Soft Tissue Injury Management Chapter 10

Chapter 10: Soft Tissue Injury, Repair, and Management

• Examination process is crucial to determine the stage of recovery (acute, subacute, or chronic) of involved tissues.
• This helps determine the appropriate type and intensity of exercises to facilitate healing without interfering with recovery.
• Preventing further problems and maximizing return of function are key goals.

Musculoskeletal Disorders and Tissue Response to Injury

• Soft Tissue Lesions:
  • Strain: Overstretching, overexertion, or overuse of soft tissue (muscle/tendon).
  • Sprain: Overstretching, overexertion, or overuse of soft tissue (ligament).
  • Dislocation: Displacement of a part (usually bony partners in a joint).
  • Subluxation: Incomplete or partial dislocation of bony partners in a joint.

Muscle Tendon Rupture or Tear

• Partial Tear: Pain during muscle stretches or contractions.
• Complete Tear: Muscle does not pull against the injury; stretching or contraction does not cause pain.
• Tendinopathy: Tendon injury affected by mechanical loading.
• Tenosynovitis: Inflammation of the synovial membrane covering a tendon.
• Tendinitis: Inflammation of a tendon.
• Tendinosis: Degeneration of a tendon due to repetitive microtrauma.
• Synovitis: Inflammation of a synovial membrane (joint or tendon sheath).

Musculoskeletal Disorders and Tissue Response to Injury

• Hemarthrosis: Bleeding into a joint.
• Ganglion: Ballooning of the wall of a joint capsule or sheath.
• Bursitis: Inflammation of a bursa.
• Contusion: Bruising from a direct blow, resulting in capillary rupture, bleeding, edema, and an inflammatory response.
• Overuse syndromes, cumulative trauma disorders, repetitive strain injuries: Conditions involving repetitive stress and strain on muscles and tendons.

Musculoskeletal Disorders and Tissue Response to Injury

• Primary pathology: Determining the primary pathology can be difficult, especially when tissue healing has limitations or secondary losses of function due to trauma or pathology.
• Dysfunction: Loss of normal function in a tissue or region.
• Joint Dysfunction: Mechanical loss of normal joint play in synovial joints.
• Contracture: Adaptive shortening of skin, fascia, muscle, or joint capsule preventing normal mobility or flexibility of a structure.
• Adhesions: Abnormal adherence of collagen fibers to surrounding structures.

Musculoskeletal Disorders and Tissue Response to Injury

• Reflex Muscle Guarding: Prolonged contraction of a muscle in response to painful stimuli.
• Intrinsic Muscle Spasm: Prolonged muscle contraction due to local circulatory and metabolic changes.
• Muscle Weakness: Decrease in the strength of muscle contractions.
• Myofascial Compartment Syndrome: Increased pressure in a closed, non-expanding myofascial compartment compromising blood vessels, muscles, and nerves.

Severity of Tissue Injury

• Grade I (first-degree): Mild pain within 24 hours of injury, mild swelling and tenderness, pain when stressed.
• Grade II (second-degree): Moderate pain requiring activity cessation, significant increase in pain with stress and palpation, some laxity.
• Grade III (third-degree): Complete or near-complete tear or avulsion of tissue, usually painless with palpation revealing a defect.

Grades of Sprain and Strain

• Grade I: Stretching, small tears.
• Grade II: Larger, but incomplete tear.
• Grade III: Complete tear.

Cardinal Signs of Inflammation

• Redness: Caused by dilation of arterioles/increased blood flow.
• Heat: Increased chemical activity and increased blood flow to the skin surface.
• Swelling: Caused by accumulation of blood and damaged tissue cells.
• Pain: Direct injury to nerve fibers, pressure of hematoma on nerve endings, chemical irritants (bradykinin, histamine, prostaglandin).
• Loss of Function: Increased pain/swelling.

Stages of Inflammation and Repair

• Acute Stage: The first phase of healing (4-6 days). Characterized by swelling, redness, heat, pain at rest, and loss of function. Painful range of motion and muscle guarding.
• Tissue responses: Early phases include vascular changes, cellular exudation, edema formation, and phagocytosis.
• Acute Phase Management Guidelines: Focus on maximum protection to help heal tissue through POLICE guidelines.
• Subacute Stage: The second phase of healing (10-17 days). Signs of inflammation decrease and eventually disappear. Pain may occur with ROM and when tissues are stressed.
• Subacute Tissue Responses: Fibroblast activity, collagen formation, and granulation tissue development increase. Myofibroblastic activity begins around day 5, and scar shrinkage starts.
• Subacute Phase Management Guidelines: Initial and progressive non-destructive exercise and activities and patient education.
• Chronic Stage: The third phase of healing (6 months-1 year). No inflammation is present. Pain may be present when testing tight structures and may be limited by contractures, adhesions, weakness etc.

