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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 5  |  Issue : 1  |  Page : 36-40

Rehabilitation of spontaneous muscle ruptures in a healthy young goalkeeper


Department of Physical Medicine and Rehabilitation, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal

Date of Submission14-Jun-2021
Date of Decision09-Jul-2021
Date of Acceptance23-Jul-2021
Date of Web Publication16-Dec-2021

Correspondence Address:
Dr. Eduardo Freitas Ferreira
Department of Physical Medicine and Rehabilitation, Hospital Professor Doutor Fernando Fonseca, E.P.E., IC 19-Venteira, 2720-276 Amadora
Portugal
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JISPRM-000140

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  Abstract 


Spontaneous muscle ruptures in young adults without previous diseases or risk factors are extremely rare. No previous reports describing simultaneous spontaneous ruptures of multiple muscles in the healthy young adult have been published, emphasizing the lack of protocolized rehabilitation programs. In this article, the authors report a case of simultaneous spontaneous multiple muscle tears in a healthy goalkeeper, proposing a rehabilitation approach. A 19-year-old male goalkeeper presented to the emergency department with intense acute low back pain initiated spontaneously after raising from bed and originating gait difficulties. Magnetic resonance imaging demonstrated muscle ruptures in the left iliacus, piriformis, and paravertebral. Investigation for systemic causes of muscle tears was negative. The patient pursued a customized and phased rehabilitation program for a total of 6 months. In the re-evaluation at the end of the rehabilitation program, the patient presented no pain, had full range of motion and full muscle strength, and presented great stability and coordination. He was referred to sports medicine to pursue reintegration as a goalkeeper with functional sports-specific training. Although no cause for the ruptures was identified, the patients' sports-related activity may lead to microtear formation and trigger spontaneous tears. Thus, sports biomechanics may explain the underlying pathogenesis of these injuries. This case also highlights that an individualized rehabilitation program optimizes activity, participation, and professional reintegration.

Keywords: Muscle, rehabilitation, rupture, skeletal, soccer, spontaneous


How to cite this article:
Ferreira EF, Portugal D, Silva N, Peixoto C, Ladeira A, Matos C, Prates L. Rehabilitation of spontaneous muscle ruptures in a healthy young goalkeeper. J Int Soc Phys Rehabil Med 2022;5:36-40

How to cite this URL:
Ferreira EF, Portugal D, Silva N, Peixoto C, Ladeira A, Matos C, Prates L. Rehabilitation of spontaneous muscle ruptures in a healthy young goalkeeper. J Int Soc Phys Rehabil Med [serial online] 2022 [cited 2022 Jul 3];5:36-40. Available from: https://www.jisprm.org/text.asp?2022/5/1/36/332683




  Introduction Top


Muscle tears, especially in young athletes, are usually related to trauma. Thus, spontaneous muscle ruptures in this population are extremely rare. In the majority of cases, these spontaneous injuries are associated with systemic diseases (diabetes mellitus, chronic kidney disease, gout, rheumatoid arthritis, systemic lupus erythematosus, connective tissue diseases, hyperthyroidism, and hyperparathyroidism) or medications (hydroxychloroquine, colchicine, and steroids) that predispose to muscle tears.[1],[2] However, a few cases of spontaneous muscle ruptures have also been reported in healthy subjects without previous risk factors.[3],[4] In one of these cases,[3] it was hypothesized that poor gastrocnemius-soleus flexibility and low-flexibility shoes (high heels) might have contributed to the tear.

Football practice, including goalkeeping, predisposes not only to traumatic but also to overuse injuries due to the biomechanical stress on muscles and tendons, especially around the hip,[5] weakening muscle ultrastructure and predisposing to tears with minor activity or spontaneously. To the authors' knowledge, no report describing simultaneous spontaneous ruptures of multiple muscles in the healthy young adult has been published. Conservative treatment originates a good prognosis for most athletes with muscle injuries. However, there is a lack of rehabilitation programs in the management of patients with tears in various muscles.

