Soft Tissue Injury, Repair, and Management
subacute stage
14-21 days, up to 6 weeks: proliferation, repair, and healing Tissue responses and characteristics: -removal of noxious stimuli -growth of capillary beds into area -collagen formation -granulation -very fragile, easily injured tissue Clinical Signs: -decreasing inflammation -pain synchronous with tissue resistance
acute stage
4-6 days: reaction & inflammation Tissue responses: -vascular changes -exudation of cells and chemicals -clot formation -phagocytosis, neutralization of irritants -early fibroblastic Clinical Signs: -inflammation -pain before tissue resistance
chronic stage
6 months-1 year: maturation and remodeling Tissue response and characteristics: -maturation of connective tissue -contracture of scar tissue -remodeling of scar -collagen aligns to stress Clinical Signs: -absence of inflammation -pain after tissue resistance
Muscle weakness
A decrease in the strength of muscle contraction that may be the result of a systemic, chemical, or local lesion of a nerve of the central or peripheral nervous system or the myoneural junction. -It may also be the result of a direct insult to the muscle or simply due to inactivity.
Grade the exercise to the stage of recovery to stress the tissues safely
A properly applied and progressed therapeutic exercise program should
Adhesion
Abnormal adherence of collagen fibers to surrounding structures during immobilization, after trauma, or as a complication of surgery, which restricts normal elasticity and gliding of the structures involved.
Contracture
Adaptive shortening of skin, fascia, muscle, or a joint capsule that prevents normal mobility or flexibility of that structure.
Subluxation
An incomplete or partial dislocation of the bony partners in a joint that often involves secondary trauma to surrounding soft tissue.
Ganglion
Ballooning of the wall of a joint capsule or tendon sheath. Ganglia may arise after trauma, and they sometimes occur with rheumatoid arthritis.
Hemarthrosis
Bleeding into a joint, usually due to severe trauma.
Contusion
Bruising from a direct blow, resulting in capillary rupture, bleeding, edema, and an inflammatory response.
Dislocation
Displacement of a part, usually the bony partners in a joint, resulting in loss of the anatomical relationship and leading to soft tissue damage, inflammation, pain, and muscle spasm
tendinopathy
Histological findings in ____ have shown a poor healing response with collagen degeneration, fiber thinning and disorientation, hypercellularity, and scattered vascular ingrowth.
partial
If a rupture or tear is ____, pain is experienced in the region of the breach when the muscle is stretched or when it contracts against resistance.
complete
If a rupture or tear is _____, the muscle does not pull against the injury, so stretching or contraction of the muscle does not cause pain.
Myofascial compartment syndromes
Increased interstitial pressure in a closed, nonexpanding, myofascial compartment that compromises the function of the blood vessels, muscles, and nerves. -It results in ischemia and irreversible muscle loss if there is no intervention. -Causes include, but are not limited to, fractures, repetitive trauma, crush injuries, skeletal traction, and restrictive clothing, wraps, or casts.
Bursitis
Inflammation of a bursa.
Synovitis
Inflammation of a synovial membrane; an excess of normal synovial fluid in a joint or tendon sheath caused by trauma or disease.
chronic pain syndrome
Longer than 6 months no link to source of pain or inflammation
Dysfunction
Loss of normal function of a tissue or region that may be caused by adaptive shortening of the soft tissues, adhesions, muscle weakness, or any condition resulting in loss of normal mobility.
Joint dysfunction
Mechanical loss of normal joint play in synovial joints; commonly causes loss of function and pain. -Precipitating factors may be trauma, immobilization, disuse, aging, or a pathological condition such as rheumatoid arthritis.
Identifying and treating the cause of the guarding.
Muscle guarding is best treated by
Strain
Overstretching, overexertion, or overuse of soft tissue; tends to be less severe than a sprain, occurs from slight trauma or unaccustomed repeated trauma of a minor degree -frequently used to refer specifically to some degree of disruption of the musculotendinous unit
As the result of repetitive, submaximal stress of a muscle or tendon
Overuse syndromes occur
Maintain fluid dynamics and nutrition in a joint
Passive ROM and grade I or II joint-mobilization techniques are appropriate during the acute stage of soft tissue healing. What do these interventions have in common when used during this stage?
