Raiyyan Tahsan

Raiyyan Tahsan
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TC(1052).(05).Orthopedics Case No 130:- Muscle Strain / পেশীর টান বা মাংসপেশী ছিঁড়ে যাওয়া

Muscle Strain / পেশীর টান বা মাংসপেশী ছিঁড়ে যাওয়া

Muscle strain হলো skeletal muscle বা muscle–tendon unit অতিরিক্ত stretch, sudden pull, overload বা direct trauma-র কারণে আংশিক বা সম্পূর্ণ fiber tear হওয়া। এটাকে সাধারণ ভাষায় pulled muscle বলা হয়। Severity অনুযায়ী Grade I = mild fiber injury, Grade II = partial tear, Grade III = complete rupture। Cleveland Clinic ও AAOS muscle strain-কে muscle fiber tear হিসেবে বর্ণনা করেছে এবং clinical assessment-এ tenderness, bruising, resisted movement pain, weakness ইত্যাদির ওপর জোর দিয়েছে।

Clinical note: নিচের চিকিৎসা adult uncomplicated muscle strain ধরে লেখা। Pregnancy, CKD, peptic ulcer, anticoagulant use, asthma with NSAID allergy, uncontrolled HTN/IHD, liver disease, elderly patient—এ NSAID/relaxant নিজে শুরু করা যাবে না।

1. Definition — সংজ্ঞা

  • Muscle strain = মাংসপেশী বা tendon attachment-এর microscopic tear থেকে complete rupture পর্যন্ত injury।
  • সাধারণত ঘটে যখন muscle তার capacity-র বেশি stretch/contract করে।
  • বেশি দেখা যায়: hamstring, calf, quadriceps, groin, back, shoulder, neck muscle।

2. Causes / Etiology — কারণগুলো

  • Sudden overstretching: হঠাৎ দৌড়, লাফ, পা পিছলে যাওয়া, heavy lifting।
  • Eccentric contraction injury: muscle lengthen অবস্থায় forcefully contract করলে—যেমন sprint-এ hamstring strain।
  • Poor warm-up: exercise/খেলার আগে warm-up না করলে muscle stiffness থাকে।
  • Muscle fatigue: দীর্ঘক্ষণ কাজ/খেলা করলে muscle control কমে strain হয়।
  • Overuse injury: একই muscle বারবার ব্যবহার—gym, running, manual labor।
  • Poor flexibility: tight hamstring/calf/hip flexor muscle।
  • Previous strain: আগের injury ঠিকমতো rehab না হলে recurrence বেশি।
  • Muscle imbalance: agonist–antagonist imbalance, যেমন quadriceps বেশি শক্তিশালী কিন্তু hamstring দুর্বল।
  • Dehydration/electrolyte imbalance: cramps ও muscle injury risk বাড়ে।
  • Direct blow/contusion: আঘাতের পর muscle fiber ও small vessel damage।
  • Inappropriate technique/equipment: ভুল lifting posture, wrong footwear, uneven ground।

3. Symptoms — লক্ষণগুলো

Grade I — Mild strain

  • হালকা localized pain।
  • movement করলে ব্যথা বাড়ে, rest-এ কমে।
  • mild tenderness।
  • swelling সাধারণত কম।
  • muscle strength প্রায় স্বাভাবিক।

Grade II — Moderate strain / partial tear

  • sudden sharp pain বা “pulling sensation”।
  • swelling ও bruising হতে পারে।
  • resisted contraction-এ pain বেশি।
  • muscle weakness থাকে।
  • range of motion কমে।
  • হাঁটা/কাজ/খেলা চালাতে অসুবিধা।

Grade III — Severe strain / complete rupture

  • তীব্র ব্যথা, অনেক সময় “pop” sensation।
  • marked swelling, hematoma, extensive bruising।
  • muscle gap/deformity palpate করা যেতে পারে।
  • muscle function markedly reduced বা absent।
  • weight-bearing/limb movement কঠিন।

4. Clinically Diagnosis — কীভাবে clinically diagnosis করবেন

Muscle strain সাধারণত history + physical examination দিয়ে diagnosis করা যায়; Merck Manual soft-tissue injury-তে history ও physical exam-কে অধিকাংশ ক্ষেত্রে sufficient বলেছে, তবে fracture সন্দেহ হলে radiograph লাগে।

