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Muscle strains strike most often in the big muscles of the body. But sometimes the pain is not what it seems …

Save Yourself from Muscle Strain!

Muscle strain (pulled muscle) and muscle pain explained and discussed in great detail, plus every imaginable treatment option

18,000 words, updated Apr 16th, 2014 — What’s new?
by Paul Ingraham, Vancouver, Canada bio
I am a science writer, the Assistant Editor of ScienceBasedMedicine.org, and a former Registered Massage Therapist with a decade of experience treating tough pain cases. I’ve written hundreds of articles and several books, and I’m known for sassy, skeptical, referenced analysis and a huge bibliography. I am a runner and ultimate player, and live in beautiful downtown Vancouver, Canada. • full bioabout SaveYourself.ca

Welcome to the most detailed information about muscle strain and pain available anywhere, especially for tough and stubborn cases. This is more than just a web page: it’s bigger than it looks — many dozens of chapters and over 100,000 words, including a second volume — for both patients and professionals that explores every myth and controversy, and every possible way of reducing pain coming from muscle. It is more scientifically current than any competitive information source, yet also more user-friendly and readable.

In 2012, Gene Lawrence, a 74-year-old weight lifter, tore his quadriceps (and not while lifting). A doctor cautiously told him he’d never do a squat again. But Gene’s passion for his sport kept him going. Several months later he was on the verge of beating his personal records — a near total recovery. You can recover from nearly anything if you are patient and methodical.1

But what method? What is muscle injury, and how does it heal? Is your muscle actually injured? What works? What doesn’t? Muscle strain and pain are usually woven together. Somewhere in your body, something hurts and you think it’s got to be a muscle strain or a muscle spasm or … well, something to do with a muscle anyway. If you’re like most people with muscle pain, you’re not sure exactly what the problem is, and you’re looking for some answers.

I am a science writer & amateur athlete in Vancouver, Canada. I’ve been writing about muscle strains for more than a decade & recovered from several that I’ve gotten while playing sports. ~ Paul Ingraham
About footnotes. There are 40 footnotes in this document. Click to make them “pop up” without losing your place. There are two types: interesting extra content, and boring reference information.1Footnotes with more interesting and/or fun extra content are bold and blue, while dry footnotes (citations and such) are lightweight and gray. Type ESC to close footnotes, or re-click the number.

2“Boring” footnotes usually contain scientific citations from my giant bibliography of pain science. Many of them actually have pretty interesting notes.

Example citation:
Berman et al. Acupuncture for Chronic Low Back Pain. New England Journal of Medicine. 2010. PubMed #20818865. ← That symbol means a link will open in a new window.
Try one!

Muscle strain and pain myths and misconceptions

Believe it or not (and it does seem a bit ridiculous in 2014) muscle pain is still a subject of great scientific mystery and many myths and misconceptions. A torn muscle is arguably among the most medically neglected of all common injuries.23 Odds are good that your family doctor is not competent to assess and treat musculoskeletal problems, including muscle strains.4

And so, although most muscle pain is relatively simple to diagnose and self-treat, an incredible number of people end up in my office who either have muscle strains that have been misdiagnosed as something else, or they have “something else” that’s been misdiagnosed as a muscle strain. Strain, pain, spasm, contracture, scar tissue, tone and tension are all poorly understood and routinely confused. They are not only surprisingly complex topics scientifically, but clinicians are not generally aware of the research that has been done.

It would be nice, for once, if someone came to my office with a muscle pain that had been accurately diagnosed … but it almost never happens! So I wrote this tutorial, because clearly there is a need for it. The world obviously needs more and better information about muscle pain. And if you’ve read this far, then so do you!

How can you trust this information about muscle strains?

I question everything and I have fun doing it. I assume that anything that sounds too good to be true probably is. I make no big promises, and I do not claim to know the “one true cause” of muscle strain and pain. When I don’t know something, I admit it. I actually read scientific journals, I clearly explain the science behind every key point (there are more than 50 footnotes here), and I always link to the original sources.

