Raiyyan Tahsan

Raiyyan Tahsan
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TC(1001).(05).Orthopedics Case No 79:- Muscle Strain

Muscle Strain — বাংলা Clinical Note

1) Definition

Muscle strain হলো skeletal muscle বা muscle–tendon unit অতিরিক্ত stretch/overload হওয়ার কারণে micro-tear, partial tear অথবা complete tear হওয়া। সাধারণত sudden forceful movement, heavy lifting, running/sports বা repetitive overuse-এ হয়। Soft-tissue injury-এর diagnosis বেশিরভাগ সময় history + physical examination দিয়েই করা যায়; fracture সন্দেহ হলে X-ray এবং tear extent জানতে MRI/USG লাগে।

2) Causes / Risk Factors — কারণগুলো

  • Sudden overstretching: দৌড়ানো, jump, sudden turn, slip/fall।
  • Heavy lifting / wrong posture: gym, কাজের সময় ভারী জিনিস তোলা।
  • Poor warm-up: exercise বা খেলার আগে warm-up না করলে muscle stiff থাকে।
  • Muscle fatigue: দীর্ঘক্ষণ কাজ/খেলা করলে muscle control কমে যায়।
  • Poor flexibility: tight hamstring/calf/back muscle।
  • Previous strain: আগের injury থাকলে re-injury risk বেশি।
  • Overuse: repetitive movement—computer posture, sports training, labour work।
  • Dehydration/electrolyte imbalance: cramp/spasm বাড়াতে পারে।
  • Direct trauma: muscle contusion বা blunt injury থেকেও strain-like pain হতে পারে।

3) Symptoms — লক্ষণগুলো

  • Pain: sudden sharp pain অথবা gradual aching pain; movement করলে বাড়ে।
  • Tenderness: নির্দিষ্ট muscle belly বা musculotendinous junction-এ চাপ দিলে ব্যথা।
  • Swelling: local edema, কখনও tight feeling।
  • Bruising/ecchymosis: grade II/III tear বা hematoma হলে দেখা যায়।
  • Muscle spasm: painful involuntary contraction।
  • Weakness: affected muscle দিয়ে force দিতে কষ্ট।
  • Restricted range of motion: হাত/পা/ঘাড়/পিঠ normal ভাবে নাড়াতে সমস্যা।
  • Pain on resisted contraction: muscle contract করালে ব্যথা বেশি—clinical clue।
  • Palpable gap/deformity: complete rupture হলে muscle gap বা lump পাওয়া যেতে পারে।
  • Popping sensation: severe partial/complete tear-এ history থাকতে পারে।

4) Clinical Grading

  • Grade I: mild overstretch/micro-tear; pain আছে, strength প্রায় normal।
  • Grade II: partial tear; swelling/bruising, weakness, painful ROM।
  • Grade III: complete rupture; severe pain initially, marked weakness, palpable gap, function loss—urgent ortho/sports medicine review দরকার। Cleveland Clinic soft-tissue injury grading-এ first-degree pull, second-degree partial tear, third-degree complete tear হিসেবে বর্ণনা করেছে।

5) Clinical Diagnosis — কীভাবে diagnosis করবেন

  • History: injury mechanism, onset, pop sound, immediate disability, previous injury, anticoagulant use।
  • Inspection: swelling, bruising, deformity, posture/gait abnormality।
  • Palpation: localized tenderness, warmth, hematoma, muscle gap।
  • ROM test: active ROM painful; passive stretch করলে pain বাড়তে পারে।
  • Strength test: resisted contraction করলে pain/weakness।
  • Neurovascular exam: numbness, distal pulse, capillary refill—especially limb injury।
  • Red flags: severe swelling, compartment-like pain, neuro deficit, inability to bear weight, fever, unexplained weight loss, severe back pain with bladder/bowel issue।

6) Investigations — Specific

  • No investigation: mild Grade I strain হলে usually দরকার নেই।
  • X-ray: fracture/avulsion সন্দেহ, bony tenderness, fall/trauma, weight-bearing impossible হলে। Mayo Clinic-ও sprain/strain evaluation-এ X-ray fracture exclude করতে পারে বলেছে।
  • Ultrasound MSK: hematoma, partial/complete tear, dynamic assessment, follow-up; cost-effective।
  • MRI: severe Grade II/III, elite athlete, deep muscle injury, diagnosis unclear, surgery planning, persistent pain >2–3 weeks, return-to-sport decision। Sports medicine review অনুযায়ী MRI ও ultrasound muscle injury assessment-এর প্রধান imaging modality।
  • CBC/ESR/CRP: fever, infection, inflammatory myositis সন্দেহ হলে।
  • CK/renal function/urine myoglobin: severe crush injury, rhabdomyolysis suspicion, dark urine, diffuse severe muscle pain।

