Soft Tissue Injuries and Healing

Objectives

• Soft tissue lesions have varying definitions that must be distinguished.
• Soft tissue healing occurs in distinct phases.
• Each phase of soft tissue healing has general treatment recommendations.
• PEACE and LOVE acronyms are related to the management of soft tissue injury.

Soft Tissue Lesions

• A strain affects the musculotendinous unit.
• A sprain affects the joint capsule and ligaments.
• Dislocation is the complete displacement of a joint.
• Subluxation is the partial displacement of a joint.
• Tendinopathy is a tendon pathology caused by mechanical load.
• Synovitis is inflammation of the synovial membrane.
• Hemarthrosis refers to bleeding into a joint.
• Bursitis is the inflammation of a bursa.
• A contusion is bruising due to trauma.

Grades of Sprain/Strain

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

Healing Times by Grade

• Exercise-induced muscle injury can heal in 0-3 days.
• Grade 1 muscle injuries take 1-4 weeks to heal.
• Grade 2 muscle injuries require 3-12 weeks of healing.
• Grade 3 muscle injuries need 1-6 months to heal.
• Tendonitis heals in 3-7 weeks.
• Tendonosis requires 3-6 months to heal.
• Grade 1 ligament sprains heal in 2-8 weeks.
• A Grade 2 ligament sprain takes 2-6 months to heal.
• Grade 3 ligament sprains require 6-12 months for recovery.
• Meniscus/Labrum injuries need 3-12 months to heal.
• Fractures typically heal in 6-8 weeks.

Soft Tissue Repair

• The inflammatory phase involves assessing damage and clearing damaged tissue, lasting 4-6 days up to 2 weeks.
• The proliferative phase involves beginning repairs, lasting 4-24 days, but up to 6 weeks in areas with limited circulation like tendons.
• Remodeling involves strengthening and completing the repairs and can last from 3 weeks to 2 years based on the tissue and damage.

Inflammatory Phase Details

• Chemical signals like histamine and bradykinin induce vascular changes and edema.
• Chemotaxis attracts leukocytes and other immune cells.
• Clot formation occurs.
• Phagocytosis via leukocytes and macrophages takes place.
• Clinical signs of inflammation include redness, swelling, heat, and pain.
• Movement causes pain before tissue resistance.

Inflammatory Phase Management

• Control stress to the injured tissue through protection.
• Reduce swelling.
• Control, but do not interfere with, the inflammatory response.
• Pain should guide management.
• PEACE: Protection, Elevation, Avoid anti-inflammatories, Compression, and Education.

PEACE Acronym

• P: PROTECTION, avoid activities that increase pain during the first few days after injury
• E: ELEVATION, elevate the injured limb higher than the heart as often as possible
• A: AVOID ANTI-INFLAMMATORIES to avoid reduced tissue healing, avoid icing
• C: COMPRESSION, use elastic bandage or taping to reduce swelling
• E: EDUCATION, let nature play its role and avoid unnecessary passive treatments / medical investigations

Proliferative Phase Details

• Growth of capillary beds occurs.
• Collagen formation (Type III) occurs.
• Granulation tissue forms.
• Movement causes pain synchronous with tissue resistance.
• Inflammation signs decrease.

Proliferative Phase Management

• Maintain controlled stressing of tissues by progressing ROM, intensity and frequency and targeting restrictions.
• Tissue remains fragile, so avoid quick and explosive stressing.
• Pain should be the guide.
• LOVE: Load, Optimism, Vascularization, Exercise.

Remodeling Phase Details

• Scar tissue matures.
• Scar tissue contracture occurs.
• Type III collagen remodels to Type I.
• Collagen aligns to stress.
• Inflammation signs are absent.
• Movement causes pain at end-range tissue resistance.

Remodeling Phase Management

• Progressively stress tissues by increasing volume, load, and intensity.
• Incorporate rapid, quick, and power movements.
• Progress toward returning to prior level of function.
• Avoid pain, but some discomfort is normal when pushing limits.
• LOVE: Load, Optimism, Vascularization, Exercise.

Factors Affecting Healing

• Lifestyle Factors: Diet, activity levels, smoking/alcohol, and stress impact healing.
• Comorbidities: Age, obesity, diabetes, and immunocompromised conditions affect healing.

Application Cases

• For each of these cases, it is important to:
• Identify which phase of healing the patient is experiencing.
• Determine when the patient will move to the next phase.
• Decide on one piece of education to provide the patient about their phase of healing.
• Determine one appropriate intervention for the patient.

Case 1

• A 16-year-old has a Grade 1 sprain of the ATFL 36 hours prior.
• There is slight swelling in the ankle
• Pain is at its worst, a 4/10 in the last 24 hours.
• Pain at end-range dorsiflexion and inversion is present.
• There is no pain with ambulation, but there is pain with running, jumping, and cutting.
• The patient wants to be ready to play in the state championship tomorrow night.

Case 2

• A 40-year-old reports a Grade 2 hamstring strain 2 months prior.
• There is absence of swelling.
• No pain occurs with daily activities, but discomfort with stairs and running (2/10).
• There is slight pain (2/10) at end-range stretch.
• The patient hopes to be prepared for slow-pitch softball season in a couple of months.

Case 3

• A 23-year-old strained his back 2 weeks prior while moving into a new apartment.
• He is slowly regaining his ROM, but still has pain (4/10) at end-range flexion and rotation.
• There is no pain at rest, except sitting for more than 30 minutes (4/10).
• The patient wants to return to running and be ready for a plane ride to Germany in 1 month.

Overview of soft tissue lesions including strains, sprains, and tendinopathies. Explains the grades of sprains/strains and phases of soft tissue healing. Includes general treatment recommendations.