So all the science and all the options for muscle strain treatment are here. If you’ve been struggling with pulled muscle injury, I think this tutorial will feel like a “good find” to you!

You are going to know all about muscle strain by the time you get to the end of this document. In fact, you’re going to know more about muscle pain — and how to treat it — than all your friends and neighbours, and probably more about it than your family doctor or your physiotherapist!

As with all the tutorials on SaveYourself.ca, I’ve worked hard to provide you with the best information available anywhere — not just better researched and referenced, but also regularly updated, and presented in a clear, friendly style that’s just like coming to my office and having a nice long conversation about it, where all your questions get answered.

So what is a muscle strain?

Actually, it's simple: any torn muscle is called a muscle strain. And this is the same as a “pulled muscle.”

(Note that there is no such thing as a “muscle sprain” — it’s a contradiction in terms.5)

Although you might have problems that make you vulnerable to a muscle strain, the direct cause of every muscle strain is traumatic ripping of the muscle tissue — arg! — usually at the point where the muscle meets its tendon. Muscle will tear under the force of your own muscular contraction, or excessive stretch.

The more muscle fibres are torn, the worse the strain. In the case of a serious strain, the entire muscle may completely rupture — literally ripped in half! Double arg!

Muscle strains are particularly common in the thigh and groin in soccer, ultimate, hockey and other fast-moving team sports.

Muscle strains are particularly common in the thigh and groin in soccer, ultimate, hockey and other fast-moving team sports.

Muscle strains are particularly common in the thigh and groin in soccer, ultimate, hockey and other fast-moving team sports.

Muscle strains are particularly common in the thigh and groin in soccer, ultimate, hockey and other fast-moving team sports.

Sometimes an impact or a laceration damages muscle fibres in such a way that the injury is basically like a muscle strain. We won’t discuss this scenario much, because there’s not much medical mystery involved if you were gouged by a hockey skate. We also won’t discuss full muscle ruptures in much detail, because they are so extreme that they are easy to diagnose — even doctors can do it! If you have a doctor who can’t help you with lacerations and contusions, you really need a new doctor.

There will be much (much) more detail below about exactly what a muscle strain is, and its complications, and how to treat it, and so on. But before we get into that, it’s important to determine whether or not you actually have a muscle strain, or some other kind of muscle pain.

Part 2

Diagnosis

How do you know that you’ve got a muscle strain?

Here is the part where I tell you that you probably have the wrong book. (But, don’t worry, the right book is included if you need it.)

Muscle strains and especially muscle ruptures are actually surprisingly rare, compared to other causes of muscle pain. Funny thing about this tutorial: most people who find this document, like most people who think they have strained a muscle, have actually not done any such thing — or (just as common) they strained a muscle once upon a time, but the strain healed long ago and has since become an entirely different problem.

This could be you!

Most people who think they have strained a muscle have actually not done any such thing.

Some of the things that get confused with muscle strains are (and these will all be covered in more detail below):

  • Spasms, cramps, and charlie horses are whole muscle contractions, ranging from uncomfortable to those howling, awful attacks that usually afflict the calves and feet.
  • Nasty muscle knots, technically known as trigger points, are small patches of localized muscle spasm and involve no actual damage to the muscle.
  • Delayed onset muscle soreness, a.k.a. DOMS, is that savage muscle soreness we all get after an unfamiliar workout … but it always (really) fades after about three days, guaranteed.
  • Low back pain is a complex phenomenon which routinely gets attributed to muscle strain, when in fact it is very rarely caused by muscle strain. Just about the only time low back pain is ever caused by muscle strain is when you have a sudden, severe onset of pain while trying to move a piano down some stairs … or something like that. (If you have low back pain, stop reading this article right now and head on over to Save Yourself from Low Back Pain!)

Cramp versus strain example: Multi-muscle cramping catastrophe on a hot summer night

In 2007, I was enjoying my athletic peak and managing, just barely, not to embarrass myself while playing quite a bit with some younger and more talented athletes. One hot night I was running low on electrolytes: too much sweating, not enough salt intake. (Actually, that’s a surprising myth.6) I was playing “goaltie” (say it like goal-tea) a variant of ultimate: a hard-running Frisbee sport with the same intensity and speed as soccer, but with more jumping.