7) Differential Diagnosis

  • Ligament sprain
  • Tendon rupture/tendinitis
  • Fracture/avulsion fracture
  • Muscle contusion/hematoma
  • DVT—calf swelling/pain হলে
  • Compartment syndrome
  • Radiculopathy/sciatica
  • Myositis/infection
  • Rhabdomyolysis

8) Complications — সহজ ভাষায়

  • Chronic pain: ঠিকমতো rest/rehab না করলে pain দীর্ঘস্থায়ী হতে পারে।
  • Recurrent strain: আগের injury পুরোপুরি heal না হলে একই muscle আবার ছিঁড়তে পারে।
  • Hematoma: muscle-এর ভিতরে blood collection হয়ে swelling/pain বাড়ায়।
  • Fibrosis/scar tissue: healing-এর সময় excessive scar হলে flexibility কমে যায়।
  • Weakness & loss of performance: strength ফিরে না এলে sports/work performance কমে।
  • Myositis ossificans: severe contusion/hematoma-এর পরে muscle-এর মধ্যে bone-like calcification হতে পারে।
  • Compartment syndrome: rare but emergency—severe pain, tight swelling, numbness, weak pulse।
  • Rhabdomyolysis: severe muscle breakdown হলে dark urine, renal injury হতে পারে।

9) Treatment / Management

A) Non-pharmacological management

  • First 24–72 hours: PRICE/PEACE principle
    • Protection: injured muscle protect করুন।
    • Rest/relative rest: complete bed rest নয়; painful activity বন্ধ।
    • Ice: 15–20 মিনিট করে দিনে 3–5 বার, direct skin-এ নয়।
    • Compression: elastic bandage; too tight নয়।
    • Elevation: limb injury হলে heart level-এর উপরে।
      AAOS soft-tissue injury treatment-এ RICE এবং physical therapy উল্লেখ করেছে; muscle injury review-এ initial phase-এ protection, rest, optimal use এবং cryotherapy বলা হয়েছে।
  • 48–72 hours পরে: pain কমলে gentle ROM → stretching → isometric strengthening → progressive loading।
  • Avoid: প্রথম 48 ঘণ্টা heat massage, deep tissue massage, alcohol, heavy exercise।
  • Physiotherapy: Grade II/III বা recurrent strain হলে structured rehab দরকার।
  • Urgent referral: complete tear, palpable gap, severe weakness, neurovascular deficit, compartment syndrome suspicion।

10) Pharmacological Drugs — Bangladesh-oriented list

Important: NSAID একসাথে ২টা দেওয়া যাবে না। Adult dose নিচে দেওয়া হলো; renal disease, PUD/GI bleed, anticoagulant use, uncontrolled HTN, IHD/stroke risk, asthma-sensitive NSAID, pregnancy—এসব থাকলে NSAID avoid/adjust করুন। NICE/BNF NSAID summary soft-tissue disorders-এ NSAID benefit থাকতে পারে বলে, তবে lowest effective dose এবং risk assessment জরুরি।

1) Paracetamol

  • Generic name: Paracetamol
  • Therapeutic category: Analgesic, antipyretic
  • Pharmacological class: Non-opioid analgesic
  • Adult dose: 500 mg–1 g PO every 6–8 hours PRN; max 4 g/day। Liver disease/alcohol use হলে max কম।
  • Duration: 2–5 days PRN
  • কেন used হয়: mild pain, NSAID contraindicated patient, fever/body ache থাকলে।
  • Side effects: nausea, rash; overdose → hepatotoxicity।
  • Interactions: alcohol, warfarin prolonged high dose, enzyme inducer drugs।
  • Bangladesh available brand examples: Ace 500 mg, Napa 500 mg, Renova 500 mg, Fast XR 665 mg, Feva 500 mg, Fevac 500 mg, Enyl 500 mg। MedEx paracetamol listing-এ Ace 500 mg, Fast XR 665 mg, Feva/Fevac/Enyl 500 mg সহ বহু brand দেখা যায়।

