takebayashi 1995, 
Peetrons 2002 
(ultrasound-based) 
Stoller 2007 
(MRI-based) 
Chan 2012 
(MRI-/ultrasound-based) 
Grade I 
No appreciable tissue 
tearing, 
no loss of function or 
strength, 
only a low-grade 
inflammatory response 
Tear of a few muscle 
fibres, 
fascia remaining intact 
No abnormalities or 
diffuse bleeding with/ 
without focal fibre rupture 
less than 5% of the 
muscle involved 
MRI-negative 
= 0% structural damage 
Hyperintense oedema 
with or without 
hemorrhage 
Includes 
Site of injury: 
-proximal, 
-middle 
-distal 
Pattern: 
-intramuscular 
-myofascial 
-myofascial/perifascial 
-musculotendinous 
-combined 
Severity: 
-comparable to Stoller 
Grade II 
Tissue damage, 
strength of the 
musculotendinous unit 
reduced, 
some residual function 
Tear of a moderate number 
of fibres, 
fascia remaining intact 
Partial rupture: focal fibre 
rupture more than 5% of 
the muscle involved 
with/without fascial injury 
MRI-positive 
with tearing up to 50% of 
the muscle fibres. 
Possible hyperintense 
focal defect and partial 
retraction of muscle fibres 
Grade III 
Complete tear of 
musculotendinous unit, 
complete loss of function 
Tear of many fibres with 
partial tearing of the fascia 
Complete muscle rupture 
with retraction, fascial 
injury 
Muscle rupture = 100% 
structural damage. 
Complete tearing with or 
without muscle retraction 
Grade IV 
X Complete tear of the 
muscle and fascia of the 
muscle –tendon unit 
X X X
Dr. med. H.-W. Müller-Wohlfahrt 
Dr. med. L. Hänsel 
PD Dr. med. P. Ueblacker 
Previous classification systems - Limitations 
O’Donoghue 1962 
Ryan 1969 
(initial for quadriceps) 
Takebayashi 1995, 
Peetrons 2002 
(ultrasound-based) 
Stoller 2007 
(MRI-based) 
Chan 2012 
(MRI-/ultrasound-based) 
Grade I 
No appreciable tissue 
tearing, 
no loss of function or 
strength, 
only a low-grade 
inflammatory response 
Tear of a few muscle 
fibres, 
fascia remaining intact 
No abnormalities or 
diffuse bleeding with/ 
without focal fibre rupture 
less than 5% of the 
muscle involved 
MRI-negative 
= 0% structural damage 
Hyperintense oedema 
with or without 
hemorrhage 
Includes 
Site of injury: 
-proximal, 
-middle 
-distal 
Pattern: 
-intramuscular 
-myofascial 
-myofascial/perifascial 
-musculotendinous 
-combined 
Severity: 
-comparable to Stoller 
Grade II 
Tissue damage, 
strength of the 
musculotendinous unit 
reduced, 
some residual function 
Tear of a moderate number 
of fibres, 
fascia remaining intact 
Partial rupture: focal fibre 
rupture more than 5% of 
the muscle involved 
with/without fascial injury 
MRI-positive 
with tearing up to 50% of 
the muscle fibres. 
Possible hyperintense 
focal defect and partial 
retraction of muscle fibres 
Grade III 
• non-structural injuries not mentioned or not differentiated 
Complete tear of 
musculotendinous unit, 
complete loss of function 
• not comprehensive 
Tear of many fibres with 
partial tearing of the fascia 
Complete muscle rupture 
with retraction, fascial 
injury 
Muscle rupture = 100% 
structural damage. 
Complete tearing with or 
without muscle retraction 
Grade IV 
X Complete tear of the 
muscle and fascia of the 
muscle –tendon unit 
X X X
Dr. med. H.-W. Müller-Wohlfahrt 
Dr. med. L. Hänsel 
PD Dr. med. P. Ueblacker 
Previous classification systems - Limitations 
O’Donoghue 1962 
Ryan 1969 
(initial for quadriceps) 
Takebayashi 1995, 
Peetrons 2002 
(ultrasound-based) 
Stoller 2007 
(MRI-based) 
Chan 2012 
(MRI-/ultrasound-based) 
Grade I 
• no differentiation within structural injuries 
> Injuries with different prognosis are diagnosed 
No appreciable tissue 
tearing, 
no loss of function or 
strength, 
only a low-grade 
inflammatory response 
Tear of a few muscle 
fibres, 
fascia remaining intact 
No abnormalities or 
diffuse bleeding with/ 
without focal fibre rupture 
less than 5% of the 
muscle involved 
MRI-negative 
= 0% structural damage 
Hyperintense oedema 
with or without 
hemorrhage 
Includes 
Site of injury: 
-proximal, 
-middle 
-distal 
Pattern: 
-intramuscular 
-myofascial 
-myofascial/perifascial 
-musculotendinous 
-combined 
Severity: 
-comparable to Stoller 
Grade II 
Tissue damage, 
strength of the 
musculotendinous unit 
reduced, 
some residual function 
in one grade 
Tear of a moderate number 
of fibres, 
fascia remaining intact 
Partial rupture: focal fibre 
rupture more than 5% of 
the muscle involved 
with/without fascial injury 
MRI-positive 
with tearing up to 50% of 
the muscle fibres. 