Both calves spasmed on a jump, bringing me down hard. That was nasty, but it was just the start: as soon as I hit the ground, both sets of hamstrings went off as well, and all that was more than enough to make for a good cramping story … but then my abdominals joined the fray, and that gave me an anecdote I’ll be sharing for the rest of my life.

The cramping all hurt, a lot, but I was too surprised and busy to focus on the pain. If you’ve ever had a strong spasm, you know that there’s a powerful instinct and need to elongate the muscles. Stretching is your only hope of relief. But I had a puzzle to solve: just try to stretch the backs of your legs and your abdominal muscles at the same time. It’s an anatomical impossibility.

That’s me in the air at the back. Check out that vertical! It was that kind of jump that triggered a massive wave of spasms …

I jackknifed back and forth so violently that the other players wondered if I was having a seizure, but I was simply on my impossible mission to stretch both sides of my body. If I stretched the legs, the abdominals would bunch up; if I stretched them, the leg muscles tried to kill me. After about three tries each way, I realized it couldn’t be done and that my only hope was compromise: to find the least awful position somewhere between the extremes. It meant that neither muscle group would really be stretched at all — but neither would be allowed to fully contract either. I gasped “cramps! lots of cramps!” so everyone knew I wasn’t actually having a seizure … and then waited it out.

Without the power of stretch, the cramps took a long time to fade. It was a long time to endure extremely powerful contractions.

A spasm is capable of injuring muscle. In this case, I was wrenching back and forth, my own muscles in a tug-of-war with each other. These were perfect conditions for injury. Something had to give, and it did — I had mild strains of all the affected muscles, resulting in not just days of soreness but severe soreness for weeks, and a vulnerability to re-injury that was still a problem a full year later.

The spasm here was the strong involuntary contraction of the muscles. The strain was the injury caused by the forces on the muscles.

True muscle strain checklist

Here’s a checklist of the signs and symptoms of a true pulled muscle. If you can say, “Yeah, that’s me,” to all of these, then congratulations: you probably have an actual, certifiable, card-carrying Muscle Strain®.

  • Did it hit you suddenly during strong stretching or a moment of athletic intensity? Were you lifting something way too danged heavy and/or awkward? In other words, did you have an “oh, shit” moment?
  • Is the injury fairly recent? A few weeks old at the most? If it’s been a long time, it’s probably not a muscle strain any more — certainly not an acute one!
  • Do you have just one muscle (or muscle group) that’s both weak and painful to use?
  • Is there a spot in the muscle that’s especially sensitive? (It may even be little bit deformed — is there a bump or a depression?)
  • Is the skin flushed and hot? Does it look puffy?

If you “woke up with it,” or the pain came on slowly over several days, or if it’s six months old, or if the pain isn’t consistently in one particular place … then we’ll be talking about other possibilities. If your real problem is actually a painful “muscle knot,” for instance, you might want to take your knots for a nice massage — but massage is mostly pointless for a strain.

The “oh shit” moment: the most essential sign of muscle strain

Muscle strain cannot occur without an “oh shit” moment. (It’s fun to explain oh-shit moments to my patients — it always gets a laugh!) In other words, it hits suddenly: you know that something nasty has happened, immediately and with perfect clarity. You feel wounded. In physical therapy, this is what we call a history of “sudden onset.”7

If your pain didn’t start suddenly (or very nearly so), it ain’t a muscle strain. Muscle strains are traumatic by nature, almost always occurring during intense athletic activity. The victim says a bad word, perhaps several of them in the case of a grade II injury. In the case of a grade III, there is generally screaming and falling down and probably turning a bit green.

Location, location, location

Another way of knowing you’ve got a muscle strain is by the location. Muscle strains are much more common in some muscles than others. Every “groin pull” is a muscle strain of one or more of your hip adductors, for instance.