History

  • Injury mechanism: sudden sprint, twist, lift, fall, direct blow?
  • Pain onset: immediate নাকি delayed?
  • Pop sound/sensation ছিল কি?
  • Activity stop করতে হয়েছে কি?
  • Previous injury আছে কি?
  • Drug history: anticoagulant, steroid, fluoroquinolone?
  • Red flag: fever, severe swelling, numbness, cold limb, dark urine, chest pain/SOB।

Examination

  • Inspection: swelling, bruising, deformity, gait।
  • Palpation: localized tenderness, muscle gap, hematoma।
  • Range of motion: active/passive ROM pain।
  • Resisted contraction test: affected muscle contract করালে pain/weakness।
  • Functional test: walking, heel raise, squat, hop test—site অনুযায়ী।
  • Neurovascular exam: distal pulse, capillary refill, sensation, motor power।
  • Adjacent joint exam: ligament sprain, tendon rupture, dislocation exclude।

5. Investigations — specific indication অনুযায়ী

Routine mild strain-এ investigation লাগে না

  • Mild Grade I strain হলে clinical diagnosis যথেষ্ট।

X-ray

  • Indication: fracture/avulsion fracture সন্দেহ, bony tenderness, inability to bear weight, severe trauma।
  • AAOS muscle strain evaluation-এ possible fracture/bone injury থাকলে X-ray দরকার হতে পারে বলেছে।

Musculoskeletal Ultrasound

  • Indication: partial tear, hematoma, dynamic assessment, follow-up healing, sports injury।
  • Ultrasound muscle injury-তে widely available এবং dynamic assessment করতে পারে; sports medicine literature-এ MRI ও ultrasound muscle injury assessment-এর key modality।

MRI

  • Indication: severe pain/weakness, suspected complete tear, elite athlete, uncertain diagnosis, persistent pain >2–3 weeks, surgical planning।
  • AAOS thigh muscle strain-এ MRI muscle/tendon further evaluation-এর জন্য ব্যবহার করা যেতে পারে বলেছে।

Laboratory test — selected cases only

  • CK, serum creatinine, urine myoglobin: severe crush injury, extensive muscle pain, dark urine → rhabdomyolysis সন্দেহ।
  • CBC, ESR/CRP: fever, cellulitis, pyomyositis, infective myositis সন্দেহ।
  • Electrolytes: recurrent cramps, dehydration, renal risk।
  • Doppler USG: calf swelling/pain with DVT risk—immobilization, surgery, malignancy, pregnancy, OCP।

6. Differential Diagnosis

  • Ligament sprain
  • Tendon rupture — Achilles, biceps, quadriceps tendon
  • Fracture / avulsion fracture
  • Muscle contusion
  • Compartment syndrome
  • Deep vein thrombosis — especially calf pain/swelling
  • Rhabdomyolysis
  • Pyomyositis / cellulitis
  • Radiculopathy — back/neck pain with nerve symptoms
  • Myositis or inflammatory myopathy

7. Complications — জটিলতা বাংলায়

  • Recurrent strain: ঠিকমতো rehab না করলে একই জায়গায় বারবার টান লাগে।
  • Chronic pain: muscle scar tissue ও weakness থাকলে দীর্ঘদিন ব্যথা থাকে।
  • Reduced flexibility: muscle tight হয়ে movement কমে যায়।
  • Weakness / performance loss: খেলাধুলা বা daily work capacity কমে।
  • Hematoma: muscle-এর ভেতরে রক্ত জমে ফুলে যায়, pain বাড়ে।
  • Myositis ossificans: severe contusion/hematoma-র পর muscle-এর মধ্যে bone-like calcification হতে পারে।
  • Complete rupture: Grade III injury হলে surgical opinion লাগতে পারে।
  • Compartment syndrome: severe swelling pressure বাড়িয়ে nerve/vessel compromise করতে পারে—এটা emergency।
  • Rhabdomyolysis: massive muscle breakdown হলে CK বেড়ে kidney injury হতে পারে—dark urine, severe generalized muscle pain হলে urgent care।
  • DVT risk: prolonged immobilization করলে calf vein clot হতে পারে।

8. Management / Treatment — guideline-based

A. Non-pharmacological management

First 48–72 hours: PRICE / POLICE approach

  • Protection: painful activity বন্ধ; severe injury হলে crutch/sling।
  • Rest / Relative rest: complete bed rest নয়; pain-free gentle movement।
  • Ice: 15–20 মিনিট, প্রতি 2–3 ঘণ্টা, প্রথম 48–72 ঘণ্টা। Mayo Clinic muscle strain-এ ice 15–20 মিনিট every 2–3 hours প্রথম কয়েক দিন বলেছে।
  • Compression: elastic bandage; খুব tight করা যাবে না।
  • Elevation: limb heart level-এর উপরে।
  • Optimal loading: pain কমলে gradual ROM → stretching → strengthening। PRICE principle muscle injury-তে immediate treatment হিসেবে বর্ণিত; modern sports rehab prolonged rest-এর বদলে safe early loading পছন্দ করে।