Possible hyperintense 
focal defect and partial 
retraction of muscle fibres 
Grade III 
Complete tear of 
musculotendinous unit, 
complete loss of function 
Tear of many fibres with 
partial tearing of the fascia 
Complete muscle rupture 
with retraction, fascial 
injury 
Muscle rupture = 100% 
structural damage. 
Complete tearing with or 
without muscle retraction 
Grade IV 
X Complete tear of the 
muscle and fascia of the 
muscle –tendon unit 
X X X
Dr. med. H.-W. Müller-Wohlfahrt 
Dr. med. L. Hänsel 
PD Dr. med. P. Ueblacker 
Typical case in professional sports 
• high level player 
• muscle problems 
• cannot start 
or must stop training/ 
competition! 
• MRI-negative – (or edema only)
Dr. med. H.-W. Müller-Wohlfahrt 
Dr. med. L. Hänsel 
PD Dr. med. P. Ueblacker 
? 
Typical case in professional sports 
• high level player 
• muscle problems 
• cannot start 
or must stop training/ 
competition! 
• MRI-negative – (or edema only) 
• no structural lesion/tear… 
= “functional (=non-structural) 
disorder/injury”
Dr. med. H.-W. Müller-Wohlfahrt 
Dr. med. L. Hänsel 
PD Dr. med. P. Ueblacker 
Relevance of 
“Functional (=non-structural) muscle disorders” 
• sub-study “hamstring-injuries” 
• in 70% no rupture detectable 
(MRI-negative or edema only) 
• cause >50% of absence in the clubs!
Dr. med. H.-W. Müller-Wohlfahrt 
Dr. med. L. Hänsel 
PD Dr. med. P. Ueblacker 
International Consensus-Conference 
3.3.2011 in Munich 
• UEFA, IOC 
• Universities: Harvard, Duke, Sydney, Berlin 
• Team doctors: FC Chelsea, ManU, Ajax, English National Team
Dr. med. H.-W. Müller-Wohlfahrt 
Dr. med. L. Hänsel 
PD Dr. med. P. Ueblacker 
A. Indirect 
Muscle Disorder/ 
Injury 
Indirect Muscle Injuries 
Mueller-Wohlfahrt et al., BJSM 2013 
Functional 
(= non-structural) 
Muscle 
Disorder 
Structural 
Muscle 
Injury 
“Painful muscle disorder without 
macroscopic evidence* 
of muscle fiber-damage.” 
*visible in MRI and/or Ultrasound 
“Acute distraction injury of a muscle 
with macroscopic evidence* 
of muscle fiber-damage.”
Dr. med. H.-W. Müller-Wohlfahrt 
Dr. med. L. Hänsel 
PD Dr. med. P. Ueblacker 
Direct Muscle Injury – Contusion 
A. Indirect 
Muscle Disorder/ 
Injury 
Mueller-Wohlfahrt et al., BJSM 2013 
B. Direct 
Muscle 
Injury 
Functional 
(= non-structural) 
Muscle 
Disorder 
Structural 
Muscle 
Injury 
Contusion 
“Direct (external) muscle trauma, 
caused by blunt external force.”
Dr. med. H.-W. Müller-Wohlfahrt 
Dr. med. L. Hänsel 
PD Dr. med. P. Ueblacker 
“Munich-Consensus-Classification” 
A. Indirect 
Muscle Disorder/ 
Injury 
Type 1: 
Overexertion-related 
Muscle Disorder 
Type 1A: 
Fatigue-induced Muscle Disorder 
Type 1B: 
DOMS 
Type 2: 
Neuromuscular 
Muscle Disorder 
Type 2A: 
Spine-related Muscle Disorder 
Type 2B: 
Muscle-related Muscle Disorder 
Type 3: 
Partial Muscle Tear 
Type 3A: 
Minor Partial Muscle Tear 
Type 3B: 
Moderate Partial Muscle Tear 
Type 4: 
(Sub)Total Tear 
Subtotal or Complete Muscle Tear 
Tendinous Avulsion 
Contusion 
Laceration 
B. Direct 
Muscle 
Injury 
Functional 
Muscle 
Disorder 
Structural 
Muscle 
Injury
Dr. med. H.-W. Müller-Wohlfahrt 
Dr. med. L. Hänsel 
PD Dr. med. P. Ueblacker 
MRI structural = t–e aRr ole off urenscotilountiaoln ( with edema) 
M. biceps femoris: 
edema – hematoma or – structural muscle injury ???