You can strain virtually any muscle in your body, but the commonly strained muscles are:

  • the hamstrings
  • the rectus femoris (the smallest of the quadriceps group, on top of the thigh)
  • gastrocnemius (the muscle that gives the calf its shape)
  • the lumbar paraspinals (thick columns of muscle on either side of the lumbar spine)
  • the biceps

The pattern here is big muscles, which we tend to use for explosive or intense effort. However, a strain is possible in any muscle.

Even more specifically …

Strains often occur where muscles meet tendons, the myotendinous junction. Tendon is the shiny white “bio rope” that connects muscles to bones (in contrast to the bone-to-bone connections of ligaments). Tendons blend smoothly into muscles, like fingers of two types laced together, but at a cellular level. When a muscle contracts, the greatest strain naturally occurs where it pulls, which is of course where the tendon is. All the force converges on the tendon, but it’s not going to give. (In many cases, even bone will give way before tendon does!) Tendon has an extraordinary tensile strength, much greater than steel cable. Instead, the muscle tissue tends to fail close to where it becomes more tendon-y.

It can be hard to tell where this zone of likelier is. For instance, in the hamstrings, the tendons are quite long and complex, and blend into the muscle along a considerable span. So you can have a myotendinous strain there that is basically right in the middle, between thigh and knee.

The hurtin’ and the weak

You know you have a muscle strain when the muscle feels weak and contraction is painful.

Strength/pain combinations are very useful diagnostically, and a good physical therapist is always looking for such combinations when assessing your case. A “weak and painful” contraction test indicates muscle strain. “Strong and painful” means something else. “Weak and painless” something else again.

Ligament sprains, for instance, do not cause weakness or pain with muscle contraction — except to the extent that sprained ligaments just don’t like to be moved. If you simply clench your muscles in place, without moving, and nothing hurts (much) … that could be a ligament sprain: strong and painless.

[Ankle taping is for sprains, not strains.]

Is this a sprain or a strain?

Definitely a sprain. Stabilizing a joint like this is for sprained ligaments, not strained muscles. Sprains always occur at joints, especially the ankles, knees and wrists.

[Ankle taping is for sprains, not strains.]

Is this a sprain or a strain?

Definitely a sprain. Stabilizing a joint like this is for sprained ligaments, not strained muscles. Sprains always occur at joints, especially the ankles, knees and wrists.

Tendinitis is sometimes mistaken for a muscle strain. But tendinitis will not cause significant weakness. It will just hurt: strong and painful.

Muscles strains make muscle contractions really weak and painful.

Now let’s look at the three alternative diagnoses, three common muscle problems that get mistaken for muscle strains: muscle spasms, DOMS, and muscle knots …

Could you have a muscle spasm instead of a strain?

You sure could! Spasms, cramps and “charlie horses” can both seem like a muscle strain and they can also actually cause one…

END OF FREE INTRODUCTION

Purchase full access to this tutorial for USD$1995. Continue reading immediately after purchase. A second tutorial about muscle pain is included free.

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  • Free second tutorial! When you buy this tutorial, you will also get Save Yourself from Trigger Points and Myofascial Pain Syndrome! — a $1995 value. Muscle strain (injury) and muscle pain (knots) are so intertwined and confused that most readers need information about both. I supply both for the price of one: a 2-volume set. You automatically get both when you purchase here.

Volume I Contents


 
TABLE OF CONTENTS PREVIEW

Volume II Contents

And here’s a sneak peak of the Table of Contents for the trigger points tutorial, which is delivered automatically with the muscle pain tutorial (yes, it’s much bigger)…

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Part 2.7

Appendices

Acknowledgements

This document and all of SaveYourself.ca was, for many years, created in my so-called “spare time” and with a lot of assistance from family and friends. Undying thanks to my wife, Kimberly, for countless indulgences large and small, and for being my “editor girlfriend”; to my parents for (possibly blind) faith in me, and much copyediting; and to Mike Gobbi, buddy and digital mentor, for many of the nifty features of this document (hidden and obvious). And thanks to all of the above, and many others, for many (many) answers to “what do you think of this?” emails.

