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Muscle Strains – Treatment and Recovery Explained Simply

Muscle Strains – Treatment and Recovery Explained Simply

Last Updated: July 1st, 2013

Welcome to the ‘Understanding Muscle Strains’ e-book.

This is an educational resource describing the latest in muscle strain science, and a simple (yet research-based) strategy for optimizing recovery and preventing re-injury.


Buy the full eBook (.pdf) right now or keep reading the introduction as well as the entire first section in this free preview!

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strains_cover


Dealing with “pulled”, “torn”, or strained muscles?

Strained Hamstrings

Strained hamstrings – one of the most common and frustrating injuries!

If you have one, or work with people who do, you’re not alone!

Muscle strains are one of the most common injuries in athletes. It’s estimated that 10 to 55% of all injuries in sports are in muscle, and 90% of those are strains. 14 It’s a bit of an issue!

Luckily, most of them heal pretty well on their own (depending of course on the severity). They hurt, but they will get better!

However, there does seem to be a high rate of re-injury (up to 31% of strain injuries will re-occur). 19 Therefore, we should probably rehabilitate them the best way we can!

Here’s a detailed, research-based (yet simple and easy to read) guide about what a strain is, how to recognize one, why it might have happened, how it heals, and how one can optimize recovery to prevent re-injury.

This book will use the hamstrings as an example when reviewing such things as anatomy, stretches and exercises. This is because the hamstrings is probably the most commonly strained muscle. We’ll also review complications, managing persistent pain, and prevention of re-injury.

Let’s go!


Table of Contents

Introduction

  • How to use this book
  • About the Author
  • Disclaimer

Part I – Understanding Muscle Strains

  • Muscle Strains – What are they?
    Muscle strains vs. soreness
    Grades I to IV
    – What are muscles for anyway?
  • How do strains happen?
  • When do strains happen?
  • Where do strains happen?
  • How do they heal?

Part II – Treatment and Recovery

  • Diagnosis
  • How Long Will This Last?
  • Will I Need Surgery?
  • Rehabilitation Strategy
  • About Pain
  • Recovery : Day 1 – 3 : (P.R.I.C.E)
    Medications
  • Recovery : Day 3 – 7 : (Early Rehabilitation: M.I.C.E.)
    What Not To Do
  • Recovery : Day 7 – 21 : (Advanced Rehabilitation)
  • Recovery : Day 21 + : (Gradual Return to Athletics)
  • Recurring Strains (re-injury)
  • Persistent Pain
  • Possible Complications
    Myositis Ossificans

Final Thoughts

  • Thank You!
  • F.A.Q.
  • References

 

 


Introduction


How to use this book

If you want to learn more about strained muscles and how they should be treated, then you’ve come to the right place. This book is an educational resource on muscle strain treatment and recovery. It’s written so anyone with a high-school education can understand it, but with scientific references for professionals and students.

It’s detailed, but not too long – only the important things are covered.

Features:

  • Clickable links: if you’re reading this on a computer or mobile device, such as an iPhone or iPad, there are links you can click on that lead to articles with more detail – like this.
  • YouTube Videos: when exercises are described, links to YouTube are occasionally provided.
  • Full Color Images:concepts and exercises are often illustrated through full color images to help the reader understand the ideas.
  • References: the information in this guide is based on numerous research studies. In case you want to check them, references are listed near the end, and numbered in superscript throughout, like this: 1

Here’s how you use this guide:

  1. First, skim the whole guide briefly to see what it’s all about. Get to know what sections exist, and how it’s organized.
  2. Read in detail the relevant sections as one progresses through their recovery. Yes, it’s long. But the more you learn, the better decisions you will make. For example: understanding how muscles heal will keep you from doing stupid things (I hope).

If you want, you can just skim over what isn’t interesting. Use the table of contents to see where one might be in the recovery process, and skip to that section. However, much of it is written under the assumption that you’ve read the prior sections. We won’t be wasting time defining or explaining things twice.