Avoid first 48 hours

  • Heat massage
  • Alcohol
  • Aggressive stretching
  • Running/return to sport
  • Deep tissue massage

Physiotherapy / rehab

  • Phase 1: pain control, swelling control, gentle ROM
  • Phase 2: isometric strengthening
  • Phase 3: eccentric strengthening, flexibility
  • Phase 4: sport/work-specific functional training
  • Return to activity when: pain-free full ROM, near-normal strength, no tenderness, functional test pain-free।

9. Pharmacological Treatment — Bangladesh commonly used prescription drugs

ACP/AAFP acute non–low-back musculoskeletal injury guideline topical NSAID ± menthol gel-কে first-line বলে; oral NSAID বা acetaminophen/paracetamol ব্যবহার করা যায়, কিন্তু routine opioid/tramadol avoid করা উচিত।

9.1 First-line: Topical NSAID

1) Generic name: Diclofenac sodium gel 1% / 2%

  • Therapeutic category: Topical analgesic / anti-inflammatory
  • Pharmacological class: NSAID; COX inhibition → prostaglandin synthesis কমায়
  • কেন used হয়: localized muscle pain, swelling, inflammation কমাতে; systemic NSAID adverse effect তুলনামূলক কম।
  • Dose: affected area-তে 2–4 g gel দিনে 3–4 বার, 5–7 দিন; open wound/eye/mucosa-তে নয়। MedEx Diclofen gel-এ 2–4 g 3–4 times daily লিখেছে।
  • Bangladesh available brand name:
    • Voltagel 1% w/w, Diclofenac sodium, Eskayef, 10/20/50 g tube
    • Voltagel DS 2% w/w, Diclofenac sodium
    • DicloGel 1% w/w, Diclofenac sodium, Incepta
    • Diclofen 1% w/w gel, Diclofenac sodium, Opsonin
    • Diclomol 1% w/w gel, Diclofenac sodium
    • VOLINAC 1% / VOLINAC Max 2%, Diclofenac sodium + methyl salicylate + linseed oil + menthol, Square
      MedEx lists these diclofenac gel brands/strengths in Bangladesh.
  • Side effects: local burning, rash, itching, photosensitivity; rare systemic NSAID effects।
  • Interactions: oral NSAID/anticoagulant সঙ্গে large-area/high-dose use করলে bleeding/GI risk বাড়তে পারে।
  • Important caution: broken skin, eczema, NSAID allergy/asthma history-এ avoid।

9.2 Analgesic: Paracetamol

2) Generic name: Paracetamol / Acetaminophen

  • Therapeutic category: Analgesic, antipyretic
  • Pharmacological class: Para-aminophenol derivative; central prostaglandin inhibition
  • কেন used হয়: pain কমায়, fever থাকলে কমায়; anti-inflammatory effect weak, তাই swelling বেশি হলে NSAID বেশি কার্যকর।
  • Adult dose: 500–1000 mg orally every 6–8 hours PRN; usual max 3 g/day safer, absolute max 4 g/day only if no liver risk।
  • Duration: 2–5 দিন বা pain অনুযায়ী।
  • Bangladesh available brand name:
    • Napa 500 mg, Paracetamol, Beximco
    • Ace 500 mg, Paracetamol, Square
    • Reset 500 mg, Paracetamol, Incepta
    • Renova 500 mg, Paracetamol, Opsonin
    • Napa One 1000 mg, Paracetamol
    • Reset ER 665 mg, Paracetamol extended release
      MedEx paracetamol indications includes myalgia, sprain, body ache and lists these brands/strengths.
  • Side effects: nausea, rash; overdose → severe hepatotoxicity। MedEx notes paracetamol side effects are usually mild but blood dyscrasias and pancreatitis/skin reactions can occur rarely.
  • Interactions: alcohol, warfarin long-term high dose, enzyme-inducing drugs; other paracetamol-containing cold medicines একসাথে নিলে overdose risk।
  • Avoid/caution: chronic liver disease, heavy alcohol use।

9.3 Oral NSAIDs — inflammation/pain বেশি হলে short course

Rule: একসাথে দুই NSAID দেবেন না। NSAID always lowest effective dose, shortest duration, preferably after meal. NSAID contraindication থাকলে paracetamol/topical option safer.

