Lecture 5: Ligament Response to Injury and Treatment Parameters

Where does ligament injury typically occur?

Fibers along the highest force (load) breaks down first —> leads to failure of other portions of the ligament

Is it likely that ligament will rupture from fatigue failure?

No, it is unlikely/rare (however, can “stretch” ligament past yield point making it ineffective to restrain a joint)

What is the pathology of a Grade I Ligament Sprain?

Stretching; very minimal tearing of collagen fibers

What is the pathology of a Grade II Ligament Sprain?

Tearing of collagen fibers; overall structure of ligament still intact (but might not be functioning)

What is the pathology of a Grade III Ligament Sprain?

Complete rupture of ligament

What are the clinical signs and symptoms of a Grade I Ligament Sprain?

Mild pain, swelling, bruising

Minimal/no impact on ligament integrity and function

What are the clinical signs and symptoms of a Grade II Ligament Sprain?

Moderate pain, swelling, bruising

Impaired ligament integrity

Moderate negative impact on function

What are the clinical signs and symptoms of a Grade III Ligament Sprain?

Severe pain, swelling, bruising

No remaining ligament integrity

Significant negative impact on function

How should we test ligaments?

Test them in the position in which they were injured

How can we feel/test for a grade three ligament?

Feel for laxity

Do females or males have more laxity?

Females

Are inflammatory processes different between men and women?

Yes, therefore response to healing is mostly likely different as well

What is an “intra-articular” ligament?

Ligament within joint capsule

What is an “extra-articular” ligament?

Ligament outside joint capsule

How does bleeding differ between an intra-articular and extra-articular ligament?

Intra-articular Ligament — swells joint capsule

Extra-articular Ligament — swells and pulls away from dependent position

For ligament, the proliferative phase is described as…

“Scarring down the ligament”

How does a scar in ligament compare to typical ligament materials/properties?

A scar has less strength and stiffness

During the remodeling phase, improvements in the quality of the scar is dependent on…

Joint movement

How do we assess a ligament injury?

• Passive ROM

• Put in mechanism of injury / position that strains ligaments

• Apply force through resistance and apply quick thrust

• Proximal and distal stabilization (“counter-force”)

How does immobilization affect strength and stiffness?

Reduces strength and stiffness

When would immobilization be beneficial?

• Reduce risk of osteoarthritis after injury (initially)

• Increase length of “healed” ligament, make it able to resist low load stressed better

Is exercise positive for healing ligaments?

Yes, as long as the force is not too great

How do we determine if the force is too great for exercise after injury?

Pain

Since ligaments are a passive structure, when will pain occur?

With both active and passive movement that elongates the tissue

How do we know what stage of healing someone is in?

• Inflammation = pain prior to tissue resistance

• Proliferative = pain at tissue resistance

• Maturation = pain past tissue resistance

How do we progress stretching?

1. AROM to point of pain

2. “Shorter” hold times at point of pain

3. “Longer” hold times at “sensation of stretch”

How do we advance strengthening?

1. Low loads, low reps in direction of injury

2. Low loads, high reps

3. High loads, low reps

What does cryotherapy do?

Reduces blood flow and will reduce swelling, thus reducing the inflammation

What is cryotherapy good for?

Limiting excessive swelling and secondary damage to other tissues

What are some negatives of cryotherapy?

It can increase the length of the inflammatory phase

When is cryotherapy not appropriate?

Early on it is contraindicated

When is cryotherapy beneficial and what does it do?

Later on in healing process may be some benefit to stimulate fibroblastic activity

When should surgical repair be performed?

When there are gaps between ligament ends that would benefit from surgical repair

Typically, you should do a surgical repair if it is a grade __ or more.

Grade II or more

What is the benefit of surgical repair?

Approximation (still have scarring)

Does surgical repair of a ligament allow for more range of motion?

No; the repaired ligament is not “strong” enough to allow for more ROM

When should a ligament replacement occur?

When ligaments do not heal well with primary means and need to be reconstructed

What is the goal of a ligament replacement?

The goal is to stabilize the joint (~80% strength and stiffness)

Ligament replacement can restore ________ and allow for….

Replacement can restore kinematics and allow for earlier (controlled) loading through the ligament

Ligament replacement cannot restore…

Cannot restore the same viscoelastic properties and proprioception