Let’s be honest… if you are not going to take the time to read this guide, then you should probably just go get help face-to-face with a professional (not that this guide is a replacement for a professional consultation anyway – it’s not).

But like people who want to lose weight, but won’t even take the time to cook a proper meal… you probably aren’t going to get the best results you can unless you invest the necessary time.

I’ve seriously tried my best to keep things short and to the point. I may have even skipped some useful things in the effort of trying to be concise. This guide reviews the essentials, and little more. So stop complaining about the length!

Go on. Read. Now!


About the Author

Why should you listen to this guy?

Tony HeadshotTony Ingram is a licensed physical therapist and a dancer, currently living in St. John’s, Newfoundland, Canada. He has a bachelor’s degree in Behavioral Neuroscience, a master’s degree in Physiotherapy, and is currently completing another master’s in Kinesiology (Exercise Physiology) while working as a physical therapist full time.

He remains very active in the dance world as well. Currently, Tony directs two dance companies whose mission is youth outreach through providing school programs. He also consults with dancers around the world, and provides workshops on injury prevention. He started bboyscience.com to write about science, training, injuries, and dancing.

He’s also strained many muscles throughout his dance career – and survived!

Thanks for reading!

Tony Ingram Signature

 

 

Tony Ingram


Disclaimer

Author’s notes:

As expected with any credible health advice you find on the Internet, there’s a disclaimer: by reading this document, you here-by agree not to sue me for any reason at all for the rest of eternity. But seriously…

Even though I’m a physical therapist, buying this book doesn’t mean you’re receiving physical therapy service from me – just information. Therefore, my insurance doesn’t cover this book, and suing me is a waste of time.

What you purchased is my opinion on how a person should approach his or her recovery – in general (this is not individualized just for you). It’s based on scientific research, but science is constantly updating and changing (which is a good thing). This was last updated in July 2013, so if it’s more than two years old, it’s probably out of date! Therefore, before trying anything in this book, discuss it with your medical professional first.

Disclaimer

The material presented in this document is intended for informational purposes only. The information represents the opinion of the author, and does not constitute medical advice. This document is not intended to replace medical advice, nor to diagnose, prescribe or treat any illness, disease, or injury. The author expressly disclaims liability for any adverse effects that may result from the use, application or interpretation of the material in this book.


Part I – Understanding Strains


Muscle Strains – What are they?

‘Strains’ are injuries that involve the tearing of muscle fibers. This is not to be confused with ‘sprains’, which are ligament injuries. For a quick review of the difference between them, see: ‘Strains vs. Sprains’.

muscle_structure_web

Muscles refer to the “meat” on your bones. Muscles connect to your bones through tendons, which usually cross over joints. Muscles work by “contracting”, which causes them to shorten, thereby pulling on a bone to create movement at a joint. If you’re still not sure what a muscle is, please speak with a healthcare professional before proceeding with this book!

Muscle Damage: Strains vs. Soreness

You might have heard that exercise also causes “micro-damage” to muscles. This is true, but strains are a very different type of muscle damage. Muscle fibers (see picture above) are made up of many ‘myofibrils’ – the individual units of muscle responsible for contraction. Myofibrils are microscopic; you literally need a microscope to see them!

When you exercise, myofibrils are damaged, which is thought to cause the ever-popular next-day muscle soreness we all know and love. 13 But it’s a good thing – the repair process for this damage is one of the most important ways your body adapts to build stronger muscles. 8 In fact, this “damage” actually looks more like “adaptive remodeling” when carefully observed with special microscopes 30 – that’s some very cool exercise biology. For more about muscle soreness, read ‘Muscle Soreness’ on bboyscience.com.

Muscle strains, however, are not so “micro”.

They can be seen “macroscopically” (with our own eyes – no magnification necessary) through the use of a CT scan or MRI. 12 This is because muscle strains are tears of whole muscle fibers (again, see picture above).

That sounds pretty harsh, but when you cut or scrape your skin, you probably do as much “damage” as you would in a small ‘Grade I’ muscle strain (see grades below). Of course, it might feel worse than a scrape – or easier to aggravate. Scrapes hurt when you touch them, but they can be easy to avoid. If you strained a leg muscle, however, you can barely walk without experiencing pain!

