Calf Strain

Definition/Description

Mechanical back strain is a subtype of back pain in which the cause is a spinal disc or the surrounding soft tissues. [1] Lumbar spine strain accounts for 70% of mechanical low back pain. [2]

This article will focus on muscular low back sprains, i.e. overstretching injuries or tears of the paraspinal muscles and tendons in the lower back (much of what is known about lumbar strain is inferred from peripheral muscle strains). [3][4][5]

• In a strain, the muscle is overstretched, causing excessive strain on the muscle fibers, causing them to rupture near the tendon junction. [5]
• Acute mechanical back strain can be triggered by physical or non-physical activities, with weightlifting being the most commonly recalled event. However, one third of patients may not necessarily remember the stimulating event [1].

Clinically Relevant Anatomy

The lumbar spine is composed of: 5 strong vertebrae; multiple bony elements connected by joint capsules; flexible ligaments/tendons; large muscles; highly sensitive nerves. It has a very strong design to protect the highly sensitive spinal cord and spinal nerve roots. At the same time, it is highly flexible, providing flexibility in many different planes, including flexion, extension, lateral bending, and rotation [6][7]

Lumbar strain can originate in the following muscles [8][9][10]: erector spinae (M. iliocostales M longissimus M. spinalis) M semispinales Mm multifidi Mm rotatores M. quadratus lumborum M. serratus posterior.

Etiology

A strain is defined as a tear (partial or total) of the musculotendinous unit.

• Muscle strains and tears are most commonly caused by severe muscle contraction during excessive muscle stretching during heavy lifting or sudden twisting motions [11].
• Any posterior spinal muscles and their associated tendons may be affected, although the most susceptible muscles are those that span multiple joints.
• Acute and Chronic Lumbar Spinal Injury Pain Manifestations: Acute pain is most intense 24 to 48 hours after injury. Chronic strains are characterized by constant pain from muscle damage. [12]

Epidemiology

More than 80% of people will suffer from low back pain in their lifetime. The global prevalence of low back pain ranges from 12% to 33%. The prevalence is higher in women and people aged 40 to 80. [1] Exact figures on the international frequency of low back injuries are not yet available A known.

• In the United States, 7-13% of sports injuries in intercollegiate athletes are low back injuries. The most common back injuries were muscle strains (60%) and disc injuries (7%). [13]
• In France, more than 50% of French people aged 30-64 experienced low back pain on at least 1 day in the past 12 months. 17% experienced LBP for more than 30 days in the same 12-month period. [14]
• In a study in Africa, the mean prevalence of LBP points in adults was 32%, the mean 1-year prevalence was 50%, and the mean lifetime prevalence was 62% [15]

Characteristics/Clinical Presentation

Acute mechanical back strain can be triggered by physical or non-physical activities, with weightlifting being the most commonly recalled event. However, one third of patients may not necessarily remember the irritant event. [1]

• Clinical manifestations include lumbar muscle pain or nonspecific pain. [3]
• Pain may be exacerbated by standing and twisting movements and is exacerbated by active contraction and passive stretching of the affected muscles. [10]
• Other symptoms include point tenderness, muscle spasms, possible swelling in and around affected muscle tissue, and possible sideways deviation of the spine with severe spasms and reduced range of motion. [16]

Differential Diagnosis[2]

• Spondylosis
• Disc herniation
• Compression fracture
• Spinal stenosis
•  Spondylolisthesis 
• Ankylosing spondylitis 

Diagnostic Procedures

In the absence of red flags, laboratory or radiological studies are not required to diagnose or manage mechanical back strain in the acute setting.

• Inflammation biomarkers, such as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), can be used to risk stratify patients with risk factors for infectious spinal pathology or malignancy but without neurological deficits on examination.
• Routine imaging is not recommended for mechanical back strain because many individuals may experience incidental abnormal findings that are not related to pain.
• More advanced imaging studies are needed when conservatively managed trauma fails with worsening symptoms and new neurologic deficits. Plain x-rays and computed tomography are useful when a fracture is suspected.

Examination

Lumbar Assessment see link.

Medical Intervention

The management of mechanical back strain depends on the chronicity of symptoms, the patient’s comorbidities, and the specific etiology. The American College of Physicians published an updated guideline in 2017 with recommendations for non-invasive options for treating low back pain.

First-line nonpharmacologic therapy:

• For acute low back pain, it includes massage, acupuncture, massage and superficial hot compress, while the first-line drug treatment for acute low back pain is non-steroidal anti-inflammatory drugs and muscle relaxants. According to the clinical policy of the American College of Emergency Medicine Physicians should not use opioids as a routine medication, but reserve them for patients whose pain is severe or unmanageable with other medications.
• For chronic low back pain, non-drug therapies are recommended as first-line medications, including exercise, tai chi, yoga, multidisciplinary rehabilitation, spinal manipulation, acupuncture, psychotherapy, low-level laser therapy, and EMG biofeedback. NSAIDs Again it is the recommended first-line drug, followed by tramadol and duloxetine as second-line therapy. Recommendations for opioid therapy are only recommended in the event of failure of the aforementioned treatments and are based on an individualized decision to determine whether the benefits outweigh the risk. [1]

Physical Therapy Management

Education: interventions that may help prevent injury

• Proper rest and ergonomically modified stretches in the workplace. Ergonomic modifications refer to adjustments made in the work environment to reduce physical stress on employees.
• Educating patients on the importance of proper posture and proper weight lifting technique may aid in prevention. regular physical activity
• Smoking cessation
• Weight loss for obese patients
• Return to normal physical activity (recent studies have found that continuing with daily activities, as pain permits, leads to faster recovery than bed rest). [17]

Techniques

Cold Therapy: During the acute phase of lumbar strain, cold therapy should be applied to the affected area (for a short period up to 48 hours) to limit local tissue inflammation and edema. [18] [19]

TENS and ultrasound: TENS and ultrasound are often used to help manage pain and reduce muscle spasms [20][21]

Stretching: Gentle stretching along with limited movement. The following stretching exercises

• Single and double knees to chest Lie on your back with your knees bent and your heels on the floor. Bring your knees or knees as close to your chest as possible and hold this position for 10 seconds. Repeat this action 3 to 5 times.
• Back Stretch Lie on your back with your hands overhead. Bend your knees, place your feet on the floor, and slowly roll your knees to one side. Hold on one side for 10 seconds and repeat 3 to 5 times.
• Press Up First lay flat on the ground (face down). When performing this exercise, it’s important to keep your hips and legs relaxed and in contact with the floor. Keep your hands in line with your shoulders. Inhale and exhale and press up with your hands, keeping your lower body relaxed. Hold until you need to inhale then move down to rest flat on the floor and repeat ten times.
• Kneeling lunge(stretching iliopsoas)
• Stretching piriformis
• Stretching quadratus lumborum[22]

Soft Tissue Manipulation: Soft tissue manipulation was found to reduce pain and improve ROM. [twenty three]

• Massage
• Strengthening exercises: Once the pain and spasms are under control, strengthening exercises should begin. The muscles that need the most emphasis are the abs, especially the obliques, trunk extensors, and glutes. put all the focus on recovery Especially not good for injured muscles. Training core stability is an important part of treating lumbar strain and further preventing low back pain. [18]

As with all spinal injuries, posture and body mechanics should be assessed and corrected as needed.