2) Ibuprofen

  • Generic name: Ibuprofen
  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: NSAID; propionic acid derivative
  • Adult dose: 400 mg PO 8 hourly after food
  • Duration: 3–5 days; lowest effective dose
  • কেন used হয়: pain + inflammation + swelling থাকলে।
  • Side effects: dyspepsia, gastritis, GI bleed, renal impairment, fluid retention, BP rise, bronchospasm in NSAID-sensitive asthma।
  • Interactions: anticoagulants/antiplatelets, steroids, ACEi/ARB + diuretics, lithium, methotrexate, other NSAIDs।
  • Bangladesh available brand examples: Profen 400 mg, G-Ibuprofen 400 mg, Neurofen 400 mg, Rapofen 400 mg। MedEx ibuprofen listing muscle pain/backache/rheumatic pain indications এবং Profen/Neurofen/Rapofen 400 mg brands দেখায়।

3) Naproxen / Naproxen Sodium

  • Generic name: Naproxen Sodium
  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: NSAID; propionic acid derivative
  • Adult dose: 250–500 mg PO 12 hourly after food
  • Duration: 3–5 days; severe pain হলে short course
  • কেন used হয়: longer pain control; back strain, calf/hamstring strain, soft-tissue inflammation।
  • Side effects: dyspepsia, GI ulcer/bleed, renal impairment, edema, BP rise।
  • Interactions: warfarin/DOAC, aspirin, clopidogrel, steroids, ACEi/ARB, diuretics, lithium, methotrexate।
  • Bangladesh available brand examples: Naprosyn 250/500 mg, Naprox 250/500 mg, Napryn 250/500 mg, Naxin 250/500 mg, Naspro 250/500 mg, Nuprafen 250/500 mg। MedEx naproxen sodium listing-এ Naprosyn 500 mg, Naprox 500 mg, Napryn 500 mg, Naxin 500 mg সহ বহু brand আছে।

4) Diclofenac

  • Generic name: Diclofenac Sodium / Diclofenac Potassium
  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: NSAID; phenylacetic acid derivative
  • Adult dose:
    • Diclofenac sodium 50 mg PO 8–12 hourly after food; max 150 mg/day
    • Diclofenac SR 100 mg once daily, selected cases
    • Diclofenac gel 1%: affected area-এ 2–4 g, দিনে 3–4 বার
  • Duration: oral 3–5 days; gel 5–7 days PRN
  • কেন used হয়: localized inflammatory pain, muscle strain with swelling, topical option when systemic NSAID avoid করতে চান।
  • Side effects: GI irritation/bleed, renal injury, edema, BP rise, higher CV risk with systemic use, local rash with gel।
  • Interactions: anticoagulant, antiplatelet, steroid, ACEi/ARB, diuretic, lithium, methotrexate, other NSAIDs।
  • Bangladesh available brand examples: Diclofen 50 mg/1% gel, DicloGel 1% gel, Diclomol gel, Diloren 50 mg/1% gel, G-Diclofenac 50 mg, A-Fenac K 50 mg। MedEx diclofenac sodium listing-এ 50 mg tablet, 100 mg SR, 75 mg/3 ml injection ও 1% gel brands; diclofenac gel dosing 2–4 g দিনে 3–4 বার উল্লেখ আছে।

5) Aceclofenac

  • Generic name: Aceclofenac
  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: NSAID; phenylacetic acid derivative
  • Adult dose: 100 mg PO 12 hourly after food
  • Duration: 3–5 days
  • কেন used হয়: musculoskeletal pain, trauma/lumbago-related pain; অনেক BD doctor acute MSK pain-এ দেন।
  • Side effects: dyspepsia, GI bleed, renal impairment, dizziness, edema, BP rise।
  • Interactions: same NSAID interactions—warfarin/DOAC, antiplatelet, steroid, ACEi/ARB, diuretics, lithium, methotrexate।
  • Bangladesh available brand examples: Flexi 100 mg, Flexi SR 200 mg, Movex 100 mg, Movex SR 200 mg, Noak 100 mg, Preservin 100 mg, Painex 100 mg। MedEx aceclofenac listing pain/inflammation, trauma and lumbago indication সহ এসব brands দেখায়।

6) Etoricoxib

  • Generic name: Etoricoxib
  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: Selective COX-2 inhibitor NSAID
  • Adult dose: 60–90 mg PO once daily after food; acute severe painে 120 mg OD very short course only
  • Duration: 3–5 days; CV risk থাকলে avoid/সতর্ক
  • কেন used হয়: NSAID দরকার কিন্তু GI irritation তুলনামূলক কমাতে COX-2 option; inflammatory musculoskeletal pain।
  • Side effects: edema, hypertension, renal impairment, dyspepsia; CV thrombotic risk।
  • Interactions: warfarin, antiplatelets, ACEi/ARB, diuretics, lithium, methotrexate, other NSAIDs।
  • Bangladesh available brand examples: Etorix 60/90/120 mg, Etoshine 60/90/120 mg, Oricox 30/60/90/120 mg, Recox 60/90 mg, Powercox 90 mg। MedEx etoricoxib listing-এ 60, 90, 120 mg strengths এবং Etorix/Etoshine/Oricox/Recox brands আছে।