Reflex muscle guarding
Prolonged contraction of a muscle in response to a painful stimulus. -The primary pain causing lesion may be in nearby or underlying tissue, or it may be a referred pain source. -When not referred, the contracting muscle functionally splints the injured tissue against movement. -ceases when the painful stimulus is relieved.
Intrinsic muscle spasm
Prolonged contraction of a muscle in response to the local circulatory and metabolic changes that occur when a muscle is in a continued state of contraction. -Pain is a result of the altered circulatory and metabolic environment, so the muscle contraction becomes self-perpetuating regardless of whether the primary lesion that caused the initial guarding is still irritable (Fig. 10.1). -may also be a response of muscle to viral infection, cold, prolonged periods of immobilization, emotional tension, or direct trauma to muscle.
Sprain
Severe stress, stretch, or tear of soft tissues, such as joint capsule, ligament, tendon, or muscle - frequently used to refer specifically to injury of a ligament and is graded as a first (mild), second (moderate), or third (severe) degree sprain
overuse, cumulative trauma, repetitive strain, re-injury of old scar, trauma (too early return), contractures or poor mobility & posture
causes of chronic inflammation
faulty mechanics or habit: o Imbalance between length and strength of muscles around the joint o Rapid or excessive repeated eccentric demand placed on muscles not prepared to withstand load o Muscle weakness or inability to respond to strength demands o Bone Malalignment or weak structural support o Change in the usual intensity or demands of an activity o Returning to an activity too soon after injury o Sustained awkward postures or motions o Environmental factors & Age-related factors o Training errors
contributing factors to chronic inflammation
chronic recurring pain
cumulative trauma/chronic inflammation: o Inflammatory process is perpetuated (Can't heal itself) -Proliferation of fibroblasts with increased collagen production and degradation of mature collagen leads to predominance of new, immature collagen. o Weakening effect o Progressive limitation of motion
Tendinosis
degeneration of the tendon due to repetitive microtrauma.
controlled
during the chronic stage, because remodeling of the maturing collagen occurs in response to the stresses placed on it, it is important to use ______ forces that replicate normal stresses on the tissue. Maximum strength of the collagen develops in the direction of the imposed forces.
stress
during the chronic stage, pain that the patient now experiences arises only when _____ is placed on restrictive contractures or adhesions or when there is soreness due to increased stress of resistive exercise.
eccentric & heavy resistance
exercises that are NOT used in the early subacute stage after muscle injury because may cause added trauma to muscle
early
inflammation is a good thing where in the healing process?
Tendinitis
inflammation of a tendon; there may be resulting scarring or calcium deposits.
Tenosynovitis
inflammation of the synovial membrane covering a tendon
Tenovaginitis
inflammation with thickening of a tendon sheath.