Dr. med. H.-W. Müller-Wohlfahrt 
Dr. med. L. Hänsel 
PD Dr. med. P. Ueblacker 
Functional (non-structural) muscle injuries 
Type 1: 
Overexertion-related 
Muscle Disorder 
Type 1A: 
Fatigue-induced 
Muscle Disorder 
Aching, increasing 
firmness during or after 
activity 
Type 1B: 
DOMS 
Inflammative pain 
after activity 
Type 2: 
Neuromuscular 
Muscle Disorder 
Type 2A: 
Spine-related 
Muscle Disorder 
Band-like firmness along 
the muscle 
Lumbar genesis! 
Type 2B: 
Muscle-related 
Muscle Disorder 
Cramp-like pain, spindle-like 
firmness within 
muscle belly 
Functional 
Muscle 
Disorder
Dr. med. H.-W. Müller-Wohlfahrt 
Dr. med. L. Hänsel 
PD Dr. med. P. Ueblacker 
Type 2a – Case: 
Spine-related neuromuscular muscle disorder 
25 years old Soccer-player, 1st Bundesliga + National team, 
recurrent painful tightness right M. gastrocnemius
Dr. med. H.-W. Müller-Wohlfahrt 
Dr. med. L. Hänsel 
PD Dr. med. P. Ueblacker 
Type 2a – Case: 
Spine-related neuromuscular muscle disorder 
19 years old Soccer-player, 1st Bundesliga, 
recurrent painful tightness hamstrings
Dr. med. H.-W. Müller-Wohlfahrt 
Dr. med. L. Hänsel 
PD Dr. med. P. Ueblacker 
Type 2b: 
Muscle-related neuromuscular disorder 
• neuromuscular tonus regulation disorder 
• of the reciprocal inhibition, 
i.e. the neuromuscular control mechanism 
> muscle firmness, cramp-like pain 
(Fig.: D. Blottner) 
- - - = Muscle-cell 
red = Nerve 
green = postsynaptic 
Membrane
Dr. med. H.-W. Müller-Wohlfahrt 
Dr. med. L. Hänsel 
PD Dr. med. P. Ueblacker 
“Munich-Consensus-Classification” 
- Structural Injuries - 
Structural 
Muscle 
Injury 
Type 3: 
Partial Muscle Tear 
Type 3A: 
Minor Partial Muscle Tear 
Type 3B: 
Moderate Partial Muscle Tear 
Type 4: 
(Sub)Total Tear 
Subtotal or 
Complete Muscle Tear 
Tendinous Avulsion
Dr. med. H.-W. Müller-Wohlfahrt 
Dr. med. L. Hänsel 
PD Dr. med. P. Ueblacker 
Injury mechanism - Structural Injuries 
• acute longitudinal distraction 
• over elastic limits of muscles 
• eccentric loading while the muscle is tensed 
Abb: D. Böhning, 2002
Dr. med. H.-W. Müller-Wohlfahrt 
Dr. med. L. Hänsel 
PD Dr. med. P. Ueblacker 
Type 3: Minor vs. Moderate partial tear 
• structural injuries must be 
subclassified 
• different absence time 
• what makes 
the difference???
Dr. med. H.-W. Müller-Wohlfahrt 
Dr. med. L. Hänsel 
PD Dr. med. P. Ueblacker 
Type 4: Complete muscle tear/ 
Tendinous avulsion 
• complete muscle tears – very rare 
• subtotal tears or 
• tendinous avulsions – more frequent 
• proximal M. rectus femoris 
MRI sagittal 
• proximal hamstrings 
• proximal M. adductor longus 
• (distal M. semitendinosus)
Dr. med. H.-W. Müller-Wohlfahrt 
Dr. med. L. Hänsel 
PD Dr. med. P. Ueblacker 
Structural muscle injuries 
Type 3: 
Partial Muscle Tear 
Type 3A: 
Minor Partial Muscle Tear 
“snap”, during activity, 
sudden onset, sharp, 
needle-like or dull pain 
- Symptoms -
Dr. med. H.-W. Müller-Wohlfahrt 
Dr. med. L. Hänsel 
PD Dr. med. P. Ueblacker 
Type 3: 
Partial Muscle Tear 
Type 3A: 
Minor Partial Muscle Tear 
“snap”, during activity, 
sudden onset, sharp, 
needle-like or dull pain 
Type 3B: 
Moderate Partial Muscle Tear 
+ possibly followed by fall, 
often noticeable tearing 
Type 4: 
(Sub)Total Tear 
Subtotal or 
Complete Muscle Tear 
Tendinous Avulsion 
during activity, sudden 
onset, often followed by 
fall, impact-like, dull pain
Dr. med. H.-W. Müller-Wohlfahrt 
Dr. med. L. Hänsel 
PD Dr. med. P. Ueblacker 
Differentiation - Location
Type 
Definition 
Symptoms 
Clinical Signs 
Location 
Ultrasound/ 
Dr. med. H.-W. Müller-MR-imaging 
Wohlfahrt 
Dr. med. L. Hänsel 
PD Dr. med. P. Ueblacker 
1A 
Fatigue-induced 
Muscle Disorder 
Aching tightness. Increasing with continued 
activity. 
