Week 1 Introduction and healing

Introduction to Orthopedic Assessment

• Overview by Nancy Cox, PTA, MS PTAS.

• References: Manske & Shankman; chapters 2, 8-12.

Eye Response, Normal

• Indicates assessment criteria and general principles of healing in orthopedic conditions.

Phases of Tissue Healing

• Acute Inflammatory Response: Initial response mechanism to injury.

• Repair & Regeneration (Proliferation): Involves the building of new tissue.

• Remodeling & Maturation: Ongoing adjustments to tissue organization.

• Additional resource: Video on Phases of Healing.

Inflammation

• Definition: Immunological defense mechanism against injury/infection. Characterized by:

  • Increased blood flow

  • Migration of white blood cells

  • Release of chemical mediators.

• Importance: Triggers tissue healing, but chronic inflammation can lead to permanent changes.

Inflammatory Response Characteristics

• Signs:

  • Pain

  • Localized tissue edema

  • Loss of function

  • Heat, redness, tenderness, swelling

• Physiological Events:

  • Increased capillary permeability

  • Releases systemic responses like fever.

Inflammation Timeframes

• Acute Inflammation: Usually lasts 4-6 days post-injury, with signs persisting up to 2 weeks.

• Subacute Inflammation: Lasts greater than 4 weeks.

• Chronic Inflammation: Extends beyond 6 months.

Signs of Inflammatory Response

• Pain:

  • Pain before end of range of motion: acute inflammation.

  • Pain at end range: subacute inflammation.

  • Stretching sensation limit: chronic inflammation.

• Localized Edema Measurement:

  • Use circumferential or figure-8 techniques; compare affected vs. non-affected sides.

Pitting and Brawny Edema

• Pitting Edema: Sustained indentation when pressed, common in CHF patients.

• Brawny Edema: Hard, leathery texture, usually found in venous disease.

Pain Assessment in Physical Therapy

• Pain is subjective and must be treated seriously.

  • Use standardized scales to evaluate pain levels thoroughly.

  • Document patient responses, such as body language and facial expressions.

Red Flag Symptoms

• PTA should halt intervention if red flag symptoms arise and report to PT or MD.

Types of Pain

• Referred Pain: Felt in a location distant from the actual injury.

• Visceral Pain: Associated with internal organs, poorly localized and may involve autonomic symptoms.

• Trigger Points: Small areas within muscles that cause localized pain upon palpation.

Irreversible Cell Injury and Death

• Apoptosis: Programmed cell death without inflammation.

• Hypoxia and Necrosis: Related to insufficient blood flow and results in inflammation.

Healing Process for Tissues

Scar Maturation

• Involves collagen fibril cross-linking and remodeling with factors including endothelial and fibroblast activity.

Regeneration of Tissue

• Injured tissue may regenerate through cytokine activation and can vary from labile to permanent cell types.

Types of Tissue Healing

• Ligaments: High elastin content, receive blood supply at origins.

• Tendons: Transmit muscle forces, often covered by synovial sheaths for nutrition and movement facilitation.

Ligament Injury Mechanisms

• Common causes include rupture of collagen fibers and insertion at bony sites.

• Classification of Injury:

  • Grade I: Mild sprain.

  • Grade II: Moderate sprain.

  • Grade III: Complete ligament tear.

Healing of Ligaments

• Ligaments generally heal slower, with scar replacement instead of actual regeneration.

• Optimal conditions for heal include proper alignment, consistent stress application, and protection from excessive forces.

Factors Impairing Ligament Healing

• Include age, blood supply, immobilization, smoking, and existing medical conditions like diabetes.

Effects of Ligament Immobilization

• Can cause joint stiffness, atrophy, and reduced hydration; 20% weight loss observed after 8 weeks of immobilization.

Remobilization Following Ligament Injury

• Introducing motion can enhance healing and strength. Continuous passive motion (CPM) is recommended to maintain tissue health and minimize complications.

Healing Stages After Ligament Injury

• Timeline from injury through gradual recovery phases, each with specific treatment recommendations.

Tendon Properties and Injuries

• Risk of injuries increase with age and overuse; tendinosis may occur in absence of clear inflammation.

Muscle Strain Assessment

• Classification into first, second, and third-degree strains based on the extent of fiber damage.

Effects of Immobility on Muscles

• Leads to decreased muscle mass, loss of endurance, and increased fall risk.

Rehabilitation During Healing

• Key approaches include promoting motion in unaffected joints and safe muscle contractions for the immobilized area.

Peripheral Nerve Injuries

• Types of nerve injuries (Neuropraxia, Axonotmesis, Neurotmesis) and their implications on recovery and treatment.

Recovery Post-Nerve Injury

• Importance of protecting repair sites and considerations for sensory reeducation are crucial during rehabilitation.

Vascular Response to Injury

• Essential processes include inflammation and remodeling, monitoring for signs such as pulselessness and hematoma.

Prevention and Treatment of DVT

• Importance of anticoagulants and early mobilization; risk factors include surgery and immobility.

Compartment Syndrome

• A condition that requires immediate attention characterized by severe pain, swelling, and potential muscle and nerve damage.

Etiology of Peripheral Vascular Disease

• Atherosclerosis can lead to intermittent claudication, emphasizing the need for early diagnosis and management.

Conclusion

• Comprehensive understanding of tissue healing is essential for effective orthopedic intervention and rehabilitation.