Soft Tissue Injury, Repair, and Management

What are two ways to determine stage of inflammation or tissue repair?

- Pain

- Time

Types of soft tissue lesions

- Strain

- Sprain

- Subluxation

- Dislocation

- Tendinopathy

- Synovitis

- Hemarthrosis

- Bursitis

- Contusion

- M./tendon rupture or tear

Possible objective findings during initial exam of a pt w/ soft tissue injury

- Inflammation (redness, warmth, discoloration, swelling)

- Limited ROM

- Weakness

- Tenderness to palpation

- Adhesion/contracture (if injury is older/has been immobilized or guarded)

Factors affecting tissue healing

- Overall health

- Nutrition

- Vascular supply

- Tissue quality

- Adequate approximation of tissue borders

- Tension or other forces across the region (think abt biomechanics!)

Muscle healing time frame

- 6 wks - 6 mo

- Contraction ability is 90%

Tendon healing time frame

- 40 - 50 wks

- Strength is 85 - 95% of normal

Ligament healing time frame

- 8 - 9 wks (collagen is mature)

- ~40 wks (near normal tensile strength)

Cartilage healing time frame

- 2 mo (satisfactory healing; defect resembles cartilage. primarily type I cartilage (scar tissue))

- 6 mo (type I & II cartilage have normal appearance)

Grade I sprain (first degree)

- Tissues are over-stretched and damaged microscopically, not actually torn

- No significant instability or loss of fxn

- Mild swelling, local tenderness, pain when tissue is stretched

Grade II sprain (second degree)

- Tissues are partially torn and allow some unwanted motion

- Pain stops activity (usually)

- Stress and palpation of tissue greatly inc pain

- May result in inc jt play in injury involved a ligament

Grade III sprain (third degree)

- Tissue is completely torn

- Joint stability and fxn are lost (excessive mobility)

- May cause diffuse swelling and bruising around the affected jt

- Stress of the tissue is usually painless

Acute stage of inflammation and tissue repair

Reaction & Inflammation

Subacute stage of inflammation and tissue repair

Proliferation, Repair & Healing

Chronic stage of inflammation and tissue repair

Maturation & Remodeling

Protection level at phase I (acute stage)

Maximum protection

Protection level at phase II (subacute stage)

Moderate protection/controlled motion

Protection level at phase III (chronic stage)

Minimum to no protection/return to fxn

Acute stage time frame

4 - 6 days

Acute stage physiologically

- Altered chemical state irritates the nerve endings & causes pain

- Clot formation

- Vascular and cellular response = edema and jt effusion = inc tissue tension

Clinical signs of acute phase

- Swelling

- Bruising

- Redness

- Warmth

- Pain at rest and/or before tissue resistance

- M. guarding

- Loss of fxn

What is the goal of rehab in the acute stage?

- Maximum protection

- Control the negative effects of inflammation

- Prevent negative effects of rest

Treatment in acute stage

- Education

- PRICES (Protection -> RICE -> Support)

- Modalities

- Controlled ROM (typically PROM)

- Intermittent m. setting in shortened range

- Gentle massage and grade I mobs

Subacute stage time frame

10 - 17 days (4 - 21 after injury; may last up to 6 wks)

Subacute stage physiologically

- Removal of noxious stimuli

- Growth of capillary beds into the area (improved blood supply)

- Collagen formation (scar tissue forming)

Clinical signs of subacute stage

- Signs of inflammation slowly dec & disappear

- Pain synchronous w/ tissue resistance

- Inc in tensile strength (tissue is fragile & easily re-injured)

- Fxn is limited d/t m. weakness

What is the goal of rehab in the subacute stage?

- Moderate protection

- Scar mobility

- Promote healing (apply controlled stress/motion)

- Progressively restore mobility

- Progressively restore strength

Criteria to progress from Stage I -> Stage II of rehab

- Decreased swelling

- Minimal to no redness or warmth

- Pain is no longer constant

- Pain is not exacerbated by motion unless it applies stress to the specific injured tissue

Treatment in subacute stage

- Continued education

- Continued protection of healing tissues

- ROM in pain free range

- NM & resisted training

Examples of NM/resisted training in subacute stage

- multi-angle submax isometrics in pain free range

- isotonic training for endurance -> strength

- cautiously progress w/ parameters

- protected CKC exercises

- pain free m. stretching

- slowly resume fxnl activities

- correction of contributing factors

- CV fitness

Chronic stage time frame

Begins at ~21 days post injury, 6 mo to 1 yr (depending on tissue involved & severity of injury)

Chronic stage physiologically

- Maturation & remodeling of connective tissue

- Collagen reorients & aligns in response to stress (stretch tissue to scar fibers align w/ pre-injured tissue fibers)

- Scar begins to remodel

Clinical signs of chronic stage

- Absence of inflammation

- Pain after tissue resistance

Rehab goal for chronic stage

- Minimal protection -> no protection -> return to fxn/sport

- Help align healing tissues in proper lines of stress

- Dec pain when stress is applied to structure

- Inc mobility

- Inc m. strength

- Develop endurance

- Improve performance

- Return to normal fxn

Criteria to progress from Stage II -> Stage III of rehab

No signs of inflammation

Treatment for chronic stage

- ROM (simple unidirectional -> complex multidirectional mvmts)

- Resistive training

- CV endurance

- Stretching

- Return to high demand activities

Types of resistive training used in chronic stage treatment

- OKC & CKC

- Concentric & eccentric

- Progression of stabilization exercises (trunk & extremities)

- Activity specific or sport specific (e.g. plyos, agility drills)

Signs that progression is too much too fast

- Inc inflammation

- Excessive fatigue

- Soreness > 24 - 48 hours

- Regression of ROM

- Inc pain

- Dec quality of mvmt

Chronic Inflammation

State of prolonged inflammation beyond normal inflammatory phase

What causes chronic inflammation?

Repetitive injury

S/s of chronic inflammation

- Pain

- Swelling

- M. guarding lasting several hours after activity

- Stiffness after rest

- Dec ROM 24 hours post activity

What is the primary goal of rehab for chronic inflammation?

- Controlling inflammation

Progression of rehab for chronic inflammation

- Will follow previous stages outlined, but timeframes are often longer

- Don't progress too quickly

- Spend time working in adj regions that may be contributing to chronic inflammation

Chronic pain syndrome

- Pain >6 mo that cannot be linked to a source of irritation or inflammation

- Fxn limitations and disability that include physical, emotional, and psychosocial parameters

Joint play as indication of injury severity

- Grade I = 3 (normal)

- Grade II = 4-5 (slightly/considerably in mvmt)

- Grade III = 6 (complete instability)

MMT as indication of injury severity

- Grade I = (3+) 4-5

- Grade II = 2-3 (3+)

- Grade III = 0 (maybe 1 if compensating)