The Five Phases of Rehabilitation for a Muscle Strain


A muscle strain is a very common injury that most active people will probably have at least once if not more in their lifetime. Many people seek out medical care for a muscle strain since they want to get back to doing the activities they love. So it seems intuitive then that rehabilitation of muscle strains is common knowledge and that everyone who suffers a muscle strain gets better, right?

Well, usually not.

You see while most physical therapists, sports chiropractors and sports medicine doctors know how to correctly manage a muscle strain, most patients do not.

The main goal of this article is to educate you. We aren’t going to reveal some magic routine that applies to each and every injury so that you can go do it all on your own. Rather, we want you to understand two important concepts:

Rather, we want you to understand two important concepts:

1. What a muscle strain is and why it needs to be rehabilitated correctly.
2. What the medical research and literature says about rehabilitating a muscle strain and why paying attention to important timelines is essential to fully recover and prevent re-injury.

In our practice, we have found that when patients really don’t understand what their injury is and what the overall goals of treatment are then they aren’t as invested in their own recovery.

That’s right, its up to YOU to take charge of your injury, know what you need to know about it, get on board with your treatment plan and most importantly, STAY on board. Doing all of these things is essential for your best outcome.

What is a Muscle Strain and Why Rehab it?

In this article, we will be talking about Grade I or mild Grade II muscle strains. These types of strains are very common in both professional and recreational athletes. They both heal very similarly and therefore, will generally follow the same phases of rehabilitation. A muscle strain is really a tear of the tissue at the junction of the muscle and the tendon (musculotendonous junction).

Grade I is mild; it may feel like a pull or a strain. It’s painful, but there is no outward sign of injury.

A Grade II strain is more severe. It may feel as if you’ve sustained a trauma to the area, and you may have a bruise. Most people are very scared by a Grade II tear, and some take a long time off to recover, or may not even go back to the activity again fearing another injury.

While taking time off is totally understandable, what if we told you too much time off could be harmful to your recovery? If rest is the ONLY thing you do after a muscle strain, then you could be setting yourself up for a more chronic injury!

Even for mild strains, the research indicates that proper rehabilitation is necessary. In 2006, a study illustrated this point. Researchers compared the strength of two sheep tendons: one healthy/uninjured and one unhealthy/injured. Twelve months after the initial injury, both tendons were tested with an applied force. The force was measured until the tendons ruptured. The previously injured tendon demonstrated only 60% of the strength of the healthy one (1).

While many people may think that rest, or even RICE (rest, ice, compression, elevation) is enough for them to heal, this study and others indicate it really isn’t. Rest is certainly very important in recovery from a muscle strain, but after a certain point in time, it can be counterproductive or even harmful! Even for a mild strain, proper rehabilitation that includes strengthening, stretching, and other modalities is essential to fully healing and preventing further or more chronic type of injuries.

Phase 1: The Vulnerability Period

The first five days after injury are what we consider to be included in this first phase. During this time, it is good to rest. After you sustain an injury, your body gets right to work at repairing the damaged tissue. In the case of a muscle strain, your body starts repairing that impaired tendon and muscle.

Early research on tendon injuries shows a very specific and important process takes place during this early phase. In 1941, work done by Mason and Allen demonstrated that an injured tendon starts to repair itself and heal by producing a gelatinous, spider web of connective tissue material (2). So during this time, it’s highly advisable for you to immobilize and start RICE or PRICE (protection, rest, ice, compression and elevation). Too much activity or even stretching at this point could damage this fragile, healing tissue and set you back in recovery.

Phase 2: The Mobilization Period

This period should start around day seven after your muscle strain. Most current research indicates that 7-21 days post injury is the optimal time to start moving and adding some selective stretching. The goal of this period is to mobilize both the joint as well as the new scar tissue that’s forming. This will decrease the risk of joint adhesions and manipulate the scar tissue into something beneficial to you in the long run.

The three components of this phase are:

• Active stretching or reciprocal inhibition stretching
• Light tissue work or manual therapy
• Passive modalities

The first component is to start active stretching. Please, do not start aggressive passive stretching. The healing fibers will be damaged by too much tension! Think gentle motion with active stretching. A good example of this type of stretch for a hamstring strain would be the following: while sitting in a chair, extend the leg by flexing the quadriceps muscle. This produces a very mild stretch in the hamstring muscle. You do not want anyone helping you or raising your lower leg for you. Pushing too hard at this point only increases the risk of greater injury.

Secondly, try adding some very light manual therapy. This is meant to help align the new scar tissue forming, making it into more of a functional scar. Think of this as a way of helping your body make a high quality scar that will go on to serve you well and lesson your future chance of re-injury. Another analogy for light massage is combing out dreadlocks. If your scar tissue is the dreadlock, it’s much easier to comb it out early rather than later when it’s fully formed! Deep tissue work only disrupts and separates these delicate, healing fibers so it’s best to avoid it for now.