In this article, the authors report a case of simultaneous spontaneous multiple muscle tears of the proximal lower limb in a healthy young goalkeeper, proposing a possible rehabilitation approach. This case report conforms to CARE guidelines (2013 CARE Checklist) and reports the required information accordingly (see Checklist, Supplemental Digital Content).


  Case Report Top


A 19-year-old male semi-professional goalkeeper, with no previous medical history, presented to the emergency department (ED) with an acute, sharp left low lumbar pain, initiated spontaneously after raising from bed and irradiating to the left hip and groin. He has played in local soccer clubs since he was 8 years old with semi-professionalization as a goalkeeper for the last 5 years. Currently, he played in the national third division and practiced 4–5 times per week with no previous serious musculoskeletal injuries documented. The pain was graded by the patient as 6/10 on the visual analogical scale (VAS), aggravating with lower leg movements (mainly with left hip flexion and rotations) and causing functional gait difficulties. He reported no trauma, excessive strain, or pain during or after the last soccer practice that occurred more than 12 h prior to the pain onset. He also denied any previous history of low back or lower extremity pain. Apart from pain on lower limb mobilization (active and passive), no other abnormalities were present on evaluation. Spine and pelvic radiography showed no acute abnormalities [Figure 1] and the patient was prescribed oral nonsteroidal anti-inflammatory drugs and discharged from the ED.
Figure 1: Spine and pelvic radiography. (a) Anteroposterior lumbar view. (b) Lateral lumbar view. (c) Anteroposterior pelvic view

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Due to increasing pain and gait abnormalities, the patient returned to the ED after 24 h. On this occasion, the patient was evaluated by neurology, presenting intense left low lumbar pain (VAS 9/10) without any clear focal signs on neurological examination but unable to actively mobilize the proximal left lower limb. He did not present atrophy, erythema, ecchymosis, or edema on physical evaluation, but tenderness over the low axial spinous processes, posterior superior iliac spine, and iliac crest was present. Laboratory findings failed to show abnormalities apart from an elevated creatine kinase (1560 U/l), C-reactive protein (7.74 mg/dl), and sedimentation rate (34 mm/h) level. Cervical and lumbar spine computerized tomography (CT) showed no signs of disc or degenerative pathology and angio-CT showed no vascular abnormalities, excluding traumatic and vascular pathology. The patient was admitted to the neurology department to clarify pain and possible proximal left lower limb paresis with a suspicion of functional impairment due to the low back pain of inflammatory or infectious myelitis, radiculitis, sacroiliitis, or lumbar plexopathy.

During hospitalization, multimodal analgesia was initiated with acetaminophen and tramadol. Spine and lumbar plexus magnetic resonance imaging (MRI) failed to show any abnormalities, excluding myelitis, radiculitis, or lumbar plexopathy. Nerve conduction studies and concentric needle electromyography of the left lower limb did not show any changes [Figure 2]. However, sacroiliac joint MRI demonstrated left iliacus muscle rupture at its origin in the iliac bone with 50 mm × 6 mm, rupture of the posterior muscle fibers in the left piriformis, and muscle rupture in the external anterior aspect of the left paravertebral muscle with 49 mm × 3 mm [Figure 3]. A thorough assessment for systemic causes of muscle rupture (such as diabetes, kidney disease, gout, rheumatoid arthritis, systemic lupus erythematosus, connective tissue diseases, or hyperthyroidism) was done, but no clinical findings or laboratory abnormalities were present. Furthermore, the patient denied recent medication usage (including antibiotics) or infections. Thus, the patient was diagnosed with spontaneous multiple muscle ruptures of unknown etiology and an evaluation by physical medicine and rehabilitation (PMR) was requested.
Figure 2: Neurophysiological studies

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Figure 3: Magnetic resonance imaging with coronal planes on the top and axial planes in the bottom. (a) Left iliacus muscle rupture at its insertion in the iliac bone. (b) Rupture of the posterior muscle fibers in the left piriformis. (c) Rupture in the external anterior aspect of the left paravertebral muscle. The area of concern is denoted by a white arrow