7) Tolperisone

  • Generic name: Tolperisone Hydrochloride
  • Therapeutic category: Skeletal muscle relaxant
  • Pharmacological class: Centrally acting muscle relaxant
  • Adult dose: 50–100 mg PO 2–3 times daily after food
  • Duration: 3–7 days; sedation/weakness monitor
  • কেন used হয়: painful muscle spasm, tightness, acute back/neck strain-এ spasm কমাতে।
  • Side effects: dizziness, weakness, hypotension, nausea, rash, somnolence।
  • Interactions: alcohol/CNS depressants sedation বাড়াতে পারে; other muscle relaxants।
  • Bangladesh available brand examples: Myolax 50/100 mg, Myoson 50/100 mg, A-Calm 50 mg, Musclex 50 mg, Tolson 50/100 mg, Tolus 50 mg। MedEx tolperisone listing-এ muscle spasm/rigidity indication এবং A-Calm, Musclex, Myolax, Myoson, Tolson brands দেখা যায়।

8) Tizanidine

  • Generic name: Tizanidine Hydrochloride
  • Therapeutic category: Skeletal muscle relaxant
  • Pharmacological class: α2-adrenergic agonist, centrally acting muscle relaxant
  • Adult dose: 2 mg PO at night or 2 mg 2–3 times daily; severe spasmে 2–4 mg TID
  • Duration: 3–7 days; avoid driving/sedative use
  • কেন used হয়: painful muscle spasm, acute neck/back spasm, severe tightness।
  • Side effects: drowsiness, dizziness, dry mouth, hypotension, bradycardia, liver enzyme elevation।
  • Interactions: ciprofloxacin/fluvoxamine contraindicated; alcohol, benzodiazepine, antihypertensive drugs, CNS depressants।
  • Bangladesh available brand examples: Sirdalud 2 mg, Tizadin 2 mg, Tizalex 2 mg, Tizalud 2 mg, Tizan 2 mg, Tizanac 2 mg। MedEx tizanidine listing painful muscle spasm-এর dose 2–4 mg TID এবং এসব 2 mg brands দেখায়।

9) Eperisone

  • Generic name: Eperisone Hydrochloride
  • Therapeutic category: Skeletal muscle relaxant
  • Pharmacological class: Centrally acting muscle relaxant
  • Adult dose: 50 mg PO three times daily after food
  • Duration: 3–7 days
  • কেন used হয়: muscle spasm, stiffness, painful contraction কমাতে।
  • Side effects: dizziness, somnolence, nausea, abdominal pain, rash, diarrhea, headache, constipation।
  • Interactions: alcohol/CNS depressants sedation বাড়াতে পারে; other relaxants।
  • Bangladesh available brand examples: Myonil 50 mg, Eprel 50 mg, Ezymas 50 mg। MedEx eperisone listing-এ adult dose দিনে ৩টি tablet divided dose after meal এবং Myonil/Eprel/Ezymas 50 mg brands আছে।

10) Pantoprazole / Esomeprazole — NSAID gastroprotection

  • Generic name: Pantoprazole Sodium / Esomeprazole
  • Therapeutic category: Anti-ulcerant
  • Pharmacological class: Proton pump inhibitor
  • Adult dose: Pantoprazole 20–40 mg OD before breakfast; Esomeprazole 20 mg OD
  • Duration: NSAID course চলাকালীন; high GI risk হলে longer as clinically indicated
  • কেন used হয়: NSAID-induced dyspepsia/ulcer/GI bleed risk কমাতে, especially elderly, PUD history, steroid/anticoagulant use। PPI co-prescribing review NSAID-related upper-GI complication risk থাকলে standard-dose PPI recommend করেছে।
  • Side effects: headache, diarrhea/constipation, nausea; long-term useে hypomagnesemia, B12 deficiency, fracture/infection risk।
  • Interactions: clopidogrel—esomeprazole/omeprazole caution; warfarin monitoring; methotrexate high dose।
  • Bangladesh available brand examples: Pantoprazole—Pantonix 20/40 mg, Pantolok 20/40 mg, Pantogut 20/40 mg, Pantodac 20/40 mg, Pantogen 20/40 mg। MedEx pantoprazole listing-এ এসব 20/40 mg brands আছে।