Can occur during activity. Can provoke pain 
at rest 
Tight muscle band, no edema. 
Dull, diffuse, tolerable pain. Athlete reports of 
“muscle tightness” 
Focal involvement up to entire 
length of muscle 
Negative for muscle 
disruption 
1B 
Delayed-Onset 
Muscle Soreness 
(DOMS) 
Acute inflammative pain. 
Pain at rest. 
Hours after activity 
Edematous swelling, stiff muscles. Limited range 
of motion of adjacent joints. 
Pain on isometric contraction. Therapeutic 
stretching leads to relief 
Mostly entire muscle or muscle 
group 
Negative for muscle 
disruption or edema only 
2A 
Spine-related 
Neuromuscular 
Muscle Disorder 
Aching tightness. Increasing with continued 
activity. 
No pain at rest 
Band-like increase of muscle tone. Edema 
between muscle and fascia. 
Occasional skin sensitivity. Defensive reaction on 
muscle stretching. 
Pressure pain. 
Lumbar/iliosacral dysfunction 
Muscle bundle or larger muscle 
group along entire length of muscle 
Negative for muscle 
disruption or edema 
(between muscle and fascia) 
only 
2B 
Muscle-related 
Neuromuscular 
Muscle Disorder 
Aching, gradually increasing muscle 
tightness and tension. 
Cramplike pain 
Circumscribed (spindle-shaped) area of 
increased muscle firmness. 
Edematous swelling. 
Therapeutic stretching leads to relief. 
Pressure pain 
Mostly within the muscle belly 
Negative for muscle 
disruption or edema 
(intramuscular) only 
3A 
Minor Partial 
Muscle Tear 
Sudden sharp, needle-like or stabbing pain 
at time of injury. 
Athlete often experiences a “snap” followed 
by a sudden onset of localized pain. 
Usually cannot continue activity 
Well-defined localized pain. 
Probably palpable defect in fiber structure within 
a hypertonic muscle band. 
Pain on passive stretching 
Primarily muscle-tendon junction 
(intramuscular tendon can be 
involved) 
Positive for fiber disruption on 
high resolution MR-imaging. 
Intramuscular hematoma 
3B 
Moderate Partial 
Muscle Tear 
Sudden stabbing, sharp or dull pain, often 
noticeable tearing at time of injury. 
Athlete often experiences a “snap” followed 
by a sudden onset of localized pain. 
Cannot continue activity 
Well-defined localized pain. 
Palpable defect in muscle structure, often 
obvious hematoma, fascial injury. 
Pain on passive stretching. 
Loss of muscle function 
Primarily muscle-tendon junction 
(intramuscular tendon can be 
involved) 
Positive for significant fiber 
disruption, probably including 
some retraction. With fascial 
injury and intermuscular 
hematoma 
4 
Subtotal/ 
Complete Muscle Tear/ 
Tendinous Avulsion 
Sudden impact-like, dull pain at time of 
injury. Cannot continue activity 
Large defect in muscle, obvious hematoma. 
Pain on passive stretching. 
Loss of muscle function 
Tendinous avulsion: palpable gap, obvious 
hematoma, muscle retraction, pain with 
movement. 
Loss of muscle function 
Muscle-tendon junction 
(intramuscular tendon can be 
involved) 
or bone-tendon junction 
Subtotal/complete 
discontinuity of muscle/ 
tendon. Possible wavy 
tendon morphology and 
retraction. With fascial injury 
and intermuscular hematoma 
Con 
tusion 
Direct muscle injury 
Dull pain at time of injury, possibly 
increasing due to increasing hematoma 
Dull, diffuse pain. 
Obvious hematoma possible. 
Pain on movement 
Any muscle, mostly vastus 
intermedius and vastus lateralis 
Diffuse or circumscribed 
hematoma in varying 
dimensions displacing or 
compressing muscle fibers. 
Muscle fibers possibly torn off 
by the impact
Dr. med. H.-W. Müller-Wohlfahrt 
Dr. med. L. Hänsel 
PD Dr. med. P. Ueblacker 
Limitations 
• since diagnosis based on clinical 
examination AND imaging: 
clinical experience and high quality 
images is needed 
• Functional disorders challenging 
to diagnose 
More studies to determine: 
• clear cut off between minor and 
moderate partial tear 
• relevance of muscle edema?