Lastly, ultrasound, TENs or E stems, things that we refer to as passive modalities, can be incorporated at this time.

Remember, the goal of this period is to minimize the amount of scar tissue while maximizing its quality! You cannot stop the formation of scar tissue. It’s the body’s natural and preprogrammed way to heal itself. Several studies have demonstrated the importance of high quality scar tissue formation after an injury. One by Watkins in 1999 and another by Williams in 2001 both showed that scar tissue of inferior quality led to greater risk of future re-injury (3)(4).

If you are going to rehab a muscle strain, you need to do it correctly! Think of your strain as a road with a pothole. Would you want to fix it by just throwing some mixed up concrete into the hole leaving it to harden any which way, or by smoothing that concrete out so that it blends seamlessly with the existing road? Your scar tissue is no different when it comes to the future functioning of that muscle.

Phase 3: The Early Strength Period

This phase is the most important, but often mismanaged or least managed in our opinion. It’s critical that you start re-strengthening that injured muscle within a certain timeframe after injury. Most research suggests that period is somewhere between day 21 to week 6.

So 3-6 weeks may sound a bit too soon, huh? While it’s totally understandable for someone with a muscle strain to be apprehensive about re-injury, it is absolutely necessary to start training at this point. The longer those muscles stay weak and atrophied, the higher the risk of re-injury. Also think about this: the longer you wait, the more precious time you lose to rebuild your body in a way that helps you perform at or above the level you were pre-injury. Remember the sheep tendon study discussed above?

The goal of this phase is to slowly start to strengthen the injured muscles and tendons. Remember, your muscles will not get strong unless you make them. Strengthening exercises in this phase are based on the SAID principle: Specific Adaptive force to Implied Demand.

This is the same principle that bodybuilders use to get huge muscles. You have to find the balance between the amount of load to stress the muscle enough, but not too much that will cause injury. We want to force the body to adapt and change to stress in a way that’s productive and controlled. A good strength and conditioning coach or sports chiropractor can help do this for you.

The exercises involved in this phase will therefore be specific to the injury that’s being rehabilitated. Generally though, it’s best to start with eccentric exercises at this point. Eccentric contractions or lengthening contractions, also known as “the negatives” have been shown in studies to be more useful in muscle strains. A 2004 study found that for hamstring strains, eccentric strengthening significantly reduced the risk of further stains when compared to training with concentric exercise (5).

Another important point to make here is that patients tend to like these types of exercises better than concentric exercises for rehabilitating injuries. A 2005 study demonstrated that eccentric exercises used for rehabilitation of Jumper’s knee had a patient satisfaction rating of 90%, significantly higher than that of those treated with concentric moves (6). Why is this important? If you like something, you are more likely to stick with it. And at this point in your rehabilitation, hanging in there and making slow and steady forward progress is absolutely necessary to fully recover.

Phase 4: The Mid Strength Period

This phase of recovery in treating a low-grade muscle strain begins around week 6 to 10 after the initial injury. This phase is one that looks a little more like a normal strength and conditioning routine. In addition, a few specific, isolated “therapy” exercises should be incorporated that are tailored for your individual injury.

The two components of this phase are:

• Reintroduction of exercise using multiple types of contractions: concertric, eccentric and isometric.
• Introduction of more deep tissue mobilization to combat the formation of excessive scar tissue around the site of the injury.

When beginning to resume a more normal exercise routine, it’s perfectly natural and even expected that someone would have quite a bit of fear and hesitation. It is important to address this fear and go into this phase of your rehabilitation knowing right of the bat that at some point, you are going to have a flare up of your injury. As you begin to push yourself more, expect it. Do not expect your recovery to be easy or go smoothly. If you have the right expectation, and are with a good practitioner that understands this, you will be able to get through these setbacks and in the end, make more progress.
Because of this, the golden rule to follow when adding load to your muscle strain at this point is to start slow and build slow. Always test loads with the direct supervision of a qualified professional. Just like in the movies when someone encounters an old, rickety bridge in the middle of nowhere, they will slowly, carefully test it out rather than just running across full speed. Your damaged muscle is that rickety bridge, so tread lightly!

Another good rule of thumb to follow is to have impeccable form. Slow and controlled movements are key in preventing injury. It is often a quick motion that produces a muscle strain. The fewer of these, the less likely you are to have a flare up of your injury.

Lastly, deep tissue mobilization is conducive in preventing excessive, lower quality scar tissue. Remember, this continues from and builds upon our previously discussed goal of making that scar tissue the most functional and least prone to further injury or re-injury. Several studies have looked at this principle and here is a brief, verbatim summary of a few of them:

“The scar tissue that is induced (7) is of inferior quality compared to the original tissue due to alterations in the biochemical composition and structural organization, compromising the functional restoration of the pre-injured structure (3). This leads to high re-injury rates when athletic activity is resumed (4).”

