Rehabilitation of Soft Tissue Injuries in the 1990s

The days of prolonged immobilization are a part of the past for the treatment of softtissue injuries. The increased attention toward sports medicine throughout the late 1970s

and 1980s has led to research and many clinical studies that will outline the course of

rehabilitation throughout the years to come. A reiew of the current literature on acutesoft tissue injuries classifies different types of soft tissue lesions as well arious phases of 

healing.1 !urrent literature redefines the aims and objecties of rehabilitation pointing out

the many benefits of the use of modalities" early mobilization" and the importance of afull rehabilitation program.

#er the past two decades" soft tissue injuries hae hit the spotlight. Almost all traumatic

injuries" automobile accidents" athletic or other injuries result in some degree of soft

tissue damage. $t%s now recognized that many soft tissue injuries result in a degree of permanent impairment and leae their host with some permanent pain" restrictions" and

loss of function.& To combat the debilitating 'aftermath( of soft tissue injury" new

technology and rehabilitation protocols hae been deeloped.

Etiology of Soft Tissue Injuries, Direct and Indirect Trauma

)any soft tissue injuries come from direct trauma such as being struc* by a moing

object or a fall+ other injuries may be classified as indirect trauma and result fromoerloading or chronic oeruse" thus giing us the classification of direct and indirect

etiology., $ndirect can be further diided into three sub-classes acute -- which occurs

from sudden oerloading as seen in many lifting injuries+ chronic or oeruse -- which are

often seen in many assembly line or factory wor*ers who must perform repetitiemoements hundreds of times daily+ acute on chronic -- occurs when a chronic conditions

hits an acute phase. This third sub-class is also ery common in the wor* enironment

where the same job is performed day in and day out. /y first defining the etiology of acondition" we are on the proper course toward treatment and the preention of further

injury.

Phases of ealing !! Phase I

The current literature describes three main phases of soft tissue healing. An initial

reaction phase which lasts up to 7& hours post-injury. This phase is also referred to as the

acute inflammation phase., The reaction phase displays with the classic signs ofinflammation with pain" swelling" redness and warmth. $n the cases of indirect etiology"

these classic signs may not be readily isible but are proceeding at the microscopic leel.

The long-used application of cryotherapy 'ice( is still supported by numerous studies as

ery effectie treatment in this initial phase.2"7"8"9 !ryotherapy slows the inflammatory process as well as proides an analgesic effect. 3ltrasound may also be used to decrease

swelling in this inflammatory phase" but must be used for short periods to preent

 

hyperemia.10 Transcutaneous nere stimulation 'T45( and electric muscle stimulation

'6)5( hae also been shown to be effectie.

The use of continuous passie motion '!)( has been shown to clear hemoarthrosis'blood present in the synoial joints post-trauma( during the initial reaction phase. $n the

& hours following trauma" the synoial fluid in joints treated with !) displayed less

 blood than immobilized joints. At 8 hours the joints treated by !) demonstrated the

synoial fluid was clear where as the immobilized joint remained grossly bloody.11 

The use of manipulation can also be employed in the reaction phase and is suggested in

the areas of fiation that hae resulted from the injury. This will epedite the remoal of

hemoarthrosis" reduce spasms" edema and pain as well as reduce nere root irritationwhen present.1& !yria states" :hen free mobility was encouraged from the onset" the

fibers in the scar were arranged lengthwise as in a normal ligament. ;entle passie

moements do not detach fibrils from their proper formation at the healing breach" but

 preent their continued adherence at abnormal sites.1, 

$n the initial reaction phase" the use of !) and manipulations 'which are both

mobilization techni<ues( must be used in a controlled protectie manner to preent any

further damage to the healing ligaments.11 

The initial reaction phase can be treated effectiely using classic cryotherapy" specificmodalities" as well as a controlled program of !) and manipulations.

Phase of ealing !! Phases II and III

The second stage of healing" the repair phase" may last from 8 up to 2 wee*s. This phaseis characterized by the production and laying down of new collagen. =uring this phase"

the collagen is not fully oriented in the direction of tensile strength. 

The third phase" the remodeling phase" which lasts from , wee*s to 1& months or more" is

the phase in which the collagen is remodeled and along with with phase $$ determines thefunctional capabilities of the soft tissue after the healing process is completed.1 True

rehabilitation must focus on maintaining these functional capabilities. #a*es, describes

the aims of rehabilitation as regaining pain-free moement with full strength" power andrange of motion" thus describing the functional capabilities of the soft tissue.