active exercises: -Multiple-angle, submaximal isometric exercises -Active ROM exercises -Muscular endurance exercises -Protected weight-bearing exercises progression of stretching: - Warm the tissues - Muscle relaxation techniques - Joint mobilization/manipulation - Stretching techniques - Massage - Use of the new range
initiation of these interventions in subacute stage
control inflammation (RICE) & prevent deleterious effects of rest (nondestructive movement: PROM< massage, and muscle setting with caution)
interventions for phase 1 of tissue healing (max protection - acute stage)
develop mobile scar (selective stretching, mobilization/manipulation of restrictions) & promote healing (non destructive active, resistive, open & closed chain stabilization, muscular endurance, and cardiopulmonary endurance exercises - carefully progress intensity and range)
interventions for phase 2 of tissue healing (mod protection - subacute stage)
increase tensile quality of scar (progressive strengthening & endurance exercise) & develop functional independence (functional exercises & specificity drills)
interventions for phase 3 of tissue healing (min protection - chronic stage)
formation of a strong, mobile scar at the site of the lesion, so there is complete and painless restoration of activities
long term goal of the acute phase
-patient education -protection of injured tissue -prevention of adverse effects of immobility
management guidelines for acute stage
-Patient education -Considerations (Criteria) for progression of exercise -Progression of stretching -Progression of exercises for muscle performance -Return to high demand activities
management guidelines for chronic stage
-patient education (encourage non-exacerbating activity, HEP, ADL modifications) -management of pain & inflammation (criteria for initiating active exercises & monitor symptoms during progression) -decreased swelling -pain no longer constant or exacerbated by movement in available range
management guidelines for subacute stage
must control to avoid continued tissue break down and excessive scar tissue
management of chronic acute stage
- Mobilize scar (watch for inflammation) - Stabilization exercise to reduce guarding - Muscle endurance, especially postural stabilizers - Functional progression
management of subacute and chronic stages of healing following chronic inflammation
subacute stage
name that stage Precautions: The signs of inflammation or joint swelling normally decrease early in this stage. Some discomfort will occur as the activity level is progressed, but it should not last longer than a couple of hours. Signs of too much motion or activity are resting pain, fatigue, increased weakness, and spasm lasting beyond 24 hours.
chronic recurring pain
name that stage Precautions: if there is progressive loss of ROM as the result of stretching, do not continue to stretch. Re-evaluate the condition and determine if there is still a chronic inflammation with contracting scar or if there is protective muscle guarding. Emphasize stabilizing the part and training in safe adaptive patterns of motion.
acute stage
name that stage Precautions: the proper dosage of rest and movement must be used during the inflammatory stage. Signs of too much movement are increased pain or increased inflammation Contraindications: Stretching and resistance exercise should not be performed at the site of the inflamed or swollen tissue.
chronic stage
name that stage: Precautions: There should be no signs of inflammation. Some discomfort will occur as the activity level is progressed, but it should not last longer than a couple of hours. Signs that activities are progressing too quickly or with too great a dosage are joint swelling, pain that lasts longer than 4 hours or that requires medication for relief, a decrease in strength, or fatigues more easily.
Grade 1 (1st degree)
o Mild pain at the time of injury or within the first 24 hours. o Mild swelling, local tenderness, and pain occur when the tissue is stressed.
Grade 2 (2nd degree)
o Moderate pain that requires stopping the activity. o Stress and palpation of the tissue greatly increase the pain. o When the injury is to ligaments, some of the fibers are torn, resulting in some increased joint mobility
Grade 3 (third degree)
o Near-complete or complete tear or avulsion of the tissue (tendon or ligament) with severe o Stress to the torn tissue is usually painless; palpation may reveal the defect. A torn ligament results in instability of the joint.
review
pain with ROM
maximum protection
physical therapy goals for acute stage of tissue healing
minimum to no protection (return to function)
physical therapy goals for chronic stage of tissue healing
moderate protection (controlled motion)
physical therapy goals for subacute stage of tissue healing
chronic inflammation
prolonged signs
Overuse syndromes, cumulative trauma disorders, and repetitive strain injury
repeated, submaximal overload and/or frictional wear to a muscle or tendon resulting in inflammation and pain.
review
signs of excessive stress with exercise/activity
vascular stasis
slowing of the blood in the bloodstream with vasodilation and fluid exudation to allow chemical mediators and inflammatory cells to collect and respond to the stimulus. *important to prevent in acute stage via circulation*
PROM low-dosage joint mobs muscle setting massage (other areas: ROM, resistance exercise, functional activities, aerobic)
specific interventions for acute stage
Tendinopathy
the general term that refers to tendon injury affected by mechanical loading
6-8 weeks
timeline for bone to heal
6-8 weeks
timeline for cartilage to heal
4-8 weeks
timeline for ligament to heal
2-6 weeks
timeline for muscle to heal
1-24 months
timeline for nerve to heal
7-10 days
timeline for skin to heal
4-6 weeks
timeline for tendon to heal
review
understand this concept