Grades of Muscle Strains

Of course, the amount of damage can vary significantly. Muscle strains are often classified into grades of severity. Here’s a four-grade system, but note there are different grading systems out there.

  • Grade I – Just a few muscle fibers are torn.
  • Grade II – Tearing of less than half the fibers of a muscle.
  • Grade III – Tearing of more than half the fibers of a muscle.
  • Grade IV – Complete tearing of a muscle.

Expected healing times are very different between grades. We’ll go over this in more detail in a later section.

What are muscles for anyway?

Many people have a basic idea of what muscles are for, but as with everything, it’s a little more complex. It will help us later to understand some of these important functions of muscle:

  • Movement – Muscles are mostly known for their role in creating movement of the body. They do this by contracting (shortening), which pulls on a bone, which then rotates at a joint. Obviously, this is an oversimplification of how it all really happens. Also, I probably don’t have to elaborate on the importance of this function – if you’re reading this, then you’re using your eye muscles to look across the page.
  • Stability – Muscles don’t just move us – sometimes they resist movement, keeping us stable. This can be just as important as movement, in many situations! When a muscle is injured, stability can change at our joints, and alter our ability to stay balanced.
  • Organ function – Different types of muscles throughout and within our bodies also help protect our internal organs, aid in digestion, and pump blood (the heart is a muscle, and there’s also “smooth” muscles in our circulatory and digestive systems, and the muscles in our legs help to pump blood back to the heart).
  • Sensory Reception – This is the function that many people forget about – but it’s very important in preventing injury. Muscles contain sensory receptors of the nervous system, which help provide your brain with feedback (without you even being aware) regarding your body’s position and movement.

The sensory receptors found in your muscles are known as ‘mechano-receptors’, and the senses they are involved in are ‘proprioception’ (your sense of position), and ‘kinesthesia’ (your sense of movement – speed, direction, etc.). 23

Proprioception and kinesthesia, as you can imagine, are two very important senses involved in coordination, and therefore stability and agility. When you injure a muscle, you may disrupt these receptors, causing deficits in your sense of position and movement. 22

This might be one of the reasons why it’s so easy to become re-injured!

Remember this when coordination training is discussed below.


How do strains happen?

Strains occur when too much force is applied to a resisting muscle. Excessive tensile force stresses the muscle fibers beyond their capability of resisting, eventually leading them to rupture. 14 This typically occurs within the normal range of motion during ‘eccentric’ contractions. 26, 10

What’s an eccentric contraction?

‘Standing Knee Flexion' – the up part = concentric; the down part = eccentric.

‘Standing Knee Flexion': the up part = concentric; the down part = eccentric.

An eccentric contraction occurs when a muscle is actively contracting, but instead of shortening, it’s lengthening (stretching out). It’s like resisting a stretch.

For example: if you are doing the exercise ‘Standing Knee Flexion’ (see image to right). The up part is called a ‘concentric’ contraction. The down part is called ‘eccentric’.

Although they’re thought to be more damaging, ‘eccentric contractions’ are normal, and a part of everyday movement. It’s the extreme situations that cause strains. This can happen when breaking a fall, switching directions, and during powerful movements like kicks or sprints.

With enough intensity, however, either type of contraction can cause a muscle strain. It’s the extreme force that causes the injury.


When do strains happen?

In what situations do these high forces occur? Here are some common examples:

  • Quick direction switches – Common in most sports, notably soccer, football, rugby, and more. Switching directions
    Fast moving sports with quick direction switches often result in strains.

    Fast moving sports with quick direction switches often result in strains.

    quickly can impart huge forces on the muscles involved.