Dr. med. H.-W. Müller-Wohlfahrt 
Dr. med. L. Hänsel 
PD Dr. med. P. Ueblacker 
Validation of the new classification system 
Ekstrand et al. 2013, BJSM Epub ahead of print 
• UCL-substudy 
• 393 thigh (ant.+post.) muscle injuries in 31 European teams 
• 100% response rate = proof of practical acceptance 
• “positive prognostic validity for return to play”: 
• “sub-classification of structural injuries correlates with return to play” 
• “functional disorders are often underestimated”
Dr. med. H.-W. Müller-Wohlfahrt 
Dr. med. L. Hänsel 
PD Dr. med. P. Ueblacker 
Absence after muscle injury 
Type 3: 
Structural Partial Muscle Tear 
Muscle 
Injury 
< 7 days 
Type 1: 
Overexertion-related 
Muscle Disorder 
Type 2: 
Neuromuscular 
Muscle Disorder 
Functional 
Muscle 
Disorder 
≈ 10-14 days 
Type 4: 
(Sub)Total Tear 
≈ 4-6 weeks 
≈ 12 weeks
Dr. med. H.-W. Müller-Wohlfahrt 
Dr. med. L. Hänsel 
PD Dr. med. P. Ueblacker 
Thank you! 
open access: www.pubmed.org 
Validation article:

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Bryan English - classification of muscle injuries in sport

  • 1. Dr. med. H.-W. Müller-Wohlfahrt Dr. med. L. Hänsel PD Dr. med. P. Ueblacker Muscle Injuries: The Munich Consensus Classification System Bryan English Peter Ueblacker Lutz Hänsel Hans-Wilhelm Müller-Wohlfahrt
  • 2. Dr. med. H.-W. Müller-Wohlfahrt Dr. med. L. Hänsel PD Dr. med. P. Ueblacker Relevance of athletic muscle injuries • 31% of all injuries in professional football/soccer • cause 27% of absence times in football/soccer • most frequent injury in track and field, basketball etc. (Malliaropoulos AJSM 2011, Borowski AJSM 2008) • 49% of all injuries in American Football (Feeley AJSM 2008, Brophy AJSM 2010)
  • 3. Dr. med. H.-W. Müller-Wohlfahrt Dr. med. L. Hänsel PD Dr. med. P. Ueblacker Previous classification systems O’Donoghue 1962 Ryan 1969 (initial for quadriceps) Takebayashi 1995, Peetrons 2002 (ultrasound-based) Stoller 2007 (MRI-based) Chan 2012 (MRI-/ultrasound-based) Grade I No appreciable tissue tearing, no loss of function or strength, only a low-grade inflammatory response Tear of a few muscle fibres, fascia remaining intact No abnormalities or diffuse bleeding with/ without focal fibre rupture less than 5% of the muscle involved MRI-negative = 0% structural damage Hyperintense oedema with or without hemorrhage Includes Site of injury: -proximal, -middle -distal Pattern: -intramuscular -myofascial -myofascial/perifascial -musculotendinous -combined Severity: -comparable to Stoller Grade II Tissue damage, strength of the musculotendinous unit reduced, some residual function Tear of a moderate number of fibres, fascia remaining intact Partial rupture: focal fibre rupture more than 5% of the muscle involved with/without fascial injury MRI-positive with tearing up to 50% of the muscle fibres. Possible hyperintense focal defect and partial retraction of muscle fibres Grade III Complete tear of musculotendinous unit, complete loss of function Tear of many fibres with partial tearing of the fascia Complete muscle rupture with retraction, fascial injury Muscle rupture = 100% structural damage. Complete tearing with or without muscle retraction Grade IV X Complete tear of the muscle and fascia of the muscle –tendon unit X X X
  • 4. Dr. med. H.-W. Müller-Wohlfahrt Dr. med. L. Hänsel PD Dr. med. P. Ueblacker Previous classification systems - Limitations O’Donoghue 1962 Ryan 1969 (initial for quadriceps) Takebayashi 1995, Peetrons 2002 (ultrasound-based) Stoller 2007 (MRI-based) Chan 2012 (MRI-/ultrasound-based) Grade I No appreciable tissue tearing, no loss of function or strength, only a low-grade inflammatory response Tear of a few muscle fibres, fascia remaining intact No abnormalities or diffuse bleeding with/ without focal fibre rupture less than 5% of the muscle involved MRI-negative = 0% structural damage Hyperintense oedema with or without hemorrhage Includes Site of injury: -proximal, -middle -distal Pattern: -intramuscular -myofascial -myofascial/perifascial -musculotendinous -combined Severity: -comparable to Stoller Grade II Tissue damage, strength of the musculotendinous unit reduced, some residual function Tear of a moderate number of fibres, fascia remaining intact Partial rupture: focal fibre rupture more than 5% of the muscle involved with/without fascial injury MRI-positive with tearing up to 50% of the muscle fibres. Possible hyperintense focal defect and partial retraction of muscle fibres Grade III • non-structural injuries not mentioned or not differentiated Complete tear of musculotendinous unit, complete loss of function • not comprehensive Tear of many fibres with partial tearing of the fascia Complete muscle rupture with retraction, fascial injury Muscle rupture = 100% structural damage. Complete tearing with or without muscle retraction Grade IV X Complete tear of the muscle and fascia of the muscle –tendon unit X X X