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On this evaluation, 1 week after clinical onset, the patient maintained pain and tenderness in the left iliac region and presented painful mobilization of the left hip limiting flexion, rotation and adduction. With strength evaluation limited by pain, the patient presented a medical research council grade 2 in hip flexion, grade 4 in knee extension and grade 5 in ankle dorsiflexion/plantar flexion. Orthopedics discarded surgical indication (complete rupture) and a 4 week relative rest period of the affected segments (lower back and left hip) with mobilization in the painless arch allowed was implemented to control pain and help regenerate muscle tissue and the patient started a structured rehabilitation program.

During hospitalization, an early and daily rehabilitation program was carried out that included cryotherapy, range of motion exercises (passive and active-assisted of the affected segments and active and resisted of other body segments), quadriceps and ischiotibial isometric muscle strengthening and isotonic exercises of other body segments, and transfer, orthostatic, and gait training (nonweight-bearing with brachial support walker) as tolerated.

After hospital discharge, the patient was re-evaluated by PMR, at 4 weeks, presenting slight pain on hip adduction and internal rotation (50% improvement with acetaminophen per re nata) and showing progressive functional improvement. At this time, the patient continued the rehabilitation program at the PMR outpatient department for another 5 months on a three times a week regimen [Table 1]. The rehabilitation program progressed to active (at 4 weeks) and resisted (at 6 weeks) range of motion exercises of the affected segments. Dynamic strengthening exercises were started at 6 weeks, initially open-chain exercises and progressively closed chain exercises. Aerobic reconditioning with an upper limb cycle ergometer was started at 4 weeks and continued throughout the program with increasing intensity with a stationary bicycle being introduced at 8 weeks and treadmill at 10 weeks. Orthostatic and gait training progressed according to tolerance to partial weight-bearing in regular floors at 4 weeks with progression to irregular floors and stairs at 8 weeks and finally, to full-weight weight-bearing at 12 weeks. Progressive proprioceptive training was introduced at 8 weeks, initially static, with progression according to tolerance to dynamic exercises. Plyometric, coordination, and agility exercises were introduced at 16 weeks.
Table 1: Patient rehabilitation program

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Left low back and hip pain was the main complaint and cause of intermittent cooperation in the early phases of the rehabilitation program, especially in gait training. Gait reacquisition was particularly difficult due to pain intensity oscillation, muscle atrophy, and patients' anxiety of lesion aggravation with mobilization. At the time of discharge from the PMR department (at 24 weeks), the patient presented only residual pain at piriformis stress testing, full range of motion of the left hip and knee, and full muscle strength of hip flexors, abductors, and rotators, except minor medium gluteal insufficiency on the Trendelenburg test. The patient was capable of squatting, lunging, and performing a single leg stance with good control and autonomous gait without ambulation aids. At this point, the patient was referred to the sports medicine department to pursue sports-related training and sports reintegration as a goalkeeper.


  Discussion Top


This case report presents a healthy young goalkeeper with simultaneous spontaneous ruptures of multiple muscles (iliacus, piriformis, and paravertebral). Spontaneous muscle tears are rare lesions. Only a few cases have been described, more frequently affecting the quadriceps,[4],[6] gastrocnemius.[3] or iliopsoas.[7] In the literature, no reports of spontaneous ruptures of the paravertebral or piriformis muscles have been described. Furthermore, simultaneous spontaneous ruptures of multiple muscles are extremely rare and apart from bilateral affection of the same muscle (generally of the quadriceps myotendinous junction), no reports of simultaneous spontaneous multiple lower limb muscle tears exist, rendering this case unique.

