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