Davis Law

• Ligaments and soft tissues, when under persistent tension, will elongate by producing new material.
• Conversely, soft tissues that aren't under tension will gradually shorten.

Wolff's Law of Bone

• Bone growth and remodeling respond to the forces acting on it.
• After an injury, stresses in specific directions help bone remodel to a healthy state.

Specific Interventions and Dosages for the Acute Phase

• Passive ROM: Used to maintain mobility within pain limits.
• Low-Dosage Joint Mobilization Techniques: Gentle isometric muscle contractions at low intensity to prevent pain or compression.
• Massage: Gently applied to injured tissues to move fluid and prevent adhesions.

Stages of Inflammation and Repair

- **Range of Motion (ROM):** Active or passive movements to maintain joint mobility, guided by the affected area.
- **Resistance Exercises:** Should be applied to muscles not directly related to injuries.
- **Functional Activities:** Use of supportive devices as needed, based on injury area and activities.

Specific Interventions and Dosages for the Subacute Phase

• Important to initiate and progress non-destructive exercises that are within the tolerance of healing tissues. Key to initiating and progressing non-destructive exercises and activities.
• Implement patient education on expected symptoms and consistent home exercise programs
• Monitoring pain levels and managing inflammation are key.

Multiple-angle, Submaximal Isometric Exercises

• Shortened, relaxed position to avoid pulling the new scar.
• Contractions kept below the perception of pain.
• Active range of motion exercises with light resistance to reinforce proper joint mechanics.

Muscular Endurance Exercises

• Begin with active range of motion (ROM).
• Progress to low intensity, high repetition exercises with light resistance.
• Implement protected weight bearing for exercises to reinforce appropriate muscle contractions and to promote development of control.
• Warm tissues, using relaxation and stretching techniques if needed, and promote new range of motion using massage to create a functional range of motion.

Initiation and Progression of Stretching

• Avoid complete or continuous immobilization.
• Gentle, but appropriate stretching is essential to maintain tissue flexibility.
• Exercise and activities should not cause pain or further injure affected areas.

Chronic Stage: Maturation and Remodeling

• The third phase of healing (6 months-1 year), characterized by no signs of inflammation, and potential for contractures or adhesions.
• Limited range of motion and muscle weakness or endurance may be present along with potential for pain to be felt when testing tight structures at the available range.

Tissue response in the Chronic Phase

• Collagen fibers become thicker and reorient in response to stresses on the connective tissue, and scar tissue development.
• Remodeling takes time depending on the size and location of the injury, along with the amount of tissue damage.
• Adaptive lengthening is supported by surgical interventions as needed.

Specific Interventions and Dosages for the Chronic Phase

• Provide patient education on biomechanically safe progressions of resistance and self-stretching.
• Re-evaluate patient progress to adapt and modify interventions as needed.

Progression of Stretching and Exercises

• Gradually increase the intensity and duration of stretching, avoiding increased pain, which typically lasts only 24 hrs after training.
• Progress strengthening exercises to better simulate muscle demands as is needed for sport specific activities
• Implement activities that mirror work and daily life activities.

Cumulative Trauma: Chronic Recurring Pain

• Repetitive stress exceeding the body's ability to repair tissue leads to chronic inflammation.
• Overuse, cumulative trauma, repetitive strain are common causes, potentially originating from injuries that have not fully healed or injuries to old scar tissue.
• Contributing factors include muscular imbalance, overuse, structural weaknesses or problems etc.

Chronic Pain Disorder (Chronic Pain Syndrome)

• A chronic condition lasting >6 months without a clear cause, leading to limitations in activity and function.
• Important to educate patients; emphasizing they are not causing continued injury, and that movement and activity may be beneficial.
• Use time-contingent approaches to physical activity and exercise, and focusing on non-destructive exercises.

Ankle Mobility & Strengthening Exercises

• A progression of exercises, from easiest to hardest, for ankle mobility and strengthening.