In the majority of cases, spontaneous lesions are associated with systemic diseases or medications that render the muscle more susceptible to lesion.[1],[2] However, spontaneous lesions in previous healthy adults have also been described[3],[6] but are extremely rare. Pre-existing degeneration has been implicated as a risk factor in acute tears. Indeed, acute injuries have been suggested as indicative of an underlying chronic impairment that contribute to the injury.[8] In this case, the muscle tears occurred in a nontraumatic context in a patient with no risk factor or identified health condition, even after exhaustive clinical and laboratory investigation. Since the muscles involved are very strong and there is no recognized trauma impact, associated disease, or risk factors, the authors consider some kind of preexisting damage to the muscles' ultrastructure or vascularization as the cause/predisposition to its rupture, with presumptive unknown systemic factors.

The goalkeeper is a specific tactical position that requires performing strenuous actions during practice sessions and competitive games.[9] Overtraining, repetitive exercises, or inadequate periods of rest can cause an injury of the involved muscles that exceeds the natural capacity to recover, originating an overuse injury. In one study, 23.1% of goalkeepers presented an overuse lesion, with 74.9% located in the lower limb.[5] Biomechanical analysis of the goalkeepers' activity showed a large exposure to overload of tissues, mainly around the hip,[10],[11] especially during interventions such as side dives and sidekicks. Excessive loading events may lead to microtear formation,[12] which, if not repaired properly, may trigger degenerative and inflammatory responses. This originates a weakened structure and increased propensity for ruptures.[2],[12] Indeed, some studies have demonstrated that goalkeepers present higher lactate dehydrogenase and interleukin-6 levels, corroborating that these players present inflammation and predisposition to muscle damage.[13] The authors argue that the repetitive and excessive loading on the lower limb, mainly on the myotendinous complex around the hip, due to the patients' activity as goalkeeper, with subclinical inflammation and/or degeneration, may have progressively weakened the patients' muscles and lead to spontaneous rupture without acute trauma. Sports biomechanics has shown that during sidekicks, a greater tension is observed in the anterior muscles and tendons of the hip and knee on the kicking lower limb, while in the pivotal lower limb, the tension is greater in the posterior muscles and tendons of the lower back and hip during the extension and rotational movement. Since the patients' injuries were all on the left side as opposed to bilateral, the authors purpose that due to the patient being right sided, this might have explained why the overuse injuries and tears occurred in the left paravertebral, piriformis, and iliac origin.

Due to the extremely rare frequency and possible heterogeneity of multiple spontaneous muscle tears, studies have never been conducted and no standard rehabilitation program exists. A possible treatment approach is proposed in [Table 1]. Clinical experience suggests that early and phased institution of a rehabilitation program is essential to maximize clinical and functional outcomes. An inflammatory process predominates in the acute phase after lesion. Rest, cryotherapy, and elevation immediately after the injury reduce the size of the hematoma, preventing muscle retraction and formation of a large muscle gap, with less inflammation and accelerated regeneration. Early mobilization induces an increase in local vascularization, better regeneration of the muscle fibers, and better orientation of the regenerated myofibrils, in comparison to movement restrictions.[14] However, renewed tearing at the original site is common if active mobilization is started too early.[15] Thus, a short immobilization period is recommended to permit scar tissue to reconnect the muscle failure and protect from further injury. After the acute phase, the initial inflammatory response decreases and early weak nonorganized scar tissue begins to develop. In this phase, passive and active-assisted range of motion exercises and isometric strengthening exercises may be initiated as this will promote proper alignment and improved strength of the scar tissue.[2] Conditioning exercises should also be initiated early to increase cardiovascular endurance and function. As this phase progresses, with stronger and more organized scar tissue, range of motion should also progress to active and resisted exercises and isotonic exercises should replace isometric strengthening. Appropriate levels of tissue stress will continue to encourage proper alignment and increased tensile strength as the scar tissue matures.[2] After the initial immobilization period, the patient should progress, as tolerated, from nonweight-bearing to partial weight-bearing and finally full weight-bearing, as this will increase functionality and reintegration. Proprioceptive exercises may be introduced in a more advanced phase with stronger scar tissue and progressively plyometric, agility and coordination exercises may be introduced. These exercises are especially important in this case, to facilitate professional reintegration as a goalkeeper.