  • Lifting something too heavy – When you’re not strong enough to lift something, trying to usually results in – nothing. It doesn’t move! However, if you fatigue during an exercise, or “cheat” to lift it, you may shift the weight awkwardly to weaker muscle fibers. That might be how you strain a muscle when lifting too heavy.
  • Overstretching – Less common than people believe, but possible during activities that require a lot of flexibility – such as martial arts, gymnastics, or dancing. It doesn’t even need to be during a fast stretch – research on professional and amateur ballet dancers has shown that up to 88 percent of muscle strains occur during slow stretch training (like the splits) with powerful movements accounting for only 12 percent! 5, 2, 1
    Read: Stretching for Dancers – Discussing the research for more details.

Of course, no matter what you do, injuries are usually just accidents. Stop feeling sorry about not stretching enough, or whatever you think you could have done differently. Unless, of course, you did something stupid. :)

For some general info on prevention read: ‘Injury Prevention Research – What Works, and What Doesn’t?


Where do strains happen?

Two common areas: 1. usually from overstretching - less common; 2. usually from sprinting - very common

Two common areas: 1. usually from overstretching – less common; 2. usually from sprinting – very common

Strains can occur in any muscle. Of course, there are some that are more common (for example, the groin, quads, lower back, etc.).

The most common seems to be the hamstrings – a group of three (some people say four) muscles in the back of your upper leg. It is estimated that between 6% and 29% of all injuries in field sports (like soccer or football) are hamstring strains. 19

Strains can happen in different parts of a muscle. According to research, 19 it might depend on what type of activity you are doing. Activities like sprinting are more likely to cause a strain in the ‘biceps femoris’, but overstretching activities are more likely to cause strain in the medial hamstrings (the ‘semimembranosus’ and ‘semitendinosus’). The former are more common than the latter. See the image to the right for a visual of the two common locations. 19

Strains typically occur close to the ‘myotendinous junction’ or ‘MTJ‘the part of a muscle that transitions into tendon – the white part of the muscle on the image. Remember, tendons connect muscles to bones. 14


Healing

Learning how muscle strains heal can give us important insight on how to treat them as time passes.

Generally, minor muscle strains can quickly heal reasonably well. However, they are also sensitive to re-injury and the healing process can be disrupted easily. As long as one is careful, recovery should go well.

According to a research review from 2005 15 there are three main phases of healing. It’s worth noting how muscle injuries heal differently from a bone. Bone are thought to heal by ‘regeneration’, while muscle are thought to heal by ‘repair’. When healing is done, the new bone is made of the same material it was before; but when muscles heal, it’s left with some scar tissue. The amount of scar tissue left behind depends on how severe the injury was, as well as how well the healing went. This might be one of the reasons why re-injury is such a problem, and why proper rehabilitation is important early in injury!

Healing proceeds similarly for each ‘grade’ of injury – ‘grades’ simply refer to the severity of injury. But while the healing process is similar no matter the severity, it still takes longer for a more severe strain to heal. There’s just more work to do, and recovery will take longer.

Three phases of muscle healing:
(note that phases 2 and 3 overlap significantly)

  1. Destruction phase : (Day 1 – 3) : Injury occurs, ‘hematoma’ (blood filling up space) develops between the rupture, the broken muscle fibers ‘necrotize’ (die off), and the inflammation process begins.
  2. Repair phase : (Day 3 – 14) : ‘Phagocytosis’ (swallowing up and breaking down) of the ‘necrotized’ (dead) tissue occurs. Muscle fibers start regenerating, and scar tissue begins to form. Blood capillaries start growing back into the injured area.
  3. Remodelling phase : (Day 8 – 21) : The new muscle fibers mature, scar tissue is re-organized neatly in the middle, and the muscle starts to regain its functional capacity.

In the end, what one is left with is isn’t a totally brand new muscle. It’s two independent muscle fibers connected by scar tissue in between. Remember: the better the healing process goes, the less scar tissue one is left with.

Can we speed up healing? Not really. Actually, we should be amazed at how good the body is at healing itself. It’s amazing. One can, however, slow healing down if they’re not careful. Most techniques that claim to “speed healing” most likely just minimize things that slow it down. Read: What Affects Healing?