Thanks finally to every reader, client, customer, and big tipper for your curiosity, your faith, and your feedback and suggestions and stories. Without you, all of this would be pointless.

And a few thanks to some health professionals who have been particularly inspiring to me: Dr. Steven Novella, Sam Homola, DC, Dr. Harriet Hall, Simon Singh, and Dr. Stephen Barrett.

Reader Comments

Here is what some readers have said about the muscle strain and pain tutorial over the years. Feedback is always welcome. I focus on the positive in this section, but I want to acknowledge that I certainly do receive some criticisms as well. In many cases I respond by making improvements to the tutorial. However, the vast majority of feedback is enthusiastic. Thanks, everyone!


The internet is a dicey place to spend money ... so many scams. I wanted to let you know how appreciative I am of your eBook on muscle strains. When I got to the stop sign, I had to reflect and realized that the style and quality of what you had written was worth a gamble. Well, paying the twenty bucks and learning what I wanted to learn — and more — was worth every penny. I am now rehabbing my level 1 calf strain with full confidence and feel very well informed moving ahead. Good luck and keep writing — we need all the help we can get out here!

— Craig Adkins, tennis player and professional skiing cameraman, Portland, Oregon


Enjoyed your web site and found the advice extremely helpful having just strained my thigh muscle.

— Paul Farley, West Sussex, England


My strained thigh muscle felt like a broken bone at first, but I'm using your icing method and it’s responding brilliantly.

— Paul Farley, West Sussex, England


I found this article when I was researching how to heal my pulled muscle. I love the mobilization exercises at the end — great for a ‘desk jockey’ like me!

— Juanita Vannay


I read your article on muscle strains, and I was very impressed. You seem to really know your stuff. I wish there was one of you in every state!

— Robin



One more special comment. In the Spring of 2009, I received an incredible endorsement from Jonathon Tomlinson, a GP in Hackney, East London, praising the whole website and every tutorial:

I'm writing to congratulate and thank you for your impressive ongoing review of musculoskeletal research. I teach a course, Medicine in Society, at St. Leonards Hospital in Hoxton. I originally stumbled across your website whilst looking for information about pain for my medical students, and have recommended your tutorials to them. Your work deserves special mention for its transparency, evidence base, clear presentation, educational content, regular documented updates, and lack of any commercial promotional material.

— Dr. Jonathon Tomlinson, MBBS, DRCOG, MRCGP, MA, The Lawson Practice, London

High praise indeed! Thank you, Dr. Tomlinson — testimonials just don’t get much better than that.


Further Reading

Here are several additional articles of interest:

And here are the articles recommended for those of you who may have muscle knots, as opposed to a muscle strain:

What’s new in this tutorial?

A major feature of my tutorials is that I actively update them as new science and information becomes available. Unlike regular books, and even ebooks — which can be obsolete by the time they are published, and can go years between editions — this tutorial is updated at least once every three months and often much more. I also log updates, making it easy for readers to see what’s changed. This tutorial has gotten 16 major and minor updates worth logging since I started logging carefully in late 2009, and countless more minor tweaks and touch-ups.

Science update (Apr 16 '14, section #4.9)More perspective and detailed information on stretching for recovery. See section #4.9, What about stretching? Can it treat or prevent strains?

Science update (Dec 24 '13, section #4.9)A (slightly) good news science update about the effect of stretching on recovery. See section #4.9, What about stretching? Can it treat or prevent strains?

Minor update (Oct 23 '13, section #2.4)Added a couple paragraphs about exactly where in a muscle strains tend to occur, and why. See section #2.4, Location, location, location.

Major update (Jul 3 '13, section #3.4)Much more detailed and evidence-based tips for estimating recovery time. See section #3.4, Good tricks for knowing when it’s safe to use a torn muscle again.

