0:00

Now in terms of grading, the first grading system

0:04

for injuries that was published was by, uh, O'Donohue.

0:09

This is the same patient with the un, uh, same, uh,

0:12

physician with the unhappy triad.

0:14

And, uh, he also described this as a triad

0:17

with three grades of injury.

0:20

Uh, unfortunately this is very imprecise

0:23

and it doesn't really help predict return to play,

0:27

which is an important thing that we're asked to, uh,

0:32

estimate, um, when we have an athlete, uh, that is injured.

0:35

So you can use it,

0:36

but it's really a clinical grading system.

0:40

Attempts were made to correlate that grading system

0:43

with imaging an early one by petron

0:46

with ultrasound in the seventies where he tried

0:49

to correlate cross-sectional involvement of the muscle

0:52

with the grade clinically, a later one

0:55

by stoller in the early days of Mr.

0:58

Describing, uh, edema,

1:01

frank gaps in fluid within the muscle,

1:03

and complete tears of the MTJ trying to correlate these.

1:08

Uh, but these have been really replaced with more modern,

1:11

uh, grading systems in the last 15, uh, years or so.

1:16

So, modern grading systems try

1:19

to do a little bit better job in terms of determining, uh,

1:23

time, uh, to play.

1:25

And one of the big problems

1:26

with the early grading systems was they lumped all

1:29

of the muscle injuries together.

1:31

And we know now that if you have an injury that is caused

1:35

by a strain, that that takes longer

1:37

to heal than an injury caused by a contusion.

1:40

So it may seem paradoxical,

1:42

but a direct blow, uh, tends

1:45

to heal much more quickly than a stretching injury

1:48

where there's actually fiber tearing.

1:50

So these injuries, uh, systems are still evolving

1:54

and, uh, I don't want to, you know, frighten, uh, you, uh,

1:58

'cause there's quite a few of them,

1:59

but I just wanna go through a couple of the ones that are,

2:02

are most commonly used.

2:04

Um, the Mueller Wolf heart was the first

2:06

of the grading systems.

2:07

It's not widely used except in Germany, Switzerland.

2:11

Um, and, uh, it, it was very useful

2:14

because it started to at least divide up the muscle traumas

2:19

into categories based on mechanism.

2:22

This functional category was fatigue and neurogenic.

2:25

The other grading systems don't use this,

2:27

but at least it separated strain from direct trauma

2:32

and noted, uh, quite astutely

2:35

that the strains took longer to heal.

2:37

Also made an attempt to try

2:39

to quantify architectural distortion,

2:42

and they basically said

2:44

that if you could see fluid collections within the muscle

2:47

greater than five millimeters in size, that that meant

2:51

that there was architectural distortion

2:53

and a higher, uh, grade injury.

2:56

So, very worthwhile contributions,

2:58

Uh, to the literature.

3:00

Currently, the most popular

3:02

of the grading systems is the British Athletics, uh, system.

3:07

And it looks a little bit overwhelming,

3:09

but it's really not too bad.

3:10

It also separates according to strain and contusion.

3:14

Then we have a size criteria, basically where it looks at

3:18

how big the lesion is in terms

3:21

of cross-sectional area length diameter,

3:24

and this is really important in British athletics,

3:28

is whether the injury is myofascial, myo, tendonous,

3:32

or involves the free tendon.

3:34

And these are an increasing degree of severity.

3:38

Our FC Barcelona is also quite popular.

3:40

It's very similar to BAM e with the difference that it looks

3:45

to see whether there has been previous

3:47

injury in the same area.

3:48

Otherwise, it's very, very similar.

3:50

Uh, uses only cross-sectional area rather than length.

3:54

Uh, for characterization,

3:56

I think right now the British Athletics, uh, uh,

3:59

system is the most, uh, popular.

4:01

Uh, this is often referred to as Baec, uh,

4:03

which is a short form, uh, for that, uh, classification.

4:07

And it pays a great deal of attention to the integrity

4:11

of the tendon.

4:12

So the edema is one thing,

4:15

but the tendon integrity,

4:16

which looks great on the case on the right compared

4:20

to the one on the left where the tendon itself is thickened,

4:24

emus and irregular, this would be a higher grade injury.

4:28

Um, and I think that's a very, uh, true

4:31

and very important, uh, finding.

4:33

And they have done some, uh, limited work in validating, uh,

4:37

this, uh, in terms of return to play, at least in the, uh,

4:41

hamstrings, quadriceps and more recently, uh, at the cap.

4:45

I'm not aware of any validation studies involving the upper

4:50

extremity, uh, with the baac, uh, system.