To regain the functional capabilities" stresses of function must be put on the healing

tissue. As described by >oy1 $f a limb is completely immobilized during the recoery

 process" the tissues may emerge fully healed but poorly adapted functionally with littlechance for change" particularly if the immobilization has been prolonged. )obilization

techni<ues must ta*e place throughout the repair and remodeling phases to insure proper

tissue adaptation. 5eeral benefits of mobilization hae been defined which includeincreased strength,"12 and fleibility of healed tissue" less scar formation and adhesions"1 

increased cartilage nutrition"17 and lesser incidence of recurrence of injury.18 

 

Rehabilitation Protocol

>ehabilitation protocol following soft tissue injury must include mobilization techni<uesto insure good functional adaptation. A program combining manipulations" the use of

modalities" mobilization techni<ue" and a strengthening program will insure optimal

rehabilitation.

)anipulations and modalities should be used during all three phases of healing to limitfiations" control pain and spasms as well as maintain neurologic integrity. )obilization

should be carried out within the limits of pain on the patient" starting with controlled

 passie motion. !ontrolled passie motion should be employed until a maimum rangeof motion is reached. At this point" actie assistie motion should be employed. As the

injury heals and the tissue adapts" the patient can be graduated to actie resistie motion.

Actie resistie motion should be followed by a strengthening program of *ineticresistie eercise. This will insure a return to maimum strength for the patient. ?eep in

mind all rehabilitation should be performed within the patient%s limits of pain and

 periodic re-ealuation and testing such as muscle testing and surface 6); should be performed to ealuate the patient%s progress. Also remember that the final remodeling

 phase can last oer a year post injury+ rehabilitation should be directed accordingly.

/y following this rehabilitation protocol and progression" a return to maimum functional

capabilities can be insured" returning the patient to maimum pain free range of motionand strength.

>ehabilitation in the 1990%s focuses on regaining function. After all" function does

determine what we can do with our lies.

 J. Scott Brown, D.C.

 Knoxville, Tennessee 

>eferences

1. ?ellett @ Acute 5oft Tissue $njuries - A >eiew of the iterature" )edicine" and

5cience in 5ports B 6ercise" pg. 89-00" )arch 1982.

&. A)A ;uides to the 6aluation of ermanent $mpairment. ,rd 6dition" pg. 7," 4o. 1988.

,. #a*es /: Acute tissue injures nature and management. Austr. Camily

hysician. 5uppl. 10,-12" 198&.. Dan =er )eulin resent state of *nowledge on process of healing in collagen

structure. $nternational @ournal of 5ports )edicine. '5uppl. 1(,-8" 198&.

. )urphy" = :hiplash and spinal trauma notes pg. 9A =ecember 1989.

2. /arnes !ryotherapy -- putting injury on ice. hys. 5ports )ed. ,1,0-1,2"1979.

7. Eocutt @6" @affe >" >ylander !>" /eebe @? !ryotherapy in an*le sprains. Am. @.

Appl. 5ports 5ci. 89-1" 198,.

 

8. ?alena* A" )edlar =6" Cleagle 5/" Eochberg :@ Athletic injuries heat s. cold.

Am. Camily hysician 1&1,1-1," 197.

9. 5tar*ey @A The treatment of an*le sprains by the inisitaneous use of intermittentcompression and ice pac*s. Am. @. 5ports )ed. 1&-1" 1972.

10. )a*ulolowe" )ouzos 3ltrasound in the treatment of sprained an*les.

ractitioner" &1882-88" 1977.11. Eerring ! The controlled passie mobilization techni<ue. Today%s !hiropractic"

 pg. 90-97" @ulyFAug. 1991.

1&. Garins / 5oft tissue injury and repair -- biochemical aspects. $nternatl. @. 5ports)ed. '5uppl. 1(,9-11" 198&.

1,. !ryia @ #rthopaedic )edicine" =iagnosis of 5oft Tissue esions. /ailliere

Tindall" Dol. 1 pg. 1" 198&.

1. Cran*" :oo" Amiel" Earwood" ;omez" A*eson )edial collateral ligamenthealing. A multidisciplinary assessment in rabbits. Am. @. 5ports )ed. 11,79-

,89" 198,.

1. >oy 5" $rin" > 5port )edicine reention" 6aluation" )anagement" and>ehabilitation. rentice-Eall" $nc. pg. 1&7" 198,.

12. Astrand" >odahl Tetboo* of :or* hysiology. 4ew Hor* )c;raw-Eill" 197,"

 pg. 11-&0.17. 5alter" 5immond" )a*olm" >umble" )ac)ichael The effect of continuous

 passie motion on the healing of articular cartilage defects. @. /one @oint 5urg.

'A(770-71" 197.18. Garins / 5oft tissue injury and repair -- biochemical aspects. $nternatl. @. 5ports

)ed. '5uppl. 1(,9-11" 198&.

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