Minor update (Mar 29 '13, section #4.1)Upgraded risk and safety information about Voltaren Gel. See section #4.1, You and “vitamin I”: anti-inflammatory meds, especially Voltaren® Gel.

New section (Mar 30 '12, section #4.17)No notes. Just a new section. See section #4.17, Prevention: will water and electrolytes make a difference?

Update (Nov 2 '11, section #4.9)Rewritten and expanded with important evidence about how stretching does not prevent strain injuries. See section #4.9, What about stretching? Can it treat or prevent strains?

Minor update (Jul 14 '11, section #2.2)Added a (very) funny clip from the TV show Glee. See section #2.2, True muscle strain checklist.

Major update (Jun 21 '11)Major improvements to the table of contents, and the display of information about updates like this one. Sections now have numbers for easier reference and bookmarking. The structure of the document has really been cleaned up in general, making it significantly easier for me to update the tutorial — which will translate into more good content for readers. Care for more detail? Really? Here’s the full announcement.

New artwork (Jun 8 '11, section #3.3)Added a nice new diagram of strain severity. See section #3.3, What’s the worst case scenario for your muscle strain?

New section (Mar 12 '11, section #2.1)No notes. Just a new section. See section #2.1, Cramp versus strain example: Multi-muscle cramping catastrophe on a hot summer night.

New section (Jan 18 '11, section #3.4)Some useful new information about how to estimate healing time more accurately. See section #3.4, Good tricks for knowing when it’s safe to use a torn muscle again.

New section (Oct 5 '10, section #4.13)Another new section and yet more good new evidence about prevention. See section #4.13, Prevention: Warmups work.

New section (Sep 15 '10, section #4.16)New section based on solid new evidence about prevention. See section #4.16, Prevention: can you prevent muscle strains by upgrading your muscle balance?

New cover (Aug 6 '10)At last! This e-book finally has a “cover.” SHOW

New section (Apr 9 '10, section #4.18)No notes. Just a new section. See section #4.18, Is there anything to the platelet-rich plasma injection hype?

Older updatesListed in a separate document, for anyone who cares to take a look.

Notes

  1. Bret “The Glute Guy” Contreras tells his story, and some other tales of extreme recovery, and extracts some lessons from them. See You’ll Never Squat Again. BACK TO TEXT
  2. Simons. Foreword of The Trigger Point Therapy Workbook. “Muscle is an orphan organ. No medical speciality claims it. As a consequence, no medical specialty is concerned with promoting funded research into the muscular causes of pain.” BACK TO TEXT
  3. You can get a rough measure of how well-studied a subject is by doing a search for it on PubMed, a large database of citations to medical research. Searching for muscle strain is a bit tricky, because “muscle strain” is mentioned in lots of papers that aren’t really about muscle strain. But if you cleverly search for the terms “muscle strain” only in titles, you will get, as of 4/14/07, only 61 search results, even less than iliotibial band syndrome (another under-studied condition). Compare that to, say, 3000 for adhesive capsulitis (frozen shoulder), or 5900 for carpal tunnel syndrome. BACK TO TEXT
  4. Doctors lack the skills and knowledge needed to care for most common aches, pains, and injury problems, especially the chronic cases, and even the best are poor substitutes for physical therapists. This has been proven in a number of studies, like Stockard et al, who found that 82% of medical graduates “failed to demonstrate basic competency in musculoskeletal medicine.” It’s just not their thing, and people with joint or meaty body pain should take their family doctor’s advice with a grain of salt. See The Medical Blind Spot for Aches and Pains. BACK TO TEXT
  5. Strain and sprain are confusingly similar words for quite different things. They both refer to tearing, but of different tissues. A torn ligament is always called a sprain. A torn muscle is always called a strain. BACK TO TEXT
  6. Was it really the electrolytes? No. That’s what I thought at the time, but a nice myth-busting 2011 experiment comparing crampy runners with their uncramped comrades showed clearly that dehydration was not the culprit. Fun science. See Schwellnus et al. BACK TO TEXT

There are 34 more footnotes in the full version of this book. I like footnotes, and I try to have fun with them.


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