One of the main things one can do to slow and complicate their healing is exercising or working the injured muscle during the first phase of healing. It’s thought that one should give it a chance to start forming some scar tissue, or they may re-rupture the healing tissue! After a few days, it’s usually safe to start moving the injured muscle again.

That thought leads us into the next section: treatment and rehabilitation.


Part II – Treatment and Rehabilitation


Diagnosis

First, are we sure this is a muscle strain? Let’s see.

But first… re-read the disclaimer! The following information is provided to help you better understand ankle sprains. This is in no way a replacement for a real professional diagnosis. Even professionals can get confused, and they may need to get you an X-ray, MRI or CT scan to be sure. Now that I’ve written that to cover my butt, let’s proceed:

lower grade strains may be hard to remember in the heat of competition.

lower grade strains may be hard to remember in the heat of competition.

Here are the key points to consider when deciding whether an injury is an ankle sprain or not. Remember, a person may have one of these things, or all of these things, or none. It’s always unique, so see a physician!

  • History – Muscle strains typically involve a memorable incident. It’s the “oh crap!” moment, when one feels or hears some kind of pop, rip, tear, pull, stretch, or another similarly uncomfortable sensation. It’s usually followed immediately with pain at the injured area. However, some grade I strains may not involve a sound or feeling, and may go unnoticed until after the exercise session has calmed down.
  • Location – Is the pain at the muscle, or at a joint? Sometimes it’s hard to tell. But if the pain feels like it’s at a joint, such as “in the knee”, then it’s probably not a strain. One would feel a strain “in the muscle” like in the picture of the hamstrings above.
  • When it hurts – Strains can hurt constantly (“background pain”), but the pain is especially felt when touching the muscle, and even more when activating (contracting) the muscle. If a thigh muscle is strained, one will feel it while walking, but maybe not while sitting relaxed. It may even be too painful to walk up and down stairs. Stretching the muscle will usually hurt too, although a light stretch sometimes feels good (wait to read more below before stretching).
  • Weakness – The injured muscle is typically weak. Not just because the muscle fibers are damaged, but because pain and inflammation can actually inhibit muscle activation.
  • Swelling, redness, or bruising – As inflammation and swelling occurs, one will likely have one of more of these signs as well. Of course, many things can cause this, so the above points are important to consider when trying to make a specific strain diagnosis.

One may also have muscle cramping. This is common. But cramps and strains are not the same thing, and don’t necessarily cause each other.

Also, don’t get a grade I strain mixed up with severe exercise induced muscle soreness (a.k.a. PEMS or DOMS). It’s sometimes difficult to tell between the two. Strains usually have that “oh crap” moment, and even if they don’t, pain is usually felt quickly. Severe exercise soreness is usually delayed by a day or two. Also, strains are typically more specific and tender to touch, while severe exercise soreness feels more like it’s in the whole muscle, and affects both legs (unless you somehow only exercised one leg).

Disclaimer: Even if you’re confident you have this injury, please see a Doctor (Physician) or Physical Therapist for a qualified clinical diagnosis. While I strive to provide the best, most up-to-date and accurate health information possible, I can’t personally see and assess your problem.


How long will this last?

A Note On Recovery Time

Every injury, and every person will recover differently.

The time course described below applies best to Grade I to II strains, which are by far the most common.


END OF FREE INTRODUCTION


Purchase full access to the eBook for $9.95 CAD to continue reading. Access is instant – a printable .pdf file will be e-mailed to you immediately after purchase.

Muscle Strain eBookYou’ll get full access to everything you’ve already read, as well as ‘Part II – Treatment and Recovery’.

  • Detailed, progressive strategy for optimizing muscle strain recovery and minimizing the chance of re-injury.
  • Photos and videos of rehabilitative exercises with simple descriptions – no expertise required.
  • Exercises are based on methods that have been shown by research to decrease chances of re-injury from 70% to only 8%6
  • 72 pages of easy to read, but highly researched information – understand why the exercises are important.
  • Download in printable .pdf format, with clickable links to further resources, videos, and more.
  • Professionals: this eBook is based on numerous peer reviewed articles – check out the references below. Purchase this eBook, and you have an evidence-based resource to give to your patients.

