PainScience.com • Good advice for aches, pains & injuries

Save Yourself from Muscle Strain!

Muscle strain (pulled muscle) and muscle pain explained and discussed in great detail, plus every imaginable treatment option

Paul Ingraham, updated

Photo of a young female runner on a bright orange running track, obviously in pain, holding an hamstring muscle strain.

Muscle strains strike most often in the big muscles of the body. But sometimes the pain is not what it seems …

Muscle strain — literally torn muscle tissue — is often extremely difficult to recover from. In 2012, Gene Lawrence, a 74-year-old weightlifter, ripped his quads (and not while lifting). A doctor told him he’d never do a squat again. But Gene’s passion for his sport kept him going. And yet several months later he was on the verge of beating his personal records — a near total recovery.1

You can recover from nearly anything if you are patient and methodical.

But how patient, and what method? What is muscle injury, and how does it heal? What works? What doesn’t? And here’s a curve ball: is your muscle even actually physically damaged? Muscle strain and pain are usually woven together, and often pain alone is mistaken for injury.

This extremely detailed guide, regularly updated for more than a decade, thoroughly explores the science of injured and hurting muscle.

Muscle strain and pain myths and misconceptions

Believe it or not (and it does seem a bit ridiculous in 2019) muscle pain is still a subject of scientific mystery and many myths and misconceptions. A torn muscle is arguably among the most medically neglected of all common injuries.23 A major recent review couldn’t find enough evidence for conclusions about any of the most popular treatments4 — for an injury that affects the highest profile athletes in the world, playing sports that involve more resources than small nations. It’s a little surprising we’re not further along at this point in history.

“We can put a man on the moon, but … ”

And so, although most muscle pain is relatively simple to diagnose and self-treat, an incredible number of people seek treatment for muscle strains that have been misdiagnosed as something else … or they have “something else” that’s been misdiagnosed as a muscle strain. Strain, pain, spasm, contracture, scar tissue, tone, tension, and stiffness are all poorly understood and routinely confused. They are not only surprisingly complex topics scientifically, but clinicians are not generally aware of the research that has been done. Certainly family doctors are not competent to assess and treat musculoskeletal problems, including muscle strains.5

The world obviously needs more and better information about muscle pain.

So what is a muscle strain exactly?

A muscle “strain” is any physical trauma to muscle caused by force applied along the length of the muscle (tensile force). That force can be applied by contraction of the muscle itself (active strain), or imposed on it by a stretch (passive strain), but there’s no practical difference between those scenarios.

A strain is also often called a “pulled muscle” or “muscle tear.”

(Note that there is no such thing as a muscle “sprain” — that’s a contradiction.6)

Although you might have problems that make you vulnerable to a muscle strain, the direct cause of every muscle strain is traumatic ripping of the muscle tissue — arg! — usually at the point where the muscle meets its tendon. Muscle will tear under the force of your own muscular contraction, or excessive stretch.

The more muscle fibres are torn, the worse the strain. In the case of a serious strain, the entire muscle may completely rupture — literally ripped in half! Triple arg! (Total ruptures are serious injuries, much worse than partial ruptures.)

Muscle strains are particularly common in the thigh and groin in soccer, ultimate, hockey and other fast-moving team sports.

Muscle strains are particularly common in the thigh & groin in soccer, ultimate, hockey & other fast-moving team sports.

Obviously a muscle can also be bruised, crushed, or lacerated, but those are quite different traumas. This tutorial is only about strains, not all kinds of muscle injuries. There’s not much medical mystery involved if you were gouged by a hockey skate. We also won’t discuss full muscle ruptures in much detail, because they are so extreme that they are easy to diagnose — even doctors can do it! 😃

There will be much (much) more detail below about exactly what a muscle strain is, and its complications, and how to treat it, and so on. But before we get into that, it’s important to determine whether or not you actually have a muscle strain, or some other kind of muscle pain.

Part 2

Diagnosis

How do you know that you’ve got a muscle strain?

Many people mistakenly think they have an injured muscle, because there are some common problems that feel like an muscle strain.

True muscle strains and especially muscle ruptures are actually surprisingly rare, compared to other causes of muscle pain. Funny thing about this tutorial: most people who find this document, like most people who think they have strained a muscle, have actually not done any such thing — or (just as common) they strained a muscle once upon a time, but the strain healed long ago and has since become an entirely different problem.

