Soft Tissue Injuries - stages of injury

3 stages of healing

inflammation, healing, maturation and remodeling

inflammation stage starts

immediately after injury and peaks at about 24-48 hours, lasting 4-6 days

characteristics of the inflammation stage

cellular and vascular response, exudation of cells and solutes from blood vessels/clot formation, phagocytosis and capillary proliferation, response serves as protective mechanism

clinical signs of inflammation stage

calor (heat), rubor(redness), dolor (pain), tumor (swelling), loss of function

with the inflammatory stage, pain is encountered

before resistance of the tissue - empty endfeel

intervention goals of inflammatory stage

control pain, inflammation, guarding, protect from further injury (casting, taping), promote biological healing with optimal dosage of movement, limit morbidity (keep the rest of the system healthy)

intervention acronym for inflammation stage

POLICE (first ICE, then RICE)

POLICE

protection, optimal loading, ice, compression, elevation

optimal loading in inflammatory phase

ROM in pain free range, no stretching (especially with muscle injuries), muscle activation injuries within pain free arc and activation

Ice for inflammatory phase

EPA for pain and inflammation (ice or otherwise), grades 1 and 2 mobilization for analgesic and fluid management

elevation for inflammatory phase

include gentle muscle activation, gentle distal to proximal massage

newest acronym for injury management

PEACE and LOVE

PEACE

used for inflammatory phase - protect, elevate, avoid anti-inflammatory, compression, education

avoiding anti-inflammatory (PEACE)

proposed that cryotherapy may negatively impact healing - no evidence for or against ice and its effect on healing, but does support analgesic effect

educate (PEACE)

education on active approach to recovery and proper load management

LOVE

management in the healing and maturation phases, load, optimism, vascularization, exercise

load (LOVE)

exercises and activities shouldnt exacerbate pain and should promote repair and optimal remodeling through mechanotrasduction

mechanotransduction

applying stress to tissues gives the fibers direction in their realignment - tissues form proportional to the stress they receive (DONT immobilize)

optimism (LOVE)

emphasis on managing beliefs and emotions early in the rehab process to promote a positive outlook on recovery

Vascularization (LOVE)

promoting good bloodflow to tissues is key to healing (not used enough)

repair/healing stage

day 4 to 21 following injury (fibroblastic activity)

characteristics of repair-healing stage

growth of capillary beds, synthesis and deposition of collagen, immature connective tissue produced is thin and unorganized

clinical signs of repair/healing stage

inflammation signs progressively disappear, new connective tissue is fragile and easily ruptured if overstressed

in the repair/healing stage, pain is encountered

simultaneous to resistance of the tissue

intervention goals of repair/healing stage

continue to progressively decrease emphasis on all goals from acute stage, initiate progressive controlled rehab to restore ROM, strength and function (optimal stress without reinjury)

potential interventions in repair/healing stage

as needed control of pain and inflammation, optimal loading is emphasized - progression of range of motion via painfree arc (PROM, AAROM, AROM), progression of muscular activation/strengthening via painfree activation (AAROM, AROM, RROM), progression of functional exercises (painfree and specific to injury and goals)

repair/healign stage is critical for rehab as

proper growth and alignment of collagen fibers is stimulated by appropriate tensile loading in line of normal stress for that tissue (pt has 50% strength at this stage)

for both inflammatory and repair stage, following intervention you do not want

increased pain or swelling - indicative of excessive aggressiveness (too much load creates a chronic inflammatory environment, should feel good leaving session)

the desired result of optimal dosage

facilitate strong and painless scar, promote healing in tissues normal lines of stresses, prevent adhesions (tendon - highly organized, ligament/capsule - loosely organized)

healing without the influence of mechanical structures can cause

adhesions between layers across fibers and poor tensile strength - pain, dysnfunction and chronic state

maturation and remodeling stage

from day 21 to several weeks or months based on injured tissue

characteristics of maturation/remodeling stage

collagen production peaks within first 2 months of healing (can persist at reduced rate up to 6 months after injury), maturation of new collagen fibers, fibers become thicker and reorient in response to stresses placed on the connective tissue to be optimal (increase in wound strength without collagen production)

clinical signs of maturation stage

residual motion, strength, function loss (no inflammation)

in the maturation phase, pain is encountered

after resistance of the tissue (tissue can take on a good amount of load)

intervention goals of maturation phase

return to optimal ROM and scar mobility, strength, function, promote maturation/remodeling, protect from injury as necessary

potential interventions for maturation phase

optimal loading with progression of range of motion, muscular activation/strengthening, progressive functional activities, return to sport/leisure activities

progression of range of motion in maturation phase

PROM to AAROM to AROM aiming for full ROM, manual therapy techniques, cross friction massage for soft tissue mobility

cross friction massage for soft tissue mobility

localized strumming over small area to spread fibers away - muscle should be shortened/relaxed to allow movement, tendon should be under tension to permit movement of surrounding tissue around tendon

progression of muscular activation/strengthening exercises in maturation phase

strengthening through full motion, progress resistance and types of exercise

when a patient leaves a session in the maturation phase

expect discomfort for no more than 2 hours (should feel like a good workout)

the higher density of connective tissue

longer remodeling time

intervention is effective to help in the anatomically optimal remodeling of fibers for

8-10 weeks after remodeling process has started

after 14 weeks

scar tissue becomes resistant to remodeling with poor response to stretch

muscle healing

repair/healing 2-3 weeks, maturation/remodeling 2-3 weeks (fastest)

tendon healing

repair/healing 4-5 weeks, maturation/remodeling 5 weeks to 6 months

ligament healing

repair/healing 6 weeks, maturation/remodeling 6 weeks to 1+ year (long time to return to full strength)

time-based info on inflammation, repair, and maturation stages should ALWAYS consider

the findings of a clinical exam

inflammation stage in clinical exam

highly irritable with pain at rest or with initial/midrange movement, pain before tissue resistance

repair/healing stage in clinical exam

moderate irritability with pain at midrange motions that worsen with endrange movement, pain concurrent with tissue resistance

maturation/remodeling stage in clinical exam

low degree of irritability with pain in sustained endrange movement or positions, pain with overpressure into tissue resistance

there are cases where the alignment or irritability and durations of symptoms

does not match - clinical exam should outweigh the time-based guidelines of stages of injury

main focus in inflammation stage

control pain, swelling and inflammation

main focus in repair/healing stage

re-establish painfree range of motion/flexibility

main focus in maturation/remodeling

re-establish strength and function (scar tissue shortens with maturation, make sure to maintain ROM)