Bangladesh doctors commonly prescribe — practical list

  • Mild strain: Paracetamol ± Diclofenac gel
  • Moderate pain + swelling: one NSAID only—Ibuprofen / Naproxen / Diclofenac / Aceclofenac / Etoricoxib
  • Painful spasm: Tolperisone / Tizanidine / Eperisone short course
  • NSAID GI-risk patient: NSAID + Pantoprazole/Esomeprazole, or avoid oral NSAID and use topical/local measures
  • Severe tear, palpable gap, major weakness: analgesia + immobilization + urgent ortho referral + USG/MRI

Cochrane review found acute soft-tissue injury pain reliefে NSAID এবং other analgesics-এর মধ্যে বড় পার্থক্য পরিষ্কার নয়; তাই drug selection patient risk, pain severity, inflammation এবং contraindication দেখে করা উচিত।

Prevention — কীভাবে প্রতিরোধ করবেন

  • Exercise/sports-এর আগে 5–10 মিনিট warm-up।
  • Regular stretching + strengthening, especially hamstring/calf/back/shoulder।
  • Sudden heavy lifting নয়; proper lifting technique।
  • Training load ধীরে বাড়াবেন—একবারে intensity বাড়াবেন না।
  • Hydration ও adequate sleep maintain।
  • Pain থাকলে “push through pain” করবেন না।
  • Previous injury থাকলে return-to-sport আগে full ROM + pain-free strength নিশ্চিত করুন।
  • Ergonomic posture—desk work, driving, mobile use-এ neck/back strain কমানো।

Overview / Summary

Muscle strain হলো muscle বা muscle–tendon unit-এর overstretch/tear। Mild case history ও physical exam দিয়েই diagnose করা যায়; severe pain, bruising, weakness, palpable gap বা fracture suspicion হলে X-ray/USG/MRI দরকার। Treatment-এর core হলো PRICE, early controlled mobilization, physiotherapy, pain control; drug হিসেবে paracetamol, topical/oral NSAID এবং selected muscle relaxant short course ব্যবহৃত হয়।

Actionable Plan / Steps

  1. Grade করুন: mild vs partial tear vs complete tear।
  2. First 48–72h: protection, relative rest, ice, compression, elevation।
  3. Pain control: paracetamol first; inflammation থাকলে one NSAID only, risk check করে।
  4. Spasm থাকলে: short-course muscle relaxant; sedation warning দিন।
  5. Red flag হলে: X-ray/USG/MRI + ortho/sports medicine referral।
  6. Rehab: pain-free ROM → stretching → strengthening → gradual return to activity।

Reference List

Textbook

  • Harrison’s Principles of Internal Medicine, 21st ed., Musculoskeletal pain/soft-tissue injury approach.
  • Davidson’s Principles and Practice of Medicine, 24th ed., Musculoskeletal symptoms and clinical assessment.
  • Bailey & Love’s Short Practice of Surgery, 28th ed., Trauma/soft tissue injury principles.
  • Katzung & Trevor’s Basic & Clinical Pharmacology, 16th ed., NSAIDs and centrally acting muscle relaxants.

Guideline / Clinical References

  • AAOS OrthoInfo: Sprains, Strains & Other Soft-Tissue Injuries—RICE and physical therapy.
  • Merck Manual Professional: Soft-tissue injury evaluation—history/physical exam, X-ray when fracture suspected.
  • NICE/BNF: NSAIDs treatment summary—soft-tissue disorders, analgesic/anti-inflammatory use and prescribing cautions.
  • MedEx Bangladesh medicine index and brand listings: paracetamol, NSAIDs, muscle relaxants, PPIs.

Peer-reviewed / DOI

  • Hotfiel T, et al. Nonoperative treatment of muscle injuries. Journal of Experimental Orthopaedics. 2018;5:24. DOI: 10.1186/s40634-018-0139-3.
  • SantAnna JPC, et al. Muscle Injury: Pathophysiology, Diagnosis, and Treatment. Rev Bras Ortop. 2022;57(1):1–13. DOI: 10.1055/s-0041-1731417.
  • Jones P, et al. Oral NSAIDs versus other oral analgesic agents for acute soft tissue injury. Cochrane Database Syst Rev. 2020. DOI: 10.1002/14651858.CD007789.pub3.
  • Mueller-Wohlfahrt H-W, et al. Terminology and classification of muscle injuries in sport: The Munich consensus statement. Br J Sports Med. 2013;47:342–350. DOI listed in PubMed record.

Md.Rafiqul Islam Lipu,Date:-14-06-2026 Sunday,Time:-12-19-12 Pm

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