Principles of Rehabilitation for Muscle and Tendon Injuries

Therapeutic Intervention 1

injury to muscle or tendon can alter…

• Force production

• Force transmission

• Movement

• Functional capacity

goal of muscle and tendon rehab

restore the ability of the entire muscle–tendon unit to tolerate the demands of activity

grade 1 strain

• Small amount of tissue disruption

• Mild discomfort

• Minimal swelling

• ROM generally preserved

• Minimal functional limitation

grade 2 strain

• Greater tissue disruption

• Increased pain and swelling

• Loss of ROM

• Moderate strength deficit

• Functional activity is limited

grade 3 strain

• Severe or complete disruption

• Marked loss of strength and ROM

• Significant functional limitation

• May include complete muscle or tendon rupture

• Surgical management may be required

DOMS

• Common after unfamiliar or intense exercise

• Frequently associated with eccentric exercise

• Symptoms typically peak approximately 24–72 hours after activity

• Usually resolves over several days to about one week

myositis ossificans

(a benign condition where bone tissue forms inside muscle or other soft tissue, usually after an injury) may occur after a severe contusion (higher incidence in quadriceps contusions)

initial rehab of contusions

• Protect the injured muscle

• Limit further bleeding and irritation

• Avoid aggressive early loading

• Progress motion and strengthening gradually

rehab for contusions

• Early protection following significant contusion

• Isometric strengthening once appropriate

• Gentle, pain-free ROM and stretching

• Avoiding reinjury during early healing

what should be avoided in early contusion rehab

• Aggressive stretching

• Aggressive massage

• Premature return to activity

• Interventions that substantially increase blood flow immediately after injury (heated modalities, etc.)

tendinopathy

useful as a broad term for tendon disorders, but it encompasses several tissue presentations under that umbrella

tendinitis

acute inflammatory response within tendon

paratenonitis

• acute

• inflammation of tissue surrounding the tendon

tendinosis

• Chronic degenerative tendon changes

• No primary histologic inflammatory response

s/s of acute tendinitis or paratenonitis

• p and tenderness

• localized swelling

• pain with tendon loading

• possible crepitus with paratenonitis

early rehab for acute tendonitis

• Reduce excessive or irritating load

• Avoid repeated activities that reproduce symptoms

• Address contributing mechanical or training factors

• Maintain pain-free motion when appropriate

• Begin gentle strengthening as symptoms allow

• Progressively reintroduce tendon loading

s/s of tendinosis

• Gradual or insidious onset

• Often associated with repetitive overload

• Collagen disorganization

• Reduced tendon quality and load tolerance

• May have little visible swelling

• Symptoms may fluctuate with activity

rehab priorities for tendinosis

• Identify the load that exceeds tendon capacity

• Modify aggravating activity as needed

• Progressively rebuild tendon load tolerance

• Develop strength and endurance

• Progress toward higher-speed and functional loading

• Match rehabilitation to the demands of activity

tenosynovitis

• Inflammation involving the synovial sheath surrounding a tendon

  • Often develops where a tendon repeatedly moves through a confined or high-friction area

    
    

  • Repetitive motion or overuse may increase irritation between the tendon and sheath

    
    

s/s of tenosynovitis

• Pain with tendon movement

• Tenderness and swelling

• Possible crepitus

• Restricted tendon gliding or ROM

common locations of tenosynovitis

• Long flexor tendons of the fingers/wrist

• Biceps tendon around the shoulder

tenosynovitis management

• Activity modification/rest

• Splinting when indicated

• Anti-inflammatory interventions

• Progressive rehabilitation after symptoms improve

• Surgical tendon release in some persistent cases

myofascial trigger points

• discrete hypersensitive area w/in a taut band of skeletal muscle and or fascia

• palpation may reveal a firm or cordlike region

• firm pressure may reproduce patient’s symptoms

• referred pain may occur away from point being palpated

cause of trigger points

• Acute trauma

• Repetitive microtrauma

• Persistent muscular stress

latent trigger point

no spontaneous pain; symptoms may occur with pressure or movement

active trigger point

may produce pain at rest

trigger point vs tender point

trigger- may produce referred pain

tender- localized pain

toe region

• beginning of curve

• collagen crimp begins to strengthen

linear region

• Tendon deforms with increasing tensile load

• Returns toward original configuration when load is removed

beyond approximately 4% strain

Progressive collagen-fiber failure may begin

increasing strain

Greater structural disruption

around 8% elongation

Complete tendon rupture may occur

what should you compare examination findings with?

• The patient's mechanism of injury

• Acute vs. chronic presentation

• Functional limitations

• Demands of the patient's activity

dynamic movement assessment

identify:

• Faulty movement patterns

• Weakness or dysfunction elsewhere in the chain

• Repetitive loading patterns

• Activity-specific technique

• Equipment or environmental contributors

MRI usage

• Partial or complete muscle tears

• Tendon pathology

• More significant injuries when clinical findings warrant further evaluation

• Useful for defining deeper tissue injury, edema, and extent of tearing

diagnostic ultrasound usage

• Can assess muscle and tendon structures

• Allows dynamic assessment during muscle contraction

• Useful for superficial tendon/muscle assessment and dynamic imaging

phase 1 rehab ACUTE

symptom control

• reduce pain and edema

• protect the tissue

phase 2 rehab ACUTE

restore motion

• pain free ROM

• begin isometric activation

phase 3 rehab ACUTE

restore capacity

• progressive strengthening

• isometric → isotonic exercise

• improve endurance

phase 4 rehab ACUTE

restore function

• NM control

• running or functional progression

• sport/ task specific exercise

phase 1 rehab chronic tendinosis

reduce aggravating load

• Modify painful or repetitive activity

• Reduce excessive tendon stress

• Use external support when indicated

phase 2 rehab chronic tendinosis

restore mobility

• Address flexibility or ROM limitations

• Begin pain-tolerable tendon loading

• Maintain activity when possible

phase 3 rehab chronic tendinosis

restore tendon capacity

• Progressive resistance exercise

• Emphasize eccentric loading

• Gradually increase tensile load

• Improve strength and endurance

phase 4 rehab chronic tendinosis

restore function

• Progress toward functional loading

• Increase speed, volume, and complexity

• Reintroduce running or task-specific activity

• Progress toward sport-specific demands

benefits of eccentric loading

• muscle produces force while lengthening

• Allows relatively high force production

• Important for controlling and decelerating movement

• Provides progressive tensile loading to the muscle–tendon unit

eccentric contraction can help restore…

• Strength and force tolerance

• Tendon loading capacity

• Functional control during lengthening

transverse friction

pressure applied across tissue fibers

circular friction

small circular movements over the targeted tissue

rehab purpose for soft tissue techniques

• Address soft-tissue mobility restrictions

• Improve tolerance to movement

• Provide short-term symptom modulation

• Facilitate subsequent ROM or exercise

corticosteroid injections

• Commonly used for symptom relief

• Evidence has not confirmed consistent long-term benefit

Platelet-rich plasma (PRP)

• Used with the goal of promoting tendon healing

• Evidence has not confirmed significant efficacy

Extracorporeal shockwave therapy (ESWT)

• Noninvasive treatment option

• Stronger evidence supports its use for some tendinopathies

Percutaneous ultrasonic tenotomy (PUT / Tenex)

• Minimally invasive procedure

• Uses an ultrasonic vibrating needle to debride and aspirate diseased tendon tissue

• Promising option, but more high-quality research is needed