Phase 5: The Late Strength Period

This period begins about 10 weeks to a year post injury. It’s during this phase that you will be well on your way to building a strength and conditioning program that looks pretty normal.

During this phase, you want to continue building on phase 4 with the same types of exercise, but slowly and steadily increase the load you place on the injured muscle and work on increasing your speed, depending on your particular injury. This phase focuses on re-educating your body on the movements involved with your particular sport while gradually increasing load and speed. For example, you may see someone at the gym rehabbing in this phase taking a few more breaks, but still using good form with less weight. They may be jogging, rowing or even doing cone drills. The point is this phase gets you back to a more normal training routine.

At this point, it’s also a good idea to incorporate more deep tissue work such as Graston technique, Active Tissue Release and foam rolling. All of these will help keep these healing tissues healthy minimizing the number of flare-ups that will inevitably happen when you really start increasing loads.

Fear and hesitation are still really high for most people during this phase, and again it’s totally understandable! Working with someone who really understands this and can develop a program that motivates and moves you along is so important. But on this flip side of this, YOU have to be on board with the plan and understand WHY you need to do what is asked of you in your rehabilitation program.

Our experience has been that about 50% of most injured “weekend warriors” drop out of rehab simply because they don’t take the time to either understand their injury or educate themselves on the principles of proper rehabilitation of a muscle strain. A study done in 2009 showed that education combined with exercise significantly decreased future disability in patients who’d undergone a single-level lumbar microdiskectomy as opposed to patients who had just exercised (8). So two groups of patients did exactly the same rehab post operatively, but one group had a deeper understanding of what they were doing and why. This was the key to a better outcome and successful return to activity for these people. The bottom line is you’ve got to make the investment in educating yourself if you want to get the most out of rehabilitation of your muscle strain!

Education is the key to your empowerment. You’ve got to be “all in” on your treatment plan if your going to get back to doing the activities you love. It really is a simple concept, but it takes a lot of work!

Pitfalls in Rehabilitation of a Muscle Strain

If you’ve suffered a Grade I or mild Grade II muscle strain and you don’t feel like you are anywhere near the timetables presented in this article, let’s talk about a few areas that may have you stuck in the process that you need to give some real consideration to.

1. Do you have the right diagnosis?

Sounds easy, but sometimes it isn’t. If you’re trying to rehab a muscle strain and you have a ligament or cartilage injury instead, that could be a big reason you’re not seeing improvement. Maybe you have the wrong plan of attack? These injuries can all act very differently. As a rule, a soft tissue injury should show a linear progression of improvement. So if this isn’t the case for you, you may want to consider some imaging, either an MRI or a Musculoskeletal Ultrasound to help pinpoint exactly what’s going on before you continue.

2. Did you take excessive rest after your muscle strain?

This is a big one for most people. Remember, there is so much critical healing and scar tissue formation that you need to be on top of in those first six months. It is really a very tight timeline for healing. So if you’ve been resting for 3 months, you may have really missed an important window of time in your healing. Not to say that you can’t recover, but you’re recovery will look very different from someone who only rested for the first 5-7 days post injury.

3. Have you been getting good, quality care for your muscle strain?

I know. You think that sounds terrible. But consider this: there are bad sports medicine chiropractors and physical therapist the same as there are bad contractors, teachers, dentists, doctors, etc, etc. The list could go on and on. The point is if you are not with someone who is extremely knowledgeable on the condition you have, you may not be getting the care you need to get better. And you may never consider this as the reason you’re not getting better until you’re not getting better! We encourage patients to seek a second or even third opinion on their injuries if they’d like. There’s nothing wrong with that! Often, an MRI or Musculoskeletal ultrasound is sufficient for us to confirm the diagnosis of a muscle strain.

YOU are the Key to Successful Rehabilitation of your Muscle Strain

If nothing else, it is our hope that this article has persuaded you to take charge of your injury. It’s perfectly natural to be worried and apprehensive about your recovery, but don’t let that fear lead you to inaction. A low-grade muscle strain is a common and very manageable injury that you can and will recover from, but you must understand the natural (and optimal) healing course for this injury, and if you’ve made it to this point in the article, you most certainly have this knowledge!

Furthermore, you need to both understand the rationale for therapy and embrace the inevitable ups and downs that will be part of your recovery. Develop a trusting and communicative relationship with someone who treats your type of injury on a daily basis. Ask questions, get involved. Don’t be a passive observer of your own recovery, but rather take the wheel and drive through each phase, confident in what you are doing to get better and why.