This could be you!

Some of the things that get confused with muscle strains are (and these will all be covered in more detail below):

Cramp versus strain example: Multi-muscle cramping catastrophe on a hot summer night

Back in the late 2000s I was enjoying my athletic peak and just barely managing not to embarrass myself with younger and more talented athletes. One hot summer night I was running low on electrolytes: too much sweating, not enough salt intake. (Actually, that’s a surprising myth.7) I was playing “goaltie” (say it like goal-tea) a variant of ultimate: a hard-running Frisbee sport with the same intensity and speed as soccer, but with more jumping.

Both calves spasmed on a jump, bringing me down hard. That was nasty, but it was just the start: as soon as I hit the ground, both sets of hamstrings went off as well, and all that was more than enough to make for a good cramping story … but then my abdominals joined the fray, and that gave me an anecdote I’ll be sharing for the rest of my life.

The cramping all hurt, a lot, but I was too surprised and busy to focus on the pain. If you’ve ever had a strong spasm, you know that there’s a powerful instinct and need to elongate the muscles. Stretching is your only hope of relief. But I had a puzzle to solve: just try to stretch the backs of your legs and your abdominal muscles at the same time. It’s an anatomical impossibility.

Photograph of me playing ultimate, a sport that has caused many cramps and a few muscle strains over the years.

That’s me in the air at the back. Check out that vertical! It was that kind of jump that triggered a massive wave of spasms …

I jackknifed back and forth so violently that the other players wondered if I was having a seizure, but I was simply on my impossible mission to stretch both sides of my body. If I stretched the legs, the abdominals would bunch up; if I stretched them, the leg muscles tried to kill me. After about three tries each way, I realized it couldn’t be done and that my only hope was compromise: to find the least awful position somewhere between the extremes. It meant that neither muscle group would really be stretched at all — but neither would be allowed to fully contract either. I gasped “cramps! lots of cramps!” so everyone knew I wasn’t actually having a seizure … and then waited it out.

Without the power of stretch, the cramps took a long time to fade. It was a long time to endure extremely powerful contractions.

A spasm is capable of injuring muscle. In this case, I was wrenching back and forth, my own muscles in a tug-of-war with each other. These were perfect conditions for injury. Something had to give, and it did — I had mild strains of all the affected muscles, resulting in not just days of soreness but severe soreness for weeks, and a vulnerability to reinjury that was still a problem a full year later.

The spasm here was the strong involuntary contraction of the muscles. The strain was the injury caused by the forces on the muscles.

True muscle strain checklist

Here’s a checklist of the signs and symptoms of a true pulled muscle. If you can say, “Yeah, that’s me,” to all of these, then congratulations: you probably have an actual, certifiable, card-carrying Muscle Strain®.

If you “woke up with it,” or the pain came on slowly over several days, or if it’s six months old, or if the pain isn’t consistently in one particular place … then we’ll be talking about other possibilities. If your real problem is actually a painful “muscle knot,” for instance, you might want to take your knots for a nice massage — but massage is mostly pointless for a strain.

The “oh shit” moment: the most essential sign of muscle strain

Muscle strain cannot occur without an “oh shit” moment. In other words, it hits suddenly: you know that something nasty has happened, immediately and with perfect clarity. You feel wounded. In physical therapy, this is what we call a history of “sudden onset.”9

If your pain didn’t start suddenly (or very nearly so), it ain’t a muscle strain. Muscle strains are traumatic by nature, almost always occurring during intense athletic activity. The victim says a bad word, perhaps several of them in the case of a grade II injury. In the case of a grade III, there is generally screaming and falling down and probably turning a bit green.

And yet …

Rupture: not as obvious as you’d think!

Complete hamstring avulsions — that is, complete ruptures of muscles where they attach to bones — are not necessarily obvious. They aren’t all as painful initially as they sound (not a strong “oh shit” sign). And according to O'Laughlin et al, they “can be difficult to diagnose acutely due to swelling and patient guarding, which may mask a visibly palpable defect and lead to delays in diagnosis.”10 Yikes!

In that case study, the only diagnosis was “hamstring pain” for several days, before the avulsion was finally confirmed by MRI, and surgically repaired on day 13. It’s not hard to imagine cases where the diagnosis would have taken much longer — too long.