  • 5. Dr. med. H.-W. Müller-Wohlfahrt Dr. med. L. Hänsel PD Dr. med. P. Ueblacker Previous classification systems - Limitations O’Donoghue 1962 Ryan 1969 (initial for quadriceps) Takebayashi 1995, Peetrons 2002 (ultrasound-based) Stoller 2007 (MRI-based) Chan 2012 (MRI-/ultrasound-based) Grade I • no differentiation within structural injuries > Injuries with different prognosis are diagnosed No appreciable tissue tearing, no loss of function or strength, only a low-grade inflammatory response Tear of a few muscle fibres, fascia remaining intact No abnormalities or diffuse bleeding with/ without focal fibre rupture less than 5% of the muscle involved MRI-negative = 0% structural damage Hyperintense oedema with or without hemorrhage Includes Site of injury: -proximal, -middle -distal Pattern: -intramuscular -myofascial -myofascial/perifascial -musculotendinous -combined Severity: -comparable to Stoller Grade II Tissue damage, strength of the musculotendinous unit reduced, some residual function in one grade Tear of a moderate number of fibres, fascia remaining intact Partial rupture: focal fibre rupture more than 5% of the muscle involved with/without fascial injury MRI-positive with tearing up to 50% of the muscle fibres. Possible hyperintense focal defect and partial retraction of muscle fibres Grade III Complete tear of musculotendinous unit, complete loss of function Tear of many fibres with partial tearing of the fascia Complete muscle rupture with retraction, fascial injury Muscle rupture = 100% structural damage. Complete tearing with or without muscle retraction Grade IV X Complete tear of the muscle and fascia of the muscle –tendon unit X X X
  • 6. Dr. med. H.-W. Müller-Wohlfahrt Dr. med. L. Hänsel PD Dr. med. P. Ueblacker Typical case in professional sports • high level player • muscle problems • cannot start or must stop training/ competition! • MRI-negative – (or edema only)
  • 7. Dr. med. H.-W. Müller-Wohlfahrt Dr. med. L. Hänsel PD Dr. med. P. Ueblacker ? Typical case in professional sports • high level player • muscle problems • cannot start or must stop training/ competition! • MRI-negative – (or edema only) • no structural lesion/tear… = “functional (=non-structural) disorder/injury”
  • 8. Dr. med. H.-W. Müller-Wohlfahrt Dr. med. L. Hänsel PD Dr. med. P. Ueblacker Relevance of “Functional (=non-structural) muscle disorders” • sub-study “hamstring-injuries” • in 70% no rupture detectable (MRI-negative or edema only) • cause >50% of absence in the clubs!
  • 9. Dr. med. H.-W. Müller-Wohlfahrt Dr. med. L. Hänsel PD Dr. med. P. Ueblacker International Consensus-Conference 3.3.2011 in Munich • UEFA, IOC • Universities: Harvard, Duke, Sydney, Berlin • Team doctors: FC Chelsea, ManU, Ajax, English National Team
  • 10. Dr. med. H.-W. Müller-Wohlfahrt Dr. med. L. Hänsel PD Dr. med. P. Ueblacker A. Indirect Muscle Disorder/ Injury Indirect Muscle Injuries Mueller-Wohlfahrt et al., BJSM 2013 Functional (= non-structural) Muscle Disorder Structural Muscle Injury “Painful muscle disorder without macroscopic evidence* of muscle fiber-damage.” *visible in MRI and/or Ultrasound “Acute distraction injury of a muscle with macroscopic evidence* of muscle fiber-damage.”
  • 11. Dr. med. H.-W. Müller-Wohlfahrt Dr. med. L. Hänsel PD Dr. med. P. Ueblacker Direct Muscle Injury – Contusion A. Indirect Muscle Disorder/ Injury Mueller-Wohlfahrt et al., BJSM 2013 B. Direct Muscle Injury Functional (= non-structural) Muscle Disorder Structural Muscle Injury Contusion “Direct (external) muscle trauma, caused by blunt external force.”
  • 12. Dr. med. H.-W. Müller-Wohlfahrt Dr. med. L. Hänsel PD Dr. med. P. Ueblacker “Munich-Consensus-Classification” A. Indirect Muscle Disorder/ Injury Type 1: Overexertion-related Muscle Disorder Type 1A: Fatigue-induced Muscle Disorder Type 1B: DOMS Type 2: Neuromuscular Muscle Disorder Type 2A: Spine-related Muscle Disorder Type 2B: Muscle-related Muscle Disorder Type 3: Partial Muscle Tear Type 3A: Minor Partial Muscle Tear Type 3B: Moderate Partial Muscle Tear Type 4: (Sub)Total Tear Subtotal or Complete Muscle Tear Tendinous Avulsion Contusion Laceration B. Direct Muscle Injury Functional Muscle Disorder Structural Muscle Injury
  • 13. Dr. med. H.-W. Müller-Wohlfahrt Dr. med. L. Hänsel PD Dr. med. P. Ueblacker MRI structural = t–e aRr ole off urenscotilountiaoln ( with edema) M. biceps femoris: edema – hematoma or – structural muscle injury ???