3) Generic name: Ibuprofen

  • Therapeutic category: Analgesic / anti-inflammatory
  • Pharmacological class: Non-selective NSAID; COX-1/COX-2 inhibitor
  • কেন used হয়: mild–moderate inflammatory muscle pain, swelling, tenderness।
  • Adult dose: 200–400 mg orally every 6–8 hours after meal; max OTC-type dose 1200 mg/day। MedEx adult/adolescent dose 200–400 mg 3–4 times daily with 6-hour interval and max 1200 mg/day উল্লেখ করেছে।
  • Duration: 3–5 দিন; persistent pain হলে reassess।
  • Bangladesh available brand name:
    • Profen 400 mg, Ibuprofen, ACME
    • Flamex 200/400 mg, Ibuprofen, ACI
    • Reumafen 200/400 mg, Ibuprofen, Beximco
    • Trufen 400 mg, Ibuprofen, Modern
    • Uniflam 400 mg, Ibuprofen, Bristol
    • Intaflam 400 mg, Ibuprofen, Incepta
    • Serviprofen 400 mg, Ibuprofen, Sandoz
      MedEx lists these ibuprofen oral brands in Bangladesh.
  • Side effects: dyspepsia, abdominal pain, nausea, vomiting, GI bleeding/ulcer, renal impairment, BP rise, bronchospasm in NSAID-sensitive asthma।
  • Interactions: warfarin/DOAC/aspirin/clopidogrel → bleeding; ACEI/ARB + diuretic → AKI risk; lithium/digoxin/methotrexate level ↑; SSRI/steroid → GI bleed risk।
  • Avoid/caution: PUD/GI bleed, CKD, heart failure, uncontrolled HTN, ischemic heart disease, third-trimester pregnancy, aspirin-sensitive asthma।

4) Generic name: Naproxen sodium

  • Therapeutic category: Analgesic / anti-inflammatory
  • Pharmacological class: Non-selective NSAID
  • কেন used হয়: moderate inflammatory pain; longer duration of action, তাই দিনে 2 বার সুবিধা।
  • Adult dose for acute musculoskeletal pain: 500 mg initially, then 250 mg every 6–8 hours PRN; max 1000 mg/day. MedEx acute musculoskeletal disorder-এ 500 mg initially then 250 mg 6–8 hourly উল্লেখ করেছে।
  • Duration: 3–5 দিন।
  • Bangladesh available brand name:
    • Naprox 250/500 mg, Naproxen sodium, Eskayef
    • Naprosyn 250/500 mg, Naproxen sodium, Radiant
    • Napro-A 250/500 mg, Naproxen sodium, ACME
    • Anaflex 250/500 mg, Naproxen sodium, ACI
    • Ecless 250/500 mg, Naproxen sodium, Incepta
    • Diproxen 250/500 mg, Naproxen sodium, Drug International
      MedEx lists these naproxen brands/strengths.
  • Side effects: heartburn, abdominal pain, nausea, diarrhea, dyspepsia, headache, vertigo, drowsiness, edema, palpitation। MedEx lists these adverse effects.
  • Interactions: ACE inhibitor effect কমতে পারে; aspirin/warfarin/SSRI → GI bleeding; diuretic effect কমতে পারে; methotrexate toxicity বাড়তে পারে।
  • Avoid/caution: GI bleed, CKD, heart failure, anticoagulant use, NSAID asthma।

5) Generic name: Aceclofenac

  • Therapeutic category: Analgesic / anti-inflammatory
  • Pharmacological class: NSAID; COX inhibitor
  • কেন used হয়: trauma, lumbago, musculoskeletal inflammatory pain; বাংলাদেশে muscle strain/soft tissue pain-এ commonly prescribed।
  • Adult dose: 100 mg orally twice daily after meal; SR 200 mg once daily। MedEx adult film-coated tablet 100 mg twice daily এবং ER 200 mg daily উল্লেখ করেছে।
  • Duration: 3–5 দিন; unnecessary prolonged use avoid।
  • Bangladesh available brand name:
    • Flexi 100 mg / Flexi SR 200 mg, Aceclofenac, Square
    • Movex 100 mg / Movex SR 200 mg, Aceclofenac, Opsonin
    • Ceclofen 100 mg, Aceclofenac, Renata
    • Avenac 100 mg, Aceclofenac, Radiant
    • Noak 100 mg, Aceclofenac, Orion
    • Preservin 100 mg / SR 200 mg, Aceclofenac, Ibn Sina
      MedEx lists these aceclofenac brands/strengths.
  • Side effects: dyspepsia, abdominal pain, nausea, dizziness, rash, edema; rare GI bleed, renal injury, hepatotoxicity।
  • Interactions: lithium/digoxin level ↑, diuretic effect ↓, anticoagulant effect ↑, methotrexate level/toxicity ↑—MedEx notes these interactions.
  • Avoid/caution: PUD, renal/cardiac/hepatic impairment, NSAID allergy/asthma, pregnancy/lactation।