So how would you know? Many of the other signs discussed here would be relatively obvious, especially substantial weakness. If the muscle is actually detached, obvious there will be a loss of strength. With some muscles, the loss is total or close to it.11 In the case of the hamstrings, there are other “strings” that can take over — which is another reason why a hamstring rupture is surprisingly hard to diagnose. The strength loss would be dramatic, probably about one third (because there are three hamstrings: the semitendinosus, semimembranosus, and biceps femoris), but it’s interesting how non-obvious that is.12 But anyone with a hamstring rupture is going to have a significant performance problem.

Location, location, location

Another way of knowing you’ve got a muscle strain is by the location. Muscle strains are much more common in some muscles than others. Every “groin pull” is a muscle strain of one or more of your hip adductors, for instance.

You can strain virtually any muscle in your body, but the commonly strained muscles are:

The pattern here is big muscles, which we tend to use for explosive or intense effort. However, a strain is possible in any muscle.

Even more specifically …

Strains often occur where muscles meet tendons, the myotendinous junction. Tendon is the shiny white “bio rope” that connects muscles to bones (in contrast to the bone-to-bone connections of ligaments). Tendons blend smoothly into muscles, like fingers of two types laced together, but at a cellular level. When a muscle contracts, the greatest strain naturally occurs where it pulls, which is of course where the tendon is. All the force converges on the tendon, but it’s not going to give. (In many cases, even bone will give way before tendon does!) Tendon has an extraordinary tensile strength, much greater than steel cable. Instead, the muscle tissue tends to fail close to where it becomes more tendon-y.

It can be hard to tell where this zone of likelihood is. For instance, in the hamstrings, the tendons are quite long and complex, and blend into the muscle along a considerable span. So you can have a myotendinous strain there that is basically right in the middle, between thigh and knee.

The hurtin’ and the weak

You know you have a muscle strain when the muscle feels weak and contraction is painful.

Strength/pain combinations are very useful diagnostically, and a good physical therapist is always looking for such combinations when assessing your case. A “weak and painful” contraction test indicates muscle strain. “Strong and painful” means something else. “Weak and painless” something else again.

Ligament sprains, for instance, do not cause weakness or pain with muscle contraction — except to the extent that sprained ligaments just don’t like to be moved. If you simply clench your muscles in place, without moving, and nothing hurts (much) … that could be a ligament sprain: strong and painless.

Photograph of an ankle being taped with a compression bandage for a sprain.

Is this a sprain or a strain?

Definitely a sprain. Stabilizing a joint like this is for sprained ligaments, not strained muscles. Sprains always occur at joints, especially the ankles, knees & wrists.

Tendinitis is sometimes mistaken for a muscle strain. But tendinitis will not cause significant weakness. It will just hurt: strong and painful.

Muscles strains make muscle contractions really weak and painful.

Now let’s look at the three alternative diagnoses, three common muscle problems that get mistaken for muscle strains: muscle spasms, DOMS, and muscle knots …

Could you have a muscle spasm instead of a strain?

You sure could! Spasms, cramps and “charlie horses” can both seem like a muscle strain and they can also actually cause one…

END OF FREE INTRODUCTION

Unlock access to 43 more chapters for USD$1995 — much less than the cost of any physical therapy, and maybe more useful. Continue reading this page right after purchase. A second book about muscle pain is included free. See the complete table of contents below. Most content on PainScience.com is free.?

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Q. What do I get, exactly? A. Payment unlocks 43 more chapters of a webpage the size of a small book, a total of 53 chapters and 23,000 words. Access is permanent, including several updates per year. Plus …

  • Free second book! When you buy this tutorial, you will automatically get a second (huge) book all about “trigger points,” because these common sore spots may be an important factor in some cases.more
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23,000 words
53 sections
68 footnotes

