The treatment of torn muscles by mobilisation and massage resembles very largely that applicable to torn ligaments. The position of these accidents is usually at or near the bony origin or attachment of the muscle. The muscle or its tendon may not be actually torn; the injury may be to the periosteal insertion. Muscle fibres may, of course, be torn anywhere. Examples of injury to the periosteum, or to the muscle near its insertion to the bone, are found in the so-called "tennis" and "golf elbows." One form of "golf shoulder" is due to rupture of some fibres in the deltoid. If suitable and early treatment is not forthcoming, granulation tissue for repair is formed and is broken down the next time the muscle contracts violently. More granulation tissue forms and again is broken down. Soon nerve fibres become involved, the pain gets worse, and use is restricted. The granulation tissue then becomes organised and an adhesion is formed, perhaps with the involvement of the nerve fibres. Wasting soon follows, and the patient is left with a chronic incapacity for his favourite game. His general health suffers, and a serious cycle of events is started. The "tennis-leg" is said to be caused by tearing of the plantaris tendon. Probably this is a rare accident. Rupture of any fibres in the calf muscles may be the cause of the pain. The patient usually imagines that he has been hit on the back of the leg by his partner.

The immediate treatment is to check effusion, or, if effusion has taken place, to disperse it before it has had time to organise. The importance of this procedure is seen after subcutaneous section of the plantar fascia in the treatment of a pes cavus. If haemorrhage is arrested by pressure, the patient is rarely if ever conscious of any discomfort in the sole; if pressure has been inefficiently applied, there may be a tender lump in the sole that will cripple the patient for weeks, or it may be even for months.

Having checked effusion locally, it is necessary to counter any vaso-motor reflex disturbance, and treatment for the first day ceases.

Next day there is little fear of recurrence of haemorrhage provided the muscle is not allowed to contract. All the other muscles in the limb may be exercised, and relaxed movement through minute amplitude may be given, in the direction which is normally controlled by the injured muscle. Local treatment should be given to any area where there is local swelling or oedema, but it must be so administered that there is no danger of loosening any clot that seals the mouth of a torn vessel. This entails pressure of an even character, slowly and gently applied, and the most suitable treatment is gentle kneading with the ball of the thumb or palm of the hand. This should follow the administration of general massage to produce reflex effect and to promote circulation throughout the limb. It is wise to maintain pressure with wool and a bandage to ensure that there is no increase in local effusion. Nothing will hasten the wasting of a muscle more effectively than separating it from its attachment. Hence the desirability of renewing its function of contraction with as little delay as possible after any portion has been torn. Herein lies a difficulty: contraction is essential; strain is most detrimental. By performing relaxed movements a muscle can be made to shorten and elongate to a certain extent, but this is not enough entirely to prevent wasting. A patient can usually be taught to contract and relax a muscle without placing any strain upon it, and if he will perform this "exercise" faithfully much may be achieved. Before active contraction is prescribed the limb should be placed in such a position that the origin and insertion of the muscle are as close together as possible. Mr. W. R. Bristow uses, with admirable success, a means whereby this end can be attained without the co-operation of the patient. He uses a faradic current of low voltage, the strength being regulated by manipulation of a metal core, which is alternately pushed into and withdrawn from the hollow in the secondary coil. In this way a graduated contraction is produced which, to quote one instance only amongst many, aids in the restoration of a victim of a rider's strain more rapidly and completely than can any amount of perseverance on the part of the patient or his masseur.

Not only is contraction essential to the maintenance of muscular strength, but, after rupture of muscular fibres, it is essential to prevent the formation of adhesions. Once any muscle, or even any group of fibres within a muscle, becomes adherent to an adjacent group, trouble is sure to follow; and the stretching of the adhesions may be a prolonged and tedious process. It can be effected by the prescription of suitable exercises, but here again contraction in response to electrical stimulation will succeed far more rapidly, in most cases, than if voluntary contraction is relied upon alone. A combination of both is, of course, the ideal.

The amount of strain that can be placed with safety on a muscle that has suffered injury must depend upon the extent of the injury. The labourer who "strains" the muscles of his forearm slightly puts on a leather wristlet, which acts as a sort of block to his movement. He then goes on with his work. Often this suffices, and Sir Robert Jones has applied the principle further, and "straps" the deltoid near its insertion, the quadriceps above the patella and the leg muscles above the ankle, when these muscles have sustained injury. Some use of the injured muscle is therefore not only to be allowed but is actually beneficial, and the masseur can often render great assistance by using one hand to replace the "wristlet" of the labourer. To decide how much movement to give or how much use to prescribe we are driven back to the golden rule of all treatment of recent injury, that movement, active or passive, must be painless. To ensure this the movements must be slow and the contraction must be performed rhythmically, not only as regards the sequence of movements, but also as regards the actual contraction during each several movement. In other words, there must be no spasmodic or irregular twitching.