If you’ve enjoyed what you’ve read so far, let’s take a second look at the table of contents to see what else you’ll get after purchasing the full eBook:

So far, you’ve read:

Introduction

  • How to use this book
  • About the Author
  • Disclaimer

Part I – Understanding Muscle Strains

  • Muscle Strains – What are they?
    Muscle strains vs. soreness
    Grades I to IV
    – What are muscles for anyway?
  • How do strains happen?
  • When do strains happen?
  • Where do strains happen?
  • How do they heal?

After purchasing, you’ll also get:

Part II – Treatment and Recovery

  • Diagnosis
  • How Long Will This Last?
  • Will I Need Surgery?
  • Rehabilitation Strategy
  • About Pain
  • Recovery : Day 1 – 3 : (P.R.I.C.E)
    Medications
  • Recovery : Day 3 – 7 : (Early Rehabilitation: M.I.C.E.)
    What Not To Do
  • Recovery : Day 7 – 21 : (Advanced Rehabilitation)
  • Recovery : Day 21 + : (Gradual Return to Athletics)
  • Recurring Strains (re-injury)
  • Persistent Pain
  • Possible Complications
    Myositis Ossificans

Final Thoughts

  • Thank You!
  • F.A.Q.
  • References

Add to Cart

Much more information awaits. Go ahead – take some time to think about it – bookmark this page!

Meanwhile, if you haven’t already checked out my site bboyscience.com, please take a moment to visit! If you enjoy learning about the science of movement, I hope you find something interesting. :)

Lastly, you can also follow me through Twitter (@bboyscience) or ‘like’ my Facebook Page, where a community of brilliant healthcare and fitness professionals grows every day. Join the conversation!

Thanks for reading so far, and I wish you a swift recovery!

Tony Ingram Signature

Tony Ingram


References

Here’s the references from the full eBook. Go ahead, check my sources before purchasing!

1. Askling C, Lund H, Saartok T, Thorstensson A. Self-reported hamstring injuries in student-dancers. Scand J Med Sci Sports. 2002 Aug;12(4):230-5. PubMed PMID: 12199872.

2. Askling CM, Tengvar M, Saartok T, Thorstensson A. Acute first-time hamstring strains during slow-speed stretching: clinical, magnetic resonance imaging, and recovery characteristics. Am J Sports Med. 2007 Oct;35(10):1716-24. Epub 2007 Jun 13. PubMed PMID: 17567821.

3. Byrne JM, Gage WH, Prentice SD. Bilateral lower limb strategies used during a step-up task in individuals who have undergone unilateral total knee arthroplasty. Clin Biomech (Bristol, Avon). 2002 Oct;17(8):580-5. PubMed PMID: 12243717.

4. Collins NC. Is ice right? Does cryotherapy improve outcome for acute soft tissue injury? Emerg Med J. 2008 Feb;25(2):65-8. doi: 10.1136/emj.2007.051664. Review. PubMed PMID: 18212134.

5. Deleget A. Overview of thigh injuries in dance. J Dance Med Sci. 2010;14(3):97-102. Review. PubMed PMID: 21067687.

6. de Visser HM, Reijman M, Heijboer MP, Bos PK. Risk factors of recurrent hamstring injuries: a systematic review. Br J Sports Med. 2012 Feb;46(2):124-30. doi: 10.1136/bjsports-2011-090317. Epub 2011 Oct 19. Review. PubMed PMID: 22011915.

7. Faria FE, Ferrari RJ, Distefano G, Ducatti AC, Soares KF, Montebelo MI, Minamoto VB. The onset and duration of mobilization affect the regeneration in the rat muscle. Histol Histopathol. 2008 May;23(5):565-71. PubMed PMID: 18283641.

8. Folland JP, Williams AG. The adaptations to strength training : morphological and neurological contributions to increased strength. Sports Med. 2007;37(2):145-68. Review. PubMed PMID: 17241104.