all myths & controversies
all diagnostic issues
all treatment options
  • 1 Introduction
  • 1.1 Muscle strain and pain myths and misconceptions
  • 1.2 So what is a muscle strain exactly?
  • 2 Diagnosis
    How do you know that you’ve got a muscle strain?
  • 2.1 Cramp versus strain example: Multi-muscle cramping catastrophe on a hot summer night
  • 2.2 True muscle strain checklist
  • 2.3 The “oh shit” moment: the most essential sign of muscle strain
  • 2.4 Location, location, location
  • 2.5 The hurtin’ and the weak
  • 2.6 Could you have a muscle spasm instead of a strain?
  • 2.7 Could you just have DOMS instead of a muscle strain?
  • 2.8 Could you have muscle “knots” instead of a muscle strain?
  • 2.9 What is a muscle knot? And how is different than spasm and strain?
  • 2.10 Referred pain from trigger points
  • 2.11 So how do you tell the difference between muscle strains and knots?
  • 2.12 Muscle strains that don’t heal have usually been hijacked by trigger points
  • 2.13 What can you do about muscle knots?
  • 3 Origins
    What caused your muscle strain?
  • 3.1 Zigging when you should have zagged
  • 3.2 The dancer’s strain (straining by stretch)
  • 3.3 What’s the worst case scenario for your muscle strain?
  • 3.4 Timing tips: when is it safe to use a torn muscle again?
  • 3.5 The risks of scar tissue
  • 4 Treatment, rehab, and prevention
    What should you do for a muscle strain? And what shouldn’t you do?
  • 4.1 Prevention: important even after you’ve been hurt
  • 4.2 Don’t challenge a strained muscle when the injury site is still sore to the touch
  • 4.3 Prevention: Warmups work
  • 4.4 Strength training, especially eccentric training
  • 4.5 Compression band training (AKA muscle “flossing”, AKA blood flow restriction training)
  • 4.6 You and “vitamin I”: anti-inflammatory meds, especially Voltaren® Gel
  • 4.7 Please, do not apply heat to a freshly pulled muscle — use ice!
  • 4.8 The ice exception in the low back
  • 4.9 After a few days, use heating or contrasting
  • 4.10 Epsom salt baths: don’t bother
  • 4.11 Don’t bother with Traumeel either
  • 4.12 Self-massage of muscle strains
  • 4.13 Getting relief from trigger points
  • 4.14 What about stretching? Can it treat or prevent strains?
  • 4.15 You need a rehab plan for grade II and III strains
  • 4.16 Use it or lose it: pain-free range of motion exercises and mobilizations
  • 4.17 Endurance training: under-rated but vital therapeutic exercise
  • 4.18 An old drug may prove to be an excellent treatment in the future
  • 4.19 Prevention: can you prevent muscle strains by upgrading your muscle balance?
  • 4.20 Prevention: will water and electrolytes make a difference?
  • 4.21 Regenerative medicine? Platelet-rich plasma
  • 4.22 Frickin’ laser beams
  • 4.23 Electric exercise: electrical muscle stimulation (EMS)
  • 5 Appendices
  • 5.1 Reader feedback … good and bad
  • 5.2 Acknowledgements
  • 5.3 Further Reading
  • 5.4 What’s new in this tutorial?
  • 5.5 Notes
dots before headings indicate updated sections ?There’s a detailed description of all updates at the bottom of the tutorial, and it’s nice to be able to see what’s new at a glance in the table of contents. Any section updated in the last 400 days is marked (hotter colours = fresher updates).

Q. Is there a print version? A. Electronic only, sorry. But you can print it yourself.

Q. Can I read this offline, like at the beach? A. Yes. Like any webpage, it can be saved for offline reading easily.

Q. Who sells this? A. PainScience.com is a small business in Vancouver, Canada, run by me, Paul Ingraham, sole author and publisher since 2007.

Q. Does the book offer a “cure” for muscle strain? A. No. I sell education about a notoriously tricky condition, not false hope. There’s nothing “too good to be true” here.

Q. Buy more & save 50%! A. Get a “boxed” set of all nine PainScience.com tutorials for great savings.MORE

Q. What’s with that surprise price tag?! A. I know it can make a poor impression, but I have to make a living and this is the best way I’ve found to keep the lights on here. Of course many people turn away, but 57,600 people have gone for it.?This is a tough number for anyone to audit, because my customer database is completely private and highly secure. But if a regulatory agency ever said “show us your math,” I certainly could. This count is automatically updated once every day or two, and rounded down to the nearest 100. It includes all individual and bundled books for sale on PainScience.com since 2007, and excludes a trickle of earlier sales, donations, and gifts. If money is tight, just ask me for free or discounted access.


