Soft Tissue Healing: Lesions, Phases & Treatment

Objectives of Soft Tissue Healing Understanding

• Understand various soft tissue lesions and their definitions
• Learn the phases of soft tissue healing.
• Know general treatment recommendations for each phase of healing
• Understand the use of the acronyms PEACE and LOVE in soft tissue injury management

Types of Soft Tissue Lesions

• Strain involves the musculotendinous unit
• Sprain affects the joint capsule and ligaments
• Dislocation refers to a complete displacement
• Subluxation is a partial displacement
• Tendinopathy is a tendon pathology due to mechanical load
• Synovitis involves inflammation of the synovial membrane
• Hemarthrosis refers to bleeding within a joint
• Bursitis is inflammation of a bursa
• Contusion refers to bruising resulting from trauma

Grades of Sprain/Strain Injuries:

• Grade 1 involves stretching or microscopic tears, minimal swelling, localized pain, and almost normal ROM.
• Grade 2 involves a partial tissue tear, moderate swelling and bruising, and loss of ROM with significant pain.
• Grade 3 is a complete tear with severe pain, swelling, bruising, and loss of ROM.

Soft Tissue Repair Phases:

• Inflammatory Phase involves damage assessment and clearing out damaged tissue and lasts 4-6 days up to 2 weeks.
• Proliferative Phase involves the start of repairs for 4-24 days, or up to 6 weeks in limited circulation areas like tendons.
• Remodeling Phase is for strengthening and completing repairs within 3 weeks to 2 years, depending on tissue and damage grade.

Characteristics and Management of the Inflammatory Phase:

• Tissue response involves chemical signals like histamine and bradykinin that cause vascular changes and edema.
• Chemotaxis attracts leukocytes and immune cells to the area, leading to clot formation and phagocytosis.
• Clinical signs include redness, swelling, heat, and pain, with movement causing pain before tissue resistance.
• Management focuses on controlling stress in the injured tissue through protection, reducing swelling, not interfering with the inflammatory response, and using pain as a guide.
• Implement PEACE: Protection, Elevation, Avoid anti-inflammatories, Compression, Education

Characteristics and Management of the Proliferative Phase:

• Tissue response involves growth of capillary beds, collagen formation (Type III), and granulation tissue.
• Clinical signs include pain synchronous with tissue resistance and decreasing inflammation.
• Management involves continued controlled stressing of tissues, progressing ROM, intensity, and frequency, with a focus on restrictions
• Still fragile tissue requires no quick, explosive movements, and monitor pain levels.
• Implement LOVE: Load, Optimism, Vascularization, Exercise

Characteristics and Management of the Remodeling Phase:

• Tissue response involves maturation of scar tissue, contracture of scar tissue, remodeling of Type III collagen to Type I, and collagen aligning to stress.
• Clinical signs include no inflammation signs, and movement causes pain at end-range tissue resistance.
• Management involves progressive stress to tissues by increasing volume, load, and intensity
• Incorporate rapid, quick, power movements, progressive return to prior levels, and avoiding pain while accepting discomfort when pushing limits.

Factors Affecting Healing:

• Lifestyle factors include diet, activity levels, smoking/alcohol, and stress.
• Comorbidities include age, obesity, diabetes, and immunocompromised conditions.

Application to Cases:

• Identify the phase of healing
• Determine when the patient will move to the next phase
• Provide education appropriate for the healing phase
• Determine an appropriate intervention for the patient

Case Examples

• The cases below are for educational use to identify the phase, what phase is next, patient education and interventions

Case 1

• A 16-year-old with a Grade 1 ATFL sprain 36 hours ago has slight swelling, 4/10 pain, pain at end-range dorsiflexion and inversion.
• No pain with ambulation, but pain with running, jumping, and cutting, is wanting to be ready for a game tomorrow night

Case 2

• A 40-year-old with a Grade 2 hamstring strain for 2 months, no swelling, no pain with daily activities, some discomfort with stairs and running (2/10), slight pain (2/10) at end-range stretch.
• Wants to be ready for softball season in a couple of months.

Case 3

• A 23-year-old strained his back 2 weeks ago, slowly regaining ROM with pain (4/10) at end-range flexion and rotation, no pain at rest except sitting for more than 30 minutes (4/10).
• Wants to be able to get back to running and be ready for a plane ride to Germany in 1 month.

Explore soft tissue lesions, healing phases, and treatments. Understand strains, sprains, dislocations, and tendinopathies. Learn treatment recommendations for each healing stage and the PEACE and LOVE principles.