  • 14. Dr. med. H.-W. Müller-Wohlfahrt Dr. med. L. Hänsel PD Dr. med. P. Ueblacker Functional (non-structural) muscle injuries Type 1: Overexertion-related Muscle Disorder Type 1A: Fatigue-induced Muscle Disorder Aching, increasing firmness during or after activity Type 1B: DOMS Inflammative pain after activity Type 2: Neuromuscular Muscle Disorder Type 2A: Spine-related Muscle Disorder Band-like firmness along the muscle Lumbar genesis! Type 2B: Muscle-related Muscle Disorder Cramp-like pain, spindle-like firmness within muscle belly Functional Muscle Disorder
  • 15. Dr. med. H.-W. Müller-Wohlfahrt Dr. med. L. Hänsel PD Dr. med. P. Ueblacker Type 2a – Case: Spine-related neuromuscular muscle disorder 25 years old Soccer-player, 1st Bundesliga + National team, recurrent painful tightness right M. gastrocnemius
  • 16. Dr. med. H.-W. Müller-Wohlfahrt Dr. med. L. Hänsel PD Dr. med. P. Ueblacker Type 2a – Case: Spine-related neuromuscular muscle disorder 19 years old Soccer-player, 1st Bundesliga, recurrent painful tightness hamstrings
  • 17. Dr. med. H.-W. Müller-Wohlfahrt Dr. med. L. Hänsel PD Dr. med. P. Ueblacker Type 2b: Muscle-related neuromuscular disorder • neuromuscular tonus regulation disorder • of the reciprocal inhibition, i.e. the neuromuscular control mechanism > muscle firmness, cramp-like pain (Fig.: D. Blottner) - - - = Muscle-cell red = Nerve green = postsynaptic Membrane
  • 18. Dr. med. H.-W. Müller-Wohlfahrt Dr. med. L. Hänsel PD Dr. med. P. Ueblacker “Munich-Consensus-Classification” - Structural Injuries - Structural Muscle Injury Type 3: Partial Muscle Tear Type 3A: Minor Partial Muscle Tear Type 3B: Moderate Partial Muscle Tear Type 4: (Sub)Total Tear Subtotal or Complete Muscle Tear Tendinous Avulsion
  • 19. Dr. med. H.-W. Müller-Wohlfahrt Dr. med. L. Hänsel PD Dr. med. P. Ueblacker Injury mechanism - Structural Injuries • acute longitudinal distraction • over elastic limits of muscles • eccentric loading while the muscle is tensed Abb: D. Böhning, 2002
  • 20. Dr. med. H.-W. Müller-Wohlfahrt Dr. med. L. Hänsel PD Dr. med. P. Ueblacker Type 3: Minor vs. Moderate partial tear • structural injuries must be subclassified • different absence time • what makes the difference???
  • 21. Dr. med. H.-W. Müller-Wohlfahrt Dr. med. L. Hänsel PD Dr. med. P. Ueblacker Type 4: Complete muscle tear/ Tendinous avulsion • complete muscle tears – very rare • subtotal tears or • tendinous avulsions – more frequent • proximal M. rectus femoris MRI sagittal • proximal hamstrings • proximal M. adductor longus • (distal M. semitendinosus)
  • 22. Dr. med. H.-W. Müller-Wohlfahrt Dr. med. L. Hänsel PD Dr. med. P. Ueblacker Structural muscle injuries Type 3: Partial Muscle Tear Type 3A: Minor Partial Muscle Tear “snap”, during activity, sudden onset, sharp, needle-like or dull pain - Symptoms -
  • 23. Dr. med. H.-W. Müller-Wohlfahrt Dr. med. L. Hänsel PD Dr. med. P. Ueblacker Type 3: Partial Muscle Tear Type 3A: Minor Partial Muscle Tear “snap”, during activity, sudden onset, sharp, needle-like or dull pain Type 3B: Moderate Partial Muscle Tear + possibly followed by fall, often noticeable tearing Type 4: (Sub)Total Tear Subtotal or Complete Muscle Tear Tendinous Avulsion during activity, sudden onset, often followed by fall, impact-like, dull pain
  • 24. Dr. med. H.-W. Müller-Wohlfahrt Dr. med. L. Hänsel PD Dr. med. P. Ueblacker Differentiation - Location
  • 25. Type Definition Symptoms Clinical Signs Location Ultrasound/ Dr. med. H.-W. Müller-MR-imaging Wohlfahrt Dr. med. L. Hänsel PD Dr. med. P. Ueblacker 1A Fatigue-induced Muscle Disorder Aching tightness. Increasing with continued activity. Can occur during activity. Can provoke pain at rest Tight muscle band, no edema. Dull, diffuse, tolerable pain. Athlete reports of “muscle tightness” Focal involvement up to entire length of muscle Negative for muscle disruption 1B Delayed-Onset Muscle Soreness (DOMS) Acute inflammative pain. Pain at rest. Hours after activity Edematous swelling, stiff muscles. Limited range of motion of adjacent joints. Pain on isometric contraction. Therapeutic stretching leads to relief Mostly entire muscle or muscle group