In the described case, rehabilitation intervention led to a favorable clinical outcome, with good pain control and functional optimization and greater competence for activities of daily living and professional activity. Aquatic physical therapy was not introduced in the rehabilitation program due to pool shutdown in the COVID-19 pandemic context. The addition of hydrotherapy would have allowed the unloading of body weight in the standing position without walking aids and in an antalgic environment, promoting greater confidence and balance in lower limb mobilization and improving active range of motion and muscle strength.


  Conclusion Top


This case report presents a rehabilitation approach to a rare case of simultaneous spontaneous multiple muscle tears. Although no cause for the ruptures was identified after extensive investigation, the patients' sports-related activity as a goalkeeper may lead to microtear formation and trigger spontaneous tears. Thus, sports biomechanics may explain the underlying pathogenesis of these injuries. This case also highlights that an individualized rehabilitation program optimizes activity and participation and may permit professional reintegration, emphasizing the available tools in the physical and rehabilitation medicine scope.

Acknowledgements

The authors would like to acknowledge Dr. Sérgio Ferreira for the help provided in the selection of the MRI images.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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van Langevelde K, Spinnato P, Carpenzano M, Moio A. Spontaneous bilateral medial head of gastrocnemius muscle rupture. BMJ Case Rep 2019;12:e229252.  Back to cited text no. 3
    
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Celik EC, Ozbaydar M, Ofluoglu D, Demircay E. Simultaneous and spontaneous bilateral quadriceps tendons rupture. Am J Phys Med Rehabil 2012;91:631-4.  Back to cited text no. 4
    
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Błażkiewicz A, Grygorowicz M, Białostocki A, Czaprowski D. Characteristics of goalkeeping injuries: A retrospective, self-reported study in adolescent soccer players. J Sports Med Phys Fitness 2018;58:1823-30.  Back to cited text no. 5
    
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Portugal DM, Capelo JA, Martins BD, Ribeiro IM, Ataíde SR, Vera-Cruz CV. Rehabilitation approach after surgical repair of spontaneous bilateral quadriceps tendon rupture in a healthy mason. Am J Phys Med Rehabil 2019;98:e43-6.  Back to cited text no. 6
    
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Rubio M, Rodriguez M, Patnaik S, Wang P. Spontaneous iliopsoas tendon tear: A rare cause of hip pain in the elderly. Geriatr Orthop Surg Rehabil 2016;7:30-2.  Back to cited text no. 7
    
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Ziv G, Lidor R. Physical characteristics, physiological attributes, and on-field performances of soccer goalkeepers. Int J Sports Physiol Perform 2011;6:509-24.  Back to cited text no. 9
    
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Schmitt KU, Nusser M, Boesiger P. Hip injuries in professional and amateur soccer goalkeepers. Sportverletz Sportschaden 2008;22:159-63.  Back to cited text no. 10
    
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Ekstrand J, Gillquist J. Soccer injuries and their mechanisms: A prospective study. Med Sci Sports Exerc 1983;15:267-70.  Back to cited text no. 11
    
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Fung DT, Wang VM, Andarawis-Puri N, Basta-Pljakic J, Li Y, Laudier DM, et al. Early response to tendon fatigue damage accumulation in a novel in vivo model. J Biomech 2010;43:274-9.  Back to cited text no. 12
    
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de Moura NR, Borges LS, Santos VC, Joel GB, Bortolon JR, Hirabara SM, et al. Muscle lesions and inflammation in futsal players according to their tactical positions. J Strength Cond Res 2013;27:2612-8.  Back to cited text no. 13
    
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Järvinen M. Healing of a crush injury in rat striated muscle. 2. A histological study of the effect of early mobilization and immobilization on the repair processes. Acta Pathol Microbiol Scand A 1975;83:269-82.  Back to cited text no. 14
    
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Lehto M, Duance VC, Restall D. Collagen and fibronectin in a healing skeletal muscle injury. An immunohistological study of the effects of physical activity on the repair of injured gastrocnemius muscle in the rat. J Bone Joint Surg Br 1985;67:820-8.  Back to cited text no. 15
    


    Figures

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