9. Fyfe JJ, Opar DA, Williams MD, Shield AJ. The role of neuromuscular inhibition in hamstring strain injury recurrence. J Electromyogr Kinesiol. 2013 Jun;23(3):523-30. doi: 10.1016/j.jelekin.2012.12.006. Epub 2013 Feb 9. PubMed PMID: 23402871.

10. Garrett WE Jr. Muscle strain injuries. Am J Sports Med. 1996;24 (6 Suppl) : S2-8. Review. PubMed PMID: 8947416.

11. Hart JM, Pietrosimone B, Hertel J, Ingersoll CD. Quadriceps activation following knee injuries: a systematic review. J Athl Train. 2010 Jan-Feb;45(1):87-97. doi: 10.4085/1062-6050-45.1.87. Review. PubMed PMID: 20064053; PubMed Central PMCID: PMC2808760.

12. Hayashi D, Hamilton B, Guermazi A, de Villiers R, Crema MD, Roemer FW. Traumatic injuries of thigh and calf muscles in athletes: role and clinical relevance of MR imaging and ultrasound. Insights Imaging. 2012 Dec;3(6):591-601. doi: 10.1007/s13244-012-0190-z. Epub 2012 Sep 16. PubMed PMID: 22983909; PubMed Central PMCID: PMC3505561.

13. Howatson G, van Someren KA. The prevention and treatment of exercise-induced muscle damage. Sports Med. 2008;38(6):483-503. Review. PubMed PMID: 18489195.

14. Järvinen TA, Järvinen TL, Kääriäinen M, Aärimaa V, Vaittinen S, Kalimo H, Järvinen M. Muscle injuries: optimising recovery. Best Pract Res Clin Rheumatol. 2007 Apr;21(2):317-31. Review. PubMed PMID: 17512485.

15. Järvinen TA, Järvinen TL, Kääriäinen M, Kalimo H, Järvinen M. Muscle injuries: biology and treatment. Am J Sports Med. 2005 May;33(5):745-64. Review. PubMed PMID: 15851777.

16. Kannus P, Parkkari J, Järvinen TL, Järvinen TA, Järvinen M. Basic science and clinical studies coincide: active treatment approach is needed after a sports injury. Scand J Med Sci Sports. 2003 Jun;13(3):150-4. Review. PubMed PMID: 12753486.

17. Malliaropoulos N, Papalexandris S, Papalada A, Papacostas E. The role of stretching in rehabilitation of hamstring injuries: 80 athletes follow-up. Med Sci Sports Exerc. 2004 May;36(5):756-9. PubMed PMID: 15126706.

18. Mason DL, Dickens VA, Vail A. Rehabilitation for hamstring injuries. Cochrane Database Syst Rev. 2012 Dec 12;12:CD004575. doi: 10.1002/14651858.CD004575.pub3. Review. PubMed PMID: 23235611.

19. Mendiguchia J, Alentorn-Geli E, Brughelli M. Hamstring strain injuries: are we heading in the right direction? Br J Sports Med. 2012 Feb;46(2):81-5. doi: 10.1136/bjsm.2010.081695. Epub 2011 Jun 15. Review. PubMed PMID: 21677318.

20. Milner CE. Interlimb asymmetry during walking following unilateral total knee arthroplasty. Gait Posture. 2008 Jul;28(1):69-73. Epub 2007 Nov 19. PubMed PMID: 18024040.

21. Oldmeadow LB, Edwards ER, Kimmel LA, Kipen E, Robertson VJ, Bailey MJ. No rest for the wounded: early ambulation after hip surgery accelerates recovery. ANZ J Surg. 2006 Jul;76(7):607-11. PubMed PMID: 16813627.

22. Opar DA, Williams MD, Shield AJ. Hamstring strain injuries: factors that lead to injury and re-injury. Sports Med. 2012 Mar 1;42(3):209-26. doi:10.2165/11594800-000000000-00000. Review. PubMed PMID: 22239734.

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