Negative for muscle disruption or edema only 2A Spine-related Neuromuscular Muscle Disorder Aching tightness. Increasing with continued activity. No pain at rest Band-like increase of muscle tone. Edema between muscle and fascia. Occasional skin sensitivity. Defensive reaction on muscle stretching. Pressure pain. Lumbar/iliosacral dysfunction Muscle bundle or larger muscle group along entire length of muscle Negative for muscle disruption or edema (between muscle and fascia) only 2B Muscle-related Neuromuscular Muscle Disorder Aching, gradually increasing muscle tightness and tension. Cramplike pain Circumscribed (spindle-shaped) area of increased muscle firmness. Edematous swelling. Therapeutic stretching leads to relief. Pressure pain Mostly within the muscle belly Negative for muscle disruption or edema (intramuscular) only 3A Minor Partial Muscle Tear Sudden sharp, needle-like or stabbing pain at time of injury. Athlete often experiences a “snap” followed by a sudden onset of localized pain. Usually cannot continue activity Well-defined localized pain. Probably palpable defect in fiber structure within a hypertonic muscle band. Pain on passive stretching Primarily muscle-tendon junction (intramuscular tendon can be involved) Positive for fiber disruption on high resolution MR-imaging. Intramuscular hematoma 3B Moderate Partial Muscle Tear Sudden stabbing, sharp or dull pain, often noticeable tearing at time of injury. Athlete often experiences a “snap” followed by a sudden onset of localized pain. Cannot continue activity Well-defined localized pain. Palpable defect in muscle structure, often obvious hematoma, fascial injury. Pain on passive stretching. Loss of muscle function Primarily muscle-tendon junction (intramuscular tendon can be involved) Positive for significant fiber disruption, probably including some retraction. With fascial injury and intermuscular hematoma 4 Subtotal/ Complete Muscle Tear/ Tendinous Avulsion Sudden impact-like, dull pain at time of injury. Cannot continue activity Large defect in muscle, obvious hematoma. Pain on passive stretching. Loss of muscle function Tendinous avulsion: palpable gap, obvious hematoma, muscle retraction, pain with movement. Loss of muscle function Muscle-tendon junction (intramuscular tendon can be involved) or bone-tendon junction Subtotal/complete discontinuity of muscle/ tendon. Possible wavy tendon morphology and retraction. With fascial injury and intermuscular hematoma Con tusion Direct muscle injury Dull pain at time of injury, possibly increasing due to increasing hematoma Dull, diffuse pain. Obvious hematoma possible. Pain on movement Any muscle, mostly vastus intermedius and vastus lateralis Diffuse or circumscribed hematoma in varying dimensions displacing or compressing muscle fibers. Muscle fibers possibly torn off by the impact
  • 26. Dr. med. H.-W. Müller-Wohlfahrt Dr. med. L. Hänsel PD Dr. med. P. Ueblacker Limitations • since diagnosis based on clinical examination AND imaging: clinical experience and high quality images is needed • Functional disorders challenging to diagnose More studies to determine: • clear cut off between minor and moderate partial tear • relevance of muscle edema?
  • 27. Dr. med. H.-W. Müller-Wohlfahrt Dr. med. L. Hänsel PD Dr. med. P. Ueblacker Validation of the new classification system Ekstrand et al. 2013, BJSM Epub ahead of print • UCL-substudy • 393 thigh (ant.+post.) muscle injuries in 31 European teams • 100% response rate = proof of practical acceptance • “positive prognostic validity for return to play”: • “sub-classification of structural injuries correlates with return to play” • “functional disorders are often underestimated”
  • 28. Dr. med. H.-W. Müller-Wohlfahrt Dr. med. L. Hänsel PD Dr. med. P. Ueblacker Absence after muscle injury Type 3: Structural Partial Muscle Tear Muscle Injury < 7 days Type 1: Overexertion-related Muscle Disorder Type 2: Neuromuscular Muscle Disorder Functional Muscle Disorder ≈ 10-14 days Type 4: (Sub)Total Tear ≈ 4-6 weeks ≈ 12 weeks
  • 29. Dr. med. H.-W. Müller-Wohlfahrt Dr. med. L. Hänsel PD Dr. med. P. Ueblacker Thank you! open access: www.pubmed.org Validation article: