Muscle damage and inflammation following a three-day trail run
Muscle Injury , Inflammation & repair
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Transcript of Muscle Injury , Inflammation & repair
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Muscle Injury Inflammation
Repair
Tahir RamzanRiphah International University
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Introduction--- Types of injuries
• Primary Injury– Injury from acute or chronic trauma
• Secondary Injury– Inflammatory response to primary injury
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3 Phases of Tissue Healing
• Inflammatory –response phase
• Fibroblastic-repair phase
• Maturation-remodeling phase– Healing process is a continuum and phases
overlap one another with no definitive beginning or end points
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Inflammatory-Response Phase
• After injury, healing process begins immediately– Destruction of tissue produces direct injury to
cells of various soft tissue
– Characterized by redness, swelling, tenderness and increased temperature
– Critical to entire healing process
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Inflammatory-Response Phase
• Leukocytes and other phagocytic cells delivered to injured tissue– Dispose of injury by-products through
phagocytosis
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Inflammatory-Response Phase
• Vascular reaction– Blood coagulation
and growth of fibrous tissue occurs
– First 5-10 minutes vasoconstriction occurs
• Best time to evaluate• Followed by
vasodilation• Effusion of blood and
plasma last 24 to 36 hours
• Chemical mediators– Released from damaged
tissue, white blood cells and plasma
– Histamine, leukotrienes and cytokines assist in limiting exudate/swelling
– Amt of swelling directly related to extent of vessel damage
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Inflammatory Response Con’t
• Formation of Clot– Platelets adhere to
collagen fibers and create sticky matrix
• Platelets and leukocytes adhere to matrix to form plug
• Clot formation occurs 12 hours after injury and is complete w/in 48 hrs
• Set stage for fibroblastic phase
• Chronic inflammation– Acute phase dos not
respond sufficiently to eliminate injury agent and restore tissue to normal physiologic state
– Damage occurs to connective tissue and prolongs healing and repair process
– Response to overuse and overload
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Inflammatory Response Con’t
• Entire phase last 2-4 days– Greater tissue damage longer
inflammatory phase
– NSAIDS may inhibit inflammatory response thus delaying healing process
• Will assist with pain and swelling
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Fibroblastic-Repair Phase
• Proliferative and regenerative activity leads to scar formation– Begins w/in 1st few hours after injury and can last
as long as 4-6 weeks
– Signs and Symptoms of inflammatory phase subside
– Increased O2 and blood flow deliver nutrients essential for tissue regeneration
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Fibroblastic-Repair Phase
• Break down of fibrin clot forms connective tissue called granulation tissue– Consist of fibroblast, collagen and capillaries
• Fills gap during healing process– Unorganized tissue/fibers form scar
• Fibroblast synthesize extracellular matrix consisting of protein fibers (Collagen and Elastin)
– Day 6 –7 collagen fibers are formed throughout scar– Increase in tensile strength increases with rate of
collagen synthesis
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Fibroblastic-Repair Phase
• Importance of Collagen– Major structural protein that forms strong, flexible
inelastic structure
– Type I, II & III• Type I found more in fibroblastic repair phase
• Holds connective tissue together and enables tissue to resist mechanical forces and deformation
– Direction of orientation of collagen fibers is along lines of tensile strength
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Fibroblastic-Repair Phase
• Importance of Collagen– Mechanical properties
• Elasticity– Capability to recover normal length after elongation
• Viscoelasticity– Allows slow return to normal length and shape after
deformation
• Plasticity– Allows permanent change and deformation
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Maturation-Remodeling Phase
• Long term process that involves realignment of collagen fibers that make up scar– Increased stress and strain causes collagen fibers to
realign to position of maximum efficiency• Parallel to lines of tension• Gradually assumes normal appearance and function• Usually after 3 weeks a firm, contracted,
nonvascular scar exist– Total maturation phase may take years to be
totally complete
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Maturation-Remodeling Phase
• Wolf’s law– Bone and soft tissue will respond to physical
demands placed on them • Remodel or realign along lines of tensile force• Critical that injured structures are exposed to
progressively increasing loads throughout rehab process
– As remodeling phase begins aggressive active range of motion and strengthening
– Use pain and tissue response as a guide to progression
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Maturation-Remodeling Phase
• Controlled mobilization vs. immobilization– Animal studies show Controlled mob. Superior to
Immobilization for scar formation• However, some injuries may require brief period of
immob. During inflammatory phase to facilitate healing process
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Factors that impede healing
• Extent of injury– Microtears vs.
