Haematomas are a common injury within contact sports such as American Football, and so is commonly something that both medical teams and athletes will encounter. Management of this injury needs to be done with care and caution so as not to cause further complications.
Haematoma – What?
A haematoma is a local accumulation of blood in a tissue, space or organ.
Within the muscle there are two ways a haematoma can develop.
- Direct – following direct impact
- Indirect – following a tear or rupture of muscle fibres
Types of haematoma
There are two types of haematoma
- Intramuscular – here the muscle sheath remains intact, thus confining the bleed within the muscle. This causes intramuscular pressure which may compress capillary beds that counteract the bleed. In this case, signs and symptoms remain localised.
- Swelling beyond 48 hrs.
- Pain and tenderness
- Decreased muscle function i.e. reduced contraction and extensibility
- Discolouration may appear a few days after the injury
- Intermuscular – in this case, the muscle fascia is torn, allowing the bleed to spread between muscles and fascia.
- Dramatic bruising and swelling below the injured site
- Discolouration and swelling may be visible within a few hours after injury
- The patient reports of pain subsiding within the first 24 hrs.
A superficial haematoma can be identified through bruising, swelling and muscle impairment, whereas deeper haematomas can be more difficult to diagnose. It is advised that you should ‘wait and see’ the damage in the first few hours after injury, particularly in intramuscular haematomas, which can continue to develop over the first 3 days post-injury. It is believed that only after 12-72 hrs post-injury can a true diagnosis be made.
Acute Injury Management (First 24-72 hrs)
- Rest – to prevent further haemorrhage and further aggravation of the injury. This will allow a stronger scar to form between the damaged muscle fibres and connective tissue. Some research advises the use of total rest, including the use of crutches for non-weight bearing mobility during the first 2 days. Once the athlete is able to move pain free they should do so.
- Ice – this method should be used in the early stages to help reduce:
- Blood flow
- Muscle spasm
- Secondary hypoxic damage i.e. cell death
- Muscle inhibition
- Compression – there is currently no conclusive evidence that compression to the haematoma area has an impact on recovery time. However it is clear that compression can reduce the impact of swelling to the injured site through deduction of space available for fluid seepage, and encouraging fluid absorption. Therefore it would be advisable to use a compressive bandage in the case of a haematoma. The bandage should be applied from bottom to top. The patient should feel the firmness of the wrap but no throbbing sensation.
- Elevation – there are no current conclusive studies that have reported its effectiveness, however it is known that elevation reduced arterial pressure and increases venous return. Therefore elevation is advised in the acute phase.
Please note that heat should not be applied within the acute injury stage for risk of bone growth within the muscle (also known as myositis ossificans).
Download your own Pitch-side Injury companion here.
Treatment (72 hrs +)
- Heat – heat is advised at during the resolution phase (3 days +) to accelerate the haematoma absorption and increase blood circulation.
- Ultrasound – it is unclear whether the use of ultrasound treatment for haematomas has positive effects.
- Exercise – Active range of motion and isometric exercises are advised i.e. the patient performs the movement voluntarily through muscular contraction. This can then be progressed (see table below)
|1. Acute Phase||Gentle Isometrics||Rest, Ice, Compression, Elevation|
|2. Resolution Phase||Active range of movement and weight bearing||Heat|
|3. Sport Specific||Progressive resistance exercise||Heat|
- Massage – is not advised due to the risk of further increasing the haemorrhage. Research looking at the effectiveness of massage for haematomas has found no conclusive results. It is currently unclear when best to apply this method of treatment.
Depending on the severity of intramuscular bleeds, the injury needs to be treated with more caution due to risk of myositis ossificans (small bone growth within the muscle).
This complication is serious and relatively common. It has been suggested that recurrent contusions are more likely to result in myositis ossificans more often.
- Reduced movement
- Harding of the muscle on palpation
- Gentle rehabilitation
- If not managed correctly surgical intervention might be needed.
Intramuscular haematomas are more severe than intermuscular haematomas, thus prognosis is longer.
If in doubt, always consult a health professional.
- Smith, T.O., Hunt, N.J. & Wood, S.J. 2006, “The physiotherapy management of muscle haematomas”, Physical Therapy in Sport, vol. 7, no. 4, pp. 201-209.
- Stainsby, B.E., Piper, S.L. & Gringmuth, R. 2012, “Management approaches to acute muscular strain and hematoma in National level soccer players: a report of two cases”, The Journal of the Canadian Chiropractic Association, vol. 56, no. 4, pp. 262.
- Prentice, W.E. and Kaminski, T.W., 2004. Rehabilitation techniques for sports medicine and athletic training (pp. 406-408). New York:: McGraw-hill.
- Anderson, M.K. and Parr, G.P., 2013. Foundations of athletic training: Prevention, assessment, and management. Wolters Kluwer Health/Lippincott Williams & Wilkins.