Q. Can I read it on my iPad, Kindle, etc? A. Yes. Any Internet-enabled gadget works fine. (The e-Ink Kindles are not a good choice.)

Q. Satisfaction guaranteed, right? A. Of course—and no time limit.

Q. Can I buy this anywhere else? Amazon? A. Not yet. Maybe someday.

Q. Can I lend it? A. Yes, with a 3-person limit.

Q. Can I give it to my clients? A. I have a generous lending policy, but not that generous. 😉 Please recommend buying it, or consider my bulk purchase program.

Q. Why do you want my postal code? A. To prevent fraud (strongly recommended by my payment processor), and to identify customers for login and repeat business.

Q. Are you going to send me e-mail? A.  Just a receipt.

Q. Why should I trust you with my credit card? A. I will never see it: it goes straight from your screen to Stripe, a payment processing service with a great reputation for Doing Things Right. They handle all the high-tech security.



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How can you trust this information?

I apply a MythBusters approach to health care (without explosives): I have fun questioning everything. I don’t claim to have The Answer for muscle strain and pain. When I don’t know, I admit it. I read scientific journals, I explain the science behind key points (there are more than 60 footnotes here, drawn from a huge bibliography), and I always link to my sources.

For instance, there’s good evidence that educational tutorials are actually effective medicine for pain.?Dear BF, Gandy M, Karin E, et al. The Pain Course: A Randomised Controlled Trial Examining an Internet-Delivered Pain Management Program when Provided with Different Levels of Clinician Support. Pain. 2015 May. PubMed #26039902.  Researchers tested a series of web-based pain management tutorials on a group of adults with chronic pain. They all experienced reductions in disability, anxiety, and average pain levels at the end of the eight week experiment as well as three months down the line. “While face-to-face pain management programs are important, many adults with chronic pain can benefit from programs delivered via the internet, and many of them do not need a lot of contact with a clinician in order to benefit.” Good information is good medicine!

So all the science and all the options for muscle strain treatment are here. If you’ve been struggling with pulled muscle injury, I think this tutorial will feel like a “good find” to you!

As with all the tutorials on PainScience.com, I’ve worked hard to provide you with the best information available anywhere — not just better researched and referenced, but also regularly updated, and presented in a clear, friendly style that’s just like coming to my office and having a nice long conversation about it, where all your questions get answered. But at a fraction of the cost.

Muscle Strain Causes

Assuming you have a muscle strain — and not trigger points or DOMS or a spasm or a small purple monster stabbing you in the back — then it’s time to discuss how it happened.

A strain really is a rip. Muscle is made up of fibres, bound together in “fractal sausage wrappings.” If enough force is applied to them, those fibres and wrappings tear just like anything if you pull on it hard enough. There are three kinds of situations where muscle tends to tear:

  1. by stretching it too far yourself
  2. by being forced into a stretch too quickly or too far
  3. by contracting hard against strong resistance

The third scenario is the most common in sports. Such strains usually happen at moments when the muscle would normally elongate to allow a movement, but is also contracting to control or limit elongation. Sometimes the muscle just isn’t strong enough to hold up under these opposing forces. Something has to give.

This “contracting while lengthening” is called an “eccentric” contraction in physio-speak. You could tear your biceps by exerting yourself too intensely to resist the descent of the barbell, for instance. But most such muscle tears occur during fast, intense eccentric contractions. They are common in sprinters, for instance.

Technically, the muscle is doing what it is “supposed” to do. Eccentric contractions are a normal part of the action, and sometimes the forces involved are simply too great. Another view, however, is that injury occurs only when the muscle action is poorly coordinated.

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Muscle Strain Treatment

You can do a few things that may improve recovery time and completeness, or at least reduce pain along the way. I will also explain some of the basics of self-treating your trigger points, because they often complicate muscle strain healing.

But it’s important to bear in mind that there are essentially no proven treatments for muscle strain — that is, nothing that definitely speeds healing along, makes it more complete, or eliminates complications. A large 2017 scientific review by Ramos et al concluded that “the evidence of the effectiveness of these modalities in muscle injuries is not fully established due to the little scientific research on the topic.” They were referring to cryotherapy, laser therapy, therapeutic ultrasound, therapeutic exercise, and manual therapy, and I will get further into most of these.

The absence of evidence doesn’t mean that nothing works — just that none of the options have really been studied well enough to actually know. Speculation is unavoidable. In many ways, this book is not about “what works,” but about how to make educated guesses about what things are the most worth trying: the safest, the cheapest, the most practical and plausible. Here’s a quick summary of all the options, roughly in order of most promising to least:

And there are some treatment approaches that I am so skeptical of that I recommend avoiding:

Continue reading much, much more…

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Part 2.7

Appendices

Reader feedback … good and bad

Testimonials on health care websites reek of quackery, so publishing them has always made me a bit queasy. But my testimonials are mostly about the quality of the information I’m selling, and I hope that makes all the difference. So here’s some highlights from the kind words I’ve received over the years … plus some of the common criticisms I receive, at the end. These are all genuine testimonials, mostly received by email. In many cases I withold or change names and identifying details.

Just to let you know your style and thoughts are so much more on target than anything I have ever read. I’m an engineer, runner, father of eight, kids that are doctors, and I find that so little is properly discussed or back up with evidence and decent reasoning. I may not agree with everything, but I’ve come to trust that you are diligent and earnest and know your subject matter as well as anyone.

~Greg Lennon


The internet is a dicey place to spend money ... so many scams. I wanted to let you know how appreciative I am of your eBook on muscle strains. When I got to the stop sign, I had to reflect and realized that the style and quality of what you had written was worth a gamble. Well, paying the twenty bucks and learning what I wanted to learn — and more — was worth every penny. I am now rehabbing my level 1 calf strain with full confidence and feel very well informed moving ahead. Good luck and keep writing — we need all the help we can get out here!

~Craig Adkins, tennis player and professional skiing cameraman, Portland, Oregon


I read your article on muscle strains, and I was very impressed. You seem to really know your stuff. I wish there was one of you in every state!

~Robin


I found this article when I was researching how to heal my pulled muscle. I love the mobilization exercises at the end — great for a ‘desk jockey’ like me!

~Juanita Vannay


One more noteworthy endorsement, with regards to this whole website and all of my books, submitted by a London physician specializing in chronic pain, medical education, and patient-advocacy (that’s a link to his excellent blog):

I’m writing to congratulate and thank you for your impressive ongoing review of musculoskeletal research. I teach a course, Medicine in Society, at St. Leonards Hospital in Hoxton. I originally stumbled across your website whilst looking for information about pain for my medical students, and have recommended your tutorials to them. Your work deserves special mention for its transparency, evidence base, clear presentation, educational content, regular documented updates, and lack of any commercial promotional material.

— Dr. Jonathon Tomlinson, MBBS, DRCOG, MRCGP, MA, The Lawson Practice, London

What about criticism and complaints?

Oh, I get those too! I do not host public comments on PainScience.com for many reasons, but emailed constructive criticism, factual corrections, requests, and suggestions are all very welcome. I have made many important changes to this tutorial inspired directly by critical, informed reader feedback.

But you can’t make everyone happy! Some people demand their money back (and get it). I have about a 1% refund rate (far better than average in retail/e-commerce). The complaints of my most disatisfied customers have strong themes:

Acknowledgements

Thanks to every reader, client, and book customer for your curiosity, your faith, and your feedback and suggestions, and your stories most of all — without you, all of this would be impossible and pointless.

Writers go on and on about how grateful they are for the support they had while writing one measly book, but this website is actually a much bigger project than a book. PainScience.com was originally created in my so-called “spare time” with a lot of assistance from family and friends. Thanks to my wife for countless indulgences large and small; to my parents for (possibly blind) faith in me, and much copyediting; and to friends and technical mentors Mike, Dirk, Aaron, and Erin for endless useful chats, repeatedly saving my ass, plus actually building many of the nifty features of this website.

Special thanks to some professionals and experts who have been particularly inspiring and/or directly supportive: Dr. Rob Tarzwell, Dr. Steven Novella, Dr. David Gorski, Sam Homola, DC, Dr. Mark Crislip, Scott Gavura, Dr. Harriet Hall, Dr. Stephen Barrett, Dr. Greg Lehman, Dr. Jason Silvernail, Todd Hargrove, Nick Ng, Alice Sanvito, Dr. Chris Moyer, Lars Avemarie, PT, Dr. Brian James, Bodhi Haraldsson, Diane Jacobs, Adam Meakins, Sol Orwell, Laura Allen, James Fell, Dr. Ravensara Travillian, Dr. Neil O’Connell, Dr. Tony Ingram, Dr. Jim Eubanks, Kira Stoops, Dr. Bronnie Thompson, Dr. James Coyne, Alex Hutchinson, Dr. David Colquhoun, Bas Asselbergs … and almost certainly a dozen more I am embarrassed to have neglected.

I work “alone,” but not really, thanks to all these people.

I have some relationship with everyone named above, but there are also many experts who have influenced me that I am not privileged to know personally. Some of the most notable are: Drs. Lorimer Moseley, David Butler, Gordon Waddell, Robert Sapolsky, Brad Schoenfeld, Edzard Ernst, Jan Dommerholt, Simon Singh, Ben Goldacre, Atul Gawande, and Nikolai Boguduk.

Further Reading

Here are several additional articles of interest:

And here are the articles recommended for those of you who may have muscle knots, as opposed to a muscle strain:

What’s new in this tutorial?

Regular updates are a key feature of PainScience.com tutorials. As new science and information becomes available, I upgrade them, and the most recent version is always automatically available to customers. Unlike regular books, and even e-books (which can be obsolete by the time they are published, and can go years between editions) this document is updated at least once every three months and often much more. I also log updates, making it easy for readers to see what’s changed. This tutorial has gotten 33 major and minor updates since I started logging carefully in late 2009 (plus countless minor tweaks and touch-ups).

JulyEditing: Polish, some more details, and better integration into the book. [Section: Compression band training (AKA muscle “flossing”, AKA blood flow restriction training).]

JulyEditing: Polish, some more details, and better integration into the book. [Section: Strength training, especially eccentric training.]

MayMajor enhancement: Added an extremely useful evidence-based strength training recommendation. This is as good as any update gets! [Section: Strength training, especially eccentric training.]

JanuaryLike new: Substantial expansion of my coverage of this topic. [Section: Compression band training (AKA muscle “flossing”, AKA blood flow restriction training).]

2018New section: No notes. Just a new section. [Section: Electric exercise: electrical muscle stimulation (EMS).]

2018New section: No notes. Just a new section. [Section: Frickin’ laser beams.]

2018Science update: Added a highly relevant citation to Grassi et al. [Section: Regenerative medicine? Platelet-rich plasma.]

2018Cleanup: No new science, but a bunch of clarifications and editorial improvements. It’s a clearer and more useful section. [Section: Prevention: important even after you’ve been hurt.]

2018New tips: Added two evidence-based tips to help estimate how long a strain takes to heal. [Section: Timing tips: when is it safe to use a torn muscle again?]

2017Expanded: Added some substance, mainly citing and discussing Ramos et al on the lack of evidence for common treatments. It’s still a short introduction to the second half to the book , but not as absurdly brief as it was. [Section: Treatment, rehab, and prevention: What should you do for a muscle strain? And what shouldn’t you do?]

2017Improvements: Added more information about swelling and muscle deformation. [Section: True muscle strain checklist.]

2017Science update: Added a very interesting good-news reference that actually provides some decent support for massaging strains. [Section: Self-massage of muscle strains.]

2016Expanded: New evidence-based prevention risks and tips. [Section: Prevention: important even after you’ve been hurt.]

2015Minor science update: Citation of Collins 2008 and Bleakley 2012, reviewing icing evidence (or the lack of it), and a few related edits. [Section: Please, do not apply heat to a freshly pulled muscle — use ice!]

2015Expanded: Added discussion of surprising data about rates of reinjury. [Section: Prevention: important even after you’ve been hurt.]

2015Expanded: More than doubled the size of the section with an interesting addition: “Rupture: not as obvious as you’d think!” [Section: The “oh shit” moment: the most essential sign of muscle strain.]

Older updates — Many older updates are listed in a separate document, for anyone who cares to take a look.

Notes

  1. Bret “The Glute Guy” Contreras tells his story, and some other tales of extreme recovery, and extracts some lessons from them. See You’ll Never Squat Again. BACK TO TEXT
  2. Simons D. Foreword of The Trigger Point Therapy Workbook. 1st ed. New Harbinger Publications; 2001. “Muscle is an orphan organ. No medical speciality claims it. As a consequence, no medical specialty is concerned with promoting funded research into the muscular causes of pain.” BACK TO TEXT
  3. You can get a rough measure of how well-studied a subject is by doing a search for it on PubMed, a large database of citations to medical research. Searching for muscle strain is a bit tricky, because “muscle strain” is mentioned in lots of papers that aren’t really about muscle strain. But if you cleverly search for the terms “muscle strain” only in titles, you will get, as of 4/14/07, only 61 search results, even less than iliotibial band syndrome (another under-studied condition). Compare that to, say, 3000 for adhesive capsulitis (frozen shoulder), or 5900 for carpal tunnel syndrome. BACK TO TEXT
  4. Ramos GA, Arliani GG, Astur DC, et al. Rehabilitation of hamstring muscle injuries: a literature review. Rev Bras Ortop. 2017;52(1):11–16. PubMed #28194375.  PainSci #52750.  BACK TO TEXT
  5. Doctors lack the skills and knowledge needed to care for most common aches, pains, and injury problems, especially the chronic cases, and even the best are poor substitutes for physical therapists. This has been proven in a number of studies, like Stockard et al, who found that 82% of medical graduates “failed to demonstrate basic competency in musculoskeletal medicine.” It’s just not their thing, and people with joint or meaty body pain should take their family doctor’s advice with a grain of salt. See The Medical Blind Spot for Aches, Pains & Injuries: Most physicians are unqualified to care for many common pain and injury problems, especially the more stubborn and tricky ones.
    Cartoon of a man sitting in a doctor’s office. The doctor is holding a clipboard with a checklist with just two items on it: stress related and age related. The caption reads: “An extremely general practitioner.”

    Cartoon by Loren Fishman, HumoresqueCartoons.com

    BACK TO TEXT
  6. Strain and sprain are confusingly similar words for quite different things. They both refer to tearing, but of different tissues. A torn ligament is always called a sprain. A torn muscle is always called a strain. BACK TO TEXT
  7. Was it really the electrolytes? No. That’s what I thought at the time, but a nice myth-busting 2011 experiment comparing crampy runners with their uncramped comrades showed clearly that dehydration was not the culprit. Fun science. See Schwellnus et al. BACK TO TEXT
  8. Rozen, I and Dudkiewicz, I. “Wound Ballistics and Tissue Damage.” Chapter in: A. Lerner and M. Soudry (eds.), Armed Conflict Injuries to the Extremities, 21 DOI: 10.1007/978-3-642-16155-1_2, Springer-Verlag Berlin Heidelberg 2011. BACK TO TEXT
  9. Mild strains can come on relatively slowly. I have experienced at least two “slow” muscle tears of my left quadriceps while playing ultimate (a hard-running Frisbee sport). I recall in each case that there was definitely a moment of injury — but it was kind of a long, drawn-out moment. I stumbled a little. There was some pain, but not enough to stop me at first. As I kept running, though, it became clear that I was going to be benched. I had torn a few fibres, perhaps, and I was tearing more as I ran — a slow rip, a few more fibres with every step. The sense of impending doom was very strong! So, in this case, the onset was not exactly a “sudden” attack of serious pain, but it was still a perfectly clear, well-defined, can’t-miss-it kind of event. BACK TO TEXT
  10. O'Laughlin SJ, Flynn TW, Westrick RB, Ross MD. Diagnosis and expedited surgical intervention of a complete hamstring avulsion in a military combatives athlete: a case report. Int J Sports Phys Ther. 2014 May;9(3):371–6. PubMed #24944856.  PainSci #53845.  BACK TO TEXT
  11. Example: if you rupture your Achilles tendon, you lose nearly all of your ankle plantarflexion strength. The only muscles pulling on the back of the heel are the gastrocnemius and soleus, which make up almost all the bulk of the calf, and all that strength is funeled into the Achilles tendon. BACK TO TEXT
  12. Imagine you’re a tough athlete, like the guy in the cited case study, a mixed martial arts fighter! How do you feel if you lose about one third of the strength in your hamstrings? You know something’s wrong, for sure … but you’re tough, so you probably don’t make all that much of it. “Doc, I hurt something and I don’t think I’d want to fight right now, but I can still walk around fine.” You don’t need anywhere close to full strength most of the time … so being 30-40% short is really not that big a deal. BACK TO TEXT

There are 56 more footnotes in the full version of the book.


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