macrotears
• Edema– Increased pressure
causes separation of tissue, inhibits neuro-muscular control, impedes nutrition, neurological changes
• Hemorrhage– Bleeding causes same
neg. effect as edema
• Poor vascular supply– Tissues with poor
vascular supply heal at a slower rate
– Failure to deliver phagocytic cells and fibroblasts for scar formation
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Factors that impede healing
• Separation of tissue– How tissue is torn
will effect healing• Smooth vs. jagged
• Traction on torn tissue, separating 2 ends– Ischemia from
spasm spasm
• Atrophy
• Corticosteroids– In early stages
shown to inhibit healing
• Keloids or hypertrophic scars
• Infection
• Health, Age and nutrition
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Healing Process-Ligament Sprains
• Tough, relatively inelastic band of tissue that connects bone to bone– Stability to joint
– Provide control of one articulating bone to another during movement
– Provide proprioceptive input or sense of joint position through mechanoreceptors
• 3 Grades of lig. tears
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Healing Process-Ligament Sprains
• Physiology– Inflammatory phase-loss of blood from damaged
vessels and attraction of inflammatory cells
– During next 6 weeks-vascular proliferation with new capillary growth and fibroblastic activity
• Immediately to 72 hours– If extraarticular bleeding in subcutaneous space– If intraarticular bleeping occurs in inside joint capsule
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Healing Process-Ligament Sprains
• Essential that 2 ends of ligament be reconnected by bridging of clot– Collagen fibers initially random woven pattern with
little organization– Failure to produce enough scar and of ligament to
reconnect 2 reasons ligaments fail
• Maturation– May take 12 months to complete– Realignment/remodeling in response to stress and
strains placed on it
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Healing Process-Ligament Sprains
• Factors that effect healing– Surgery or non surgical approach
• Surgery of extraarticular ligaments stronger at first but may not last over time
• Non surgical will heal through fibrous scarring , but may also have some instability
– Immobilization• Long periods of immobilization may decrease
tensile strength weakening of insertion at bone• Minimize immobilization time• Surrounding muscle and tendon will provide
stability through strengthening and increased muscle tension
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Healing Process-Cartilage
• Cartilage– Rigid connective tissue that provides support
• Hyaline cartilage: articulating surface of bone
• Fibro cartilage: interverterbral disk and menisci. Withstands a great deal of pressure
• Elastic cartilage: more flexible than other types-auricle of ear and larynx
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Healing Process-Cartilage
• Physiology of healing– Relatively limited healing capacity
• Dependant on damage to cartilage alone or subchondral bone.
• Articular cartilage fails to elicit clot formation or cellular response
• Subchondral bone can formulate granulation tissue and normal collagen can form
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Healing Process-Cartilage
• Articular cartilage repair– Patients own cartilage can be harvested and
implanted into damages tissue to help form new cartilage
– Promise for long term results
• Fibrocartilage/Menisci– Depends on where damage occurs– 3 zones of various vascularity
• Greater that blood supply better chance of healing on own
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Healing Process-Bone
• Similar to soft tissue healing, however regeneration capabilities somewhat limited– Bone has additional forces such as torsion,
bending and compression not just tensile force– After 1 week fibroblast lay down fibrous collagen– Chondroblast cells lay down fibrocartilage creating
callus– At first soft and firm, but becomes more firm and
rubbery– Osteoblast proliferate and enter the callus
• Form cancellous bone and callus crystallizes into bone
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Healing Process-Bone
• Osteoclasts reabsorb bone fragments and clean up debris– Process continues as osteoblast lay down new
bone and osteoclasts remove and break down new bone
• Follow Wolfs law-forces placed on callus-changes size, shape and structure
• Immobilization longer 3 to 8 weeks depending on the bone
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Healing Process-Muscle
• Similar to other soft tissue discussed– Hemorrhage and edema followed by phagocytosis to
clean up debris– Myoblastic cells from in the area and regenerate new
myofibrils– Active contraction critical to regaining normal tensile
strength according to Wolff's Law– Healing time lengthy-Longer than ligament healing
• Return to soon will lead to re-injury and become very problematic
• 6-8 weeks?
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Healing Process-Tendon
• Not as vascular as muscle– Can cause problems in healing– Fibrous union required to provide extensibility
and flexibility• Abundance of collagen needed to achieve good
tensile strength• Collagen synthesis can become excessive can
result in fibrosis: adhesions from in surrounding structures
– Interfere with gliding and smooth movement– Tensile strength not sufficient to permit strong pull for
4 to 5 weeks» At risk of strong contraction pulling tendons ends
apart
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Healing Process-Nerve
• Nerve cell is specialized and cannot regenerate once nerve cell dies– Injured peripheral nerve- nerve fiber can
regenerate if injury does not affect cell body
– Regeneration is very slow 3-4 mm /day• Axon regeneration obstructed by scar formation
• Damaged nerve within CNS regenerate poorly compared to peripheral nervous system
– Lack connective tissue sheath and nerve cells fail to proliferate
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Rehabilitation philosophy• Choose therapeutic exercises/modalities that
facilitate healing process at specific phases– Stimulate structural function and integrity of injured
part– Positive influence on the inflammation and repair
process to expedite recovery of function– Minimize early effects of inflammatory process
including pain, edema control, and reduction of muscle spasm.
• Produce loss of joint motion and contracture
– Finally concentrate on preventing reoccurrence of injury by assuring structural stability of injured tissue
• Appropriate return to play guidelines