6) Generic name: Diclofenac sodium / potassium oral

  • Therapeutic category: Analgesic / anti-inflammatory
  • Pharmacological class: NSAID; COX inhibitor
  • কেন used হয়: acute painful inflammation; তবে GI/CV risk বিবেচনা করতে হবে।
  • Adult dose: Diclofenac sodium 50 mg orally 2–3 times daily after meal; max 150 mg/day; SR 100 mg once daily usually। Diclofenac potassium MedEx dose 25–50 mg every 8 hours if necessary, max 150 mg/day.
  • Duration: 2–5 দিন।
  • Bangladesh available brand name:
    • Diclofen 50 mg / SR 100 mg / gel 1%, Diclofenac sodium, Opsonin
    • Voltalin 50 mg / SR 75/100 mg / inj 75 mg/3 ml, Diclofenac sodium
    • Clofenac DT 46.5 mg / SR 100 mg, Diclofenac sodium, Square
    • Diclomol SR 100 mg / gel 1%, Diclofenac sodium
    • Diclorex 50 mg / RTD 100 mg / inj 75 mg/3 ml, Diclofenac sodium
      MedEx lists diclofenac sodium brands/forms and gel strengths.
  • Side effects: dyspepsia, nausea, diarrhea, GI ulcer/bleeding, renal impairment, edema, BP rise, rash, bronchospasm; CV thrombotic risk dose/duration related।
  • Interactions: lithium/digoxin levels ↑, anticoagulants/antiplatelets/SSRIs/steroids → bleeding risk, ACEI/ARB/diuretic → renal risk, methotrexate toxicity। MedEx diclofenac interaction section notes lithium/digoxin interaction.
  • Avoid/caution: IHD/stroke risk, uncontrolled HTN, CKD, PUD/GI bleed, pregnancy late trimester।

7) Generic name: Etoricoxib

  • Therapeutic category: Analgesic / anti-inflammatory
  • Pharmacological class: Selective COX-2 inhibitor NSAID
  • কেন used হয়: GI irritation কমানোর উদ্দেশ্যে কিছু ডাক্তার short course দেন; তবে CV risk বিবেচনা করা জরুরি।
  • Adult dose: 60 mg once daily; severe acute pain-এ physician-selected short course 90 mg once daily; generally 3–5 দিন।
  • Bangladesh available brand name:
    • Etorix 60/90/120 mg, Etoricoxib, Eskayef
    • Oricox 30/60/90/120 mg, Etoricoxib, Incepta
    • Recox 60/90/120 mg, Etoricoxib, Renata
    • Ribox 60/90/120 mg, Etoricoxib, Beximco
    • Etoshine 60/90 mg, Etoricoxib, Sun Pharma Bangladesh
    • Rito 60 mg, Etoricoxib, Opsonin
      MedEx lists etoricoxib brands/strengths in Bangladesh.
  • Side effects: dyspepsia, edema, hypertension, palpitation, dizziness, fatigue; MedEx lists palpitation, fatigue, ecchymosis and other effects.
  • Interactions: warfarin/anticoagulants → bleeding/INR issue, ACEI/ARB/diuretic → renal risk, lithium/methotrexate toxicity, other NSAIDs avoid।
  • Avoid/caution: ischemic heart disease, stroke/TIA, peripheral vascular disease, uncontrolled HTN, heart failure, CKD।

9.4 Muscle relaxant — spasm বেশি হলে short course

Muscle strain-এ muscle relaxant routine নয়; painful spasm, neck/back strain, sleep-disturbing spasm হলে 2–5 দিনের short course দেওয়া যায়। Sedation থাকলে driving/operating machine avoid।

8) Generic name: Tizanidine hydrochloride

  • Therapeutic category: Skeletal muscle relaxant
  • Pharmacological class: Centrally acting α2-adrenergic agonist
  • কেন used হয়: painful muscle spasm কমাতে, especially neck/back strain-এ।
  • Adult dose: 2 mg at night বা 2 mg 2–3 times daily; severe spasm-এ 2–4 mg TDS under supervision. MedEx painful muscle spasm-এ 2–4 mg three times daily উল্লেখ করেছে।
  • Duration: 2–5 দিন; prolonged use avoid।
  • Bangladesh available brand name:
    • Relentus 2 mg, Tizanidine, Beximco
    • Sirdalud 2 mg, Tizanidine, Sandoz
    • Tizadin 2 mg, Tizanidine, ACI
    • Tizalex 2 mg, Tizanidine, Apex
    • Tizalud 2 mg, Tizanidine, Opsonin
    • Tizan 2 mg, Tizanidine, Sun Pharma Bangladesh
      MedEx lists these tizanidine brands.
  • Side effects: drowsiness, dizziness, dry mouth, hypotension, bradycardia, fatigue, liver enzyme elevation।
  • Interactions: ciprofloxacin/fluvoxamine contraindicated or avoid; alcohol, benzodiazepine, sedatives → CNS depression; antihypertensive → hypotension।
  • Avoid/caution: liver disease, elderly, hypotension, driving job।

9) Generic name: Tolperisone hydrochloride

  • Therapeutic category: Skeletal muscle relaxant
  • Pharmacological class: Centrally acting muscle relaxant
  • কেন used হয়: muscle tone/tension ও painful spasm কমাতে। MedEx tolperisone-কে centrally acting muscle relaxant হিসেবে উল্লেখ করেছে।
  • Adult dose: 50 mg 2–3 times daily after meal; severe spasm-এ 100 mg 2–3 times daily physician advice অনুযায়ী।
  • Duration: 3–7 দিন।
  • Bangladesh available brand name:
    • A-Calm 50 mg, Tolperisone, ACME
    • Myolax 50/100 mg, Tolperisone, Incepta
    • Musclex 50 mg, Tolperisone, Aristopharma
    • Myoson 50/100 mg, Tolperisone, Ibn Sina
    • Tolson 50/100 mg, Tolperisone, Opsonin
    • Tolus 50 mg, Tolperisone, Healthcare
      MedEx lists these tolperisone brands/strengths.
  • Side effects: nausea, epigastric discomfort, dizziness, weakness, hypotension, allergic rash; rare severe hypersensitivity।
  • Interactions: other muscle relaxant/sedatives/alcohol → dizziness/sedation বাড়তে পারে।
  • Avoid/caution: myasthenia gravis, known allergy, pregnancy/lactation without specialist advice।

10) Generic name: Eperisone hydrochloride

  • Therapeutic category: Skeletal muscle relaxant
  • Pharmacological class: Centrally acting muscle relaxant
  • কেন used হয়: painful muscular spasm/tightness কমাতে; Bangladesh-এ কিছু prescription-এ ব্যবহৃত হয়।
  • Adult dose: 50 mg orally 2–3 times daily after meal।
  • Duration: 3–7 দিন।
  • Bangladesh available brand name:
    • Eprel 50 mg, Eperisone, Orion
    • Ezymas 50 mg, Eperisone, Novelta Bestway
      MedEx eperisone brands হিসেবে এগুলো দেখিয়েছে।
  • Side effects: dizziness, drowsiness, nausea, GI upset, rash, weakness।
  • Interactions: alcohol/sedatives → CNS depression; other muscle relaxant সঙ্গে additive effect।
  • Avoid/caution: driving, liver dysfunction, pregnancy/lactation without advice।

9.5 Gastroprotection with NSAID — selected patients

11) Generic name: Omeprazole / Pantoprazole / Esomeprazole

  • Therapeutic category: Anti-ulcerant / gastroprotective
  • Pharmacological class: Proton pump inhibitor, H+/K+ ATPase inhibitor
  • কেন used হয়: NSAID-associated gastritis/ulcer risk কমাতে—especially age >60, dyspepsia/PUD history, steroid/anticoagulant use।
  • Dose:
    • Omeprazole 20 mg once daily before breakfast
    • Pantoprazole 20–40 mg once daily before breakfast
    • Esomeprazole 20 mg once daily before breakfast
  • Duration: NSAID course চলাকালীন 3–7 দিন; ulcer/PUD হলে guideline অনুযায়ী 4–8 সপ্তাহ। MedEx omeprazole NSAID-associated ulcer prophylaxis-এ 20 mg daily উল্লেখ করেছে এবং pantoprazole NSAID-induced ulcer-এ indicated।
  • Bangladesh available brand name:
    • Seclo 20 mg, Omeprazole, Square
    • Losectil 20 mg, Omeprazole, Eskayef
    • Seclo MUPS 20 mg, Omeprazole MUPS, Square
    • Pantonix 20/40 mg, Pantoprazole, Incepta
    • Proton-P 20/40 mg, Pantoprazole, Aristopharma
    • Maxpro 20/40 mg, Esomeprazole, Renata
    • Sergel 20/40 mg, Esomeprazole, Healthcare
      MedEx lists these PPI brands/strengths.
  • Side effects: headache, abdominal pain, nausea, diarrhea/constipation; long-term—B12/Mg deficiency, fracture risk, C. difficile risk।
  • Interactions: clopidogrel with omeprazole/esomeprazole caution; warfarin/phenytoin level issue; long-term methotrexate high-dose caution।

10. Bangladesh doctors commonly prescribe — practical list

নিচের list Bangladesh outpatient prescription-এ muscle strain/soft tissue injury-তে commonly দেখা যায়; drug selection রোগীর age, comorbidity, pain severity, site ও contraindication অনুযায়ী বদলায়।

  1. Diclofenac gel 1% / 2%
    • কেন: localized pain/swelling; first-line topical NSAID।
    • Example: Voltagel, DicloGel, Diclofen gel, VOLINAC।
  2. Paracetamol 500 mg
    • কেন: mild pain; NSAID contraindicated হলে safer analgesic।
    • Example: Napa, Ace, Reset, Renova।
  3. Ibuprofen 400 mg
    • কেন: mild–moderate inflammatory pain; short course।
    • Example: Profen, Flamex, Trufen, Uniflam 400।
  4. Naproxen 250/500 mg
    • কেন: longer acting NSAID; moderate pain/swelling।
    • Example: Naprox, Naprosyn, Anaflex, Diproxen।
  5. Aceclofenac 100 mg
    • কেন: trauma/lumbago/soft tissue pain-এ commonly prescribed NSAID।
    • Example: Flexi, Movex, Ceclofen, Avenac।
  6. Diclofenac 50 mg or SR 100 mg
    • কেন: acute inflammatory pain; কিন্তু GI/CV/renal risk বেশি বিবেচনা করতে হয়।
    • Example: Diclofen, Voltalin, Clofenac।
  7. Etoricoxib 60/90 mg
    • কেন: selected patient-এ COX-2 NSAID; GI tolerance consideration, কিন্তু CV risk থাকলে avoid।
    • Example: Etorix, Oricox, Recox, Ribox।
  8. Tizanidine 2 mg
    • কেন: painful spasm, neck/back strain; night dose useful due to sedation।
    • Example: Relentus, Sirdalud, Tizadin, Tizalud।
  9. Tolperisone 50 mg
    • কেন: muscle spasm/tightness; less sedating option হিসেবে অনেক ডাক্তার দেন।
    • Example: Myolax, A-Calm, Musclex, Tolson।
  10. PPI — Omeprazole/Pantoprazole/Esomeprazole
  • কেন: NSAID gastritis/ulcer risk কমাতে selected patient-এ।
  • Example: Seclo, Losectil, Pantonix, Maxpro, Sergel।

11. When to refer urgently — জরুরি referral

  • Severe pain with rapid swelling
  • Limb cold/pale, pulse weak, numbness
  • Suspected complete rupture or visible deformity
  • Inability to bear weight after trauma
  • Extensive bruising/hematoma
  • Dark urine, severe generalized muscle pain → rhabdomyolysis
  • Fever/redness/warmth → infection
  • Calf swelling + SOB/chest pain → DVT/PE concern
  • Pain not improving after 7–10 days or recurrent strain

12. Prevention — কীভাবে প্রতিরোধ করবেন

  • Exercise/খেলার আগে 10–15 মিনিট warm-up।
  • Regular stretching + strengthening, বিশেষ করে hamstring, calf, quadriceps, core।
  • Sudden intensity increase নয়; 10% rule—weekly load ধীরে বাড়ানো।
  • Proper lifting technique: back straight, load body-র কাছে।
  • Adequate hydration ও electrolyte balance।
  • Fatigue হলে rest; pain নিয়ে training continue নয়।
  • Proper footwear, safe surface।
  • Previous strain হলে full rehab complete না করে sports-এ return নয়।
  • Strength imbalance correction—physiotherapist-guided eccentric training।
  • Diabetes, hypothyroidism, vitamin D deficiency, steroid use থাকলে risk factor optimize।

Overview / Summary

Muscle strain হলো muscle fiber বা muscle–tendon unit-এর overstretch/tear। Mild case clinical diagnosis-এ ধরা যায়; severe case-এ X-ray, ultrasound বা MRI দরকার হতে পারে। Treatment-এর মূল হলো protection, ice, compression, elevation, early safe loading, physiotherapy। Guideline অনুযায়ী localized acute musculoskeletal pain-এ topical NSAID first-line, এরপর paracetamol বা short-course oral NSAID। Spasm থাকলে short-course muscle relaxant দেওয়া যায়, কিন্তু sedation ও interaction খেয়াল রাখতে হবে।

Actionable Plan / Steps

  1. প্রথম 48–72 ঘণ্টা: rest from painful activity + ice 15–20 min every 2–3 hours + compression + elevation।
  2. Pain control: প্রথমে diclofenac gel ± paracetamol।
  3. Swelling/inflammatory pain বেশি হলে: contraindication না থাকলে 3–5 দিনের oral NSAID; একসাথে দুই NSAID নয়।
  4. Spasm থাকলে: tizanidine/tolperisone short course, driving avoid।
  5. NSAID risk থাকলে: PPI consider; CKD/PUD/IHD/anticoagulant/pregnancy-তে NSAID avoid or specialist decision।
  6. Rehab: pain-free ROM → strengthening → gradual return to work/sport।
  7. Red flag থাকলে: urgent orthopedic/sports medicine evaluation।

Reference List — Textbook + Guideline + DOI

Textbooks

  1. Davidson’s Principles and Practice of Medicine, 24th ed. Musculoskeletal pain/soft tissue disorders section.
  2. Harrison’s Principles of Internal Medicine, 21st ed. Musculoskeletal symptoms and pain approach.
  3. Robbins & Cotran Pathologic Basis of Disease, 10th ed. Tissue injury, inflammation, repair and fibrosis.
  4. Guyton and Hall Textbook of Medical Physiology, 14th ed. Skeletal muscle contraction and neuromuscular physiology.
  5. Goodman & Gilman’s The Pharmacological Basis of Therapeutics, 14th ed. NSAIDs, acetaminophen, opioids, anti-inflammatory pharmacology.
  6. Katzung Basic & Clinical Pharmacology, 15th/16th ed. NSAIDs, acetaminophen, skeletal muscle relaxants, PPIs.
  7. KD Tripathi Essentials of Medical Pharmacology, latest ed. NSAIDs, analgesics, muscle relaxants, PPIs.

Guidelines / Authoritative sources

  1. ACP/AAFP Clinical Guideline 2020: Nonpharmacologic and Pharmacologic Management of Acute Pain From Non–Low Back Musculoskeletal Injuries in Adults. Ann Intern Med. DOI: 10.7326/M19-3602.
  2. AAOS OrthoInfo: Muscle Strains in the Thigh—clinical exam, X-ray/MRI indications, RICE.
  3. Merck Manual Professional: Overview of sprains and other soft-tissue injuries—history and physical exam usually sufficient; radiographs when fracture concern.

Peer-reviewed journals with DOI

  1. Qaseem A, et al. Nonpharmacologic and Pharmacologic Management of Acute Pain From Non–Low Back, Musculoskeletal Injuries in Adults. Ann Intern Med. 2020. DOI: 10.7326/M19-3602.
  2. Hsu JR, Mir H, Wally MK, Seymour RB. Clinical Practice Guidelines for Pain Management in Acute Musculoskeletal Injury. J Orthop Trauma. 2019;33(5):e158–e182. DOI: 10.1097/BOT.0000000000001430.
  3. Crema MD, Yamada AF, Guermazi A, Roemer FW, Skaf AY. Imaging techniques for muscle injury in sports medicine and clinical relevance. Curr Rev Musculoskelet Med. 2015;8(2):154–161. DOI: 10.1007/s12178-015-9260-4.
  4. Guermazi A, Roemer FW, Robinson P, et al. Imaging of Muscle Injuries in Sports Medicine. Radiology. 2017;282(3):646–663. DOI: 10.1148/radiol.2017160267.
  5. Sant’Anna JPC, Pedrinelli A, Hernandez AJ, Fernandes TL. Muscle Injury: Pathophysiology, Diagnosis, and Treatment. Rev Bras Ortop. 2022;57(1):1–13. DOI: 10.1055/s-0041-1731417.

Md.Rafiqul Islam Lipu,Date:-18-06-2026 